Effectiveness of Digital Health Interventions on Rehabilitation Outcomes in Patients After Total Knee Arthroplasty: Systematic Review and Network Meta-Analysis
Journal of Medical Internet Research ·
Background: Total knee arthroplasty (TKA) is the most effective treatment for end-stage knee osteoarthritis, but some patients continue to experience persistent postoperative pain, stiffness, and impaired functional recovery. Digital health interventions are increasingly used in rehabilitation after TKA, but their comparative effectiveness remains unclear. Objective: This study aimed to evaluate the effects of different digital health interventions on rehabilitation outcomes in patients after TKA and to compare and rank these interventions in terms of pain relief, active knee flexion range of motion (ROM), and knee function to provide evidence for selecting optimal rehabilitation strategies. Methods: We searched PubMed, Embase, Cochrane Library, Web of Science, Google Scholar, Scopus, CINAHL, MEDLINE (via OvidSP), CNKI, Wanfang, and VIP to identify randomized controlled trials (RCTs) meeting the inclusion criteria. The RoB 2 tool (Risk of Bias 2; Cochrane) was used to assess risk of bias, and the confidence in network meta-analysis (CINeMA) framework was used to evaluate certainty of evidence. Traditional meta-analysis and network meta-analysis (NMA) were performed using Stata (version 17.0; StataCorp LLC). A random-effects model (DerSimonian-Laird method for estimating ) was consistently used across all analyses. For outcomes measured with the same or convertible scales, mean differences (MDs) with 95% CIs were used to pool effect sizes. Surface under the cumulative ranking curve (SUCRA) values were calculated to summarize the ranking probabilities. Results: A total of 36 RCTs involving 3067 patients after TKA were included. NMA results showed that compared with conventional rehabilitation (CR), for active flexion ROM, rehabilitation robot (RR; MD 8.96, 95% CI 5.86-12.05), mobile app–based telerehabilitation (MAT; MD 6.36, 95% CI 2.81-9.91), and virtual reality (VR; MD 5.92, 95% CI 2.94-8.90) were significantly superior to CR; for the Hospital for Special Surgery knee score, VR (MD 9.53, 95% CI 5.18-13.88), intelligent rehabilitation system-based telerehabilitation (MD 6.90, 95% CI 2.35-11.44), and RR (MD 5.32, 95% CI 1.61-9.04) were significantly superior to CR; for pain, RR and MAT had relatively high ranking probabilities, but the 95% CIs of most comparisons included 0; for the Western Ontario and McMaster Universities Osteoarthritis Index and Timed Up and Go test, only internet videoconference-based telerehabilitation and VR-based telerehabilitation, respectively, were significantly superior to CR. The certainty of evidence for most comparisons was low or very low. Conclusions: Digital health interventions may improve pain, active knee flexion ROM, and knee function in patients after TKA. In the SUCRA ranking, RR, VR, and MAT showed favorable ranking probabilities; however, because the network was predominantly star-shaped and the rankings were derived largely from indirect comparisons, these findings should be interpreted as suggestive rather than definitive. Further high-quality studies with direct head-to-head comparisons are needed. Trial Registration: PROSPERO CRD420251244837; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251244837