Patient engagement strategies for joint replacement: digital drip-feed, prehab, and GP optimisation
A GP-facing summary of Dr Wu’s talk on engagement apps from −90 days, prehab adherence and social-cognitive benefits, iron/nutrition thresholds, modern fasting, CT/robotic planning, early rehab step limits, and digital follow-up — distinct from the separate enhanced-recovery seminar.
- Speaker
- Dr Wu — orthopaedic surgeon (given name not stated in the Otter transcript). Host thanked him with a token of appreciation and named his wife as Dr Fiona Hatha. This blog covers Wu’s patient-engagement / digital pathway talk only.
- Session context
- Gold Coast CPD Saturday afternoon. Immediately after Wu’s Q&A, the host introduced Dr Michael Feigen for foot-and-ankle — covered separately on allcpd.
Key messages
- A well-informed patient who understands the roadmap is more confident, less anxious, and tends to do better — psychological factors strongly affect outcome.
- Replace the unread booklet with a phone engagement app that drip-feeds education from −90 days, plus weekly surgeon video; monitor engagement and call non-engagers.
- Prehab addresses sarcopenia/deconditioning and builds self-efficacy — compliant patients were more likely to be exercising at one year.
- Optimisation is more than cardiology clearance: nutrition, iron infusion thresholds for joint replacement (speaker: Hb <130 with ferritin <50), vitamin D and zinc for wound healing.
- Early rehab has abandoned “no pain, no gain”: limit steps for the first two weeks, ice hourly, then progress; app messaging + next-day physio telehealth support home recovery.
Digital engagement app (−90 day drip-feed)
Dr Wu’s practice moved beyond covering everything in one consult plus a handout few patients read, and relying on pre-admission clinic content that is partly forgotten. Most patients now sign up to a patient engagement app on their phone; those without a phone still receive mailed material.
Content starts at minus 90 days before surgery. Each week patients receive different modules — anaesthesia and hospital stay, what to expect after surgery, swelling and pain management, and exercises. The underlying product is a US app, but modules were written for local culture and region. Because medicine still needs a human touch, Wu also records weekly video messages so patients hear him inviting questions.
The clinician can see whether patients open modules. Wu has not gone as far as cancelling surgery for low completion (he has heard of surgeons who do), but he rings patients who are not engaging — treating app use as clinically important, not optional entertainment.
Prehab, sarcopenia, and social-cognitive benefits
The app also delivers a structured prehab programme. Many joint-replacement candidates are deconditioned with sarcopenia, which affects rehab quality and fall risk after surgery. Goals include muscle strength, flexibility, and balance, plus practising crutches and stairs before the operation so those skills feel more natural afterwards. Patients can mark exercise difficulty and swap modules that are too hard. Clinicians can see compliance.
Wu stressed that prehab is not only physical. The social-cognitive benefits matter: self-efficacy, motivation, and facilitating one’s own recovery. In their digital feedback programme, patients who complied with prehab were much more likely to be regularly exercising at one year after surgery — a better general health outlook, treating the person and lifestyle, not only the joint.
GP optimisation: iron, vitamin D, zinc
“Fit for surgery” from a cardiologist is no longer the whole optimisation story. Address deconditioning and run nutritional screening. Wu frequently asks GPs to arrange an iron infusion and often hears back that the patient is “not iron deficient” by everyday thresholds.
Speaker: studies and a consensus statement he wrote recently for the Parker group — thresholds in joint replacement are slightly higher. Anyone with haemoglobin less than 130 and ferritin less than 50 may benefit from an iron infusion. If you are not comfortable giving the infusion, that is fine — he will find an alternative (previously many went to haematology; cost and access vary).
Timing depends on lead-in to surgery. Evidence comparing infusion versus oral iron is not clear-cut; if deficiency is only found two weeks before surgery (late bloods), infusion may be needed; if found ~90 days out, oral iron may suffice. He also screens vitamin D (deficiency under 50 mentioned in the talk) and zinc, framed as important for wound healing. Anaemia work-up has occasionally uncovered cancers — patients who later said the pathway “saved my life.”
Modern fasting and carbohydrate loading
Midnight fasting for the whole list is outdated. Each patient gets a fasting time tied to anticipated anaesthetic start:
- Solids until 6 hours pre-op
- Clear fluids until 2 hours pre-op
- On admission (Gold Coast Private mentioned): DEX carbohydrate drink
Aim: avoid a catabolic state under anaesthesia, which was linked to more hypotension, nausea, and even higher pain. On the ward they encourage drinking to thirst rather than routine IV saline.
CT planning and robotics
Most patients get CT-based patient-specific implant planning before theatre — likely sizes and targets known so nurses can prepare instruments, improving accuracy and efficiency. Robotics for hip and knee are tools (“power steering, not autopilot”). For anterior hip, a muscle-sparing approach with a limited surgical view, robotics add real-time audible/visual feedback and help lock pelvis position reproducibly. Knees are mapped for soft-tissue laxity and bone shape so the replacement can be planned before cuts.
Early rehab: step limits, ice, digital follow-up
“No pain, no gain” is no longer the philosophy. Surgically injuring the joint is treated like a sports injury: you would not send someone out to train hard the day after. For the first two weeks:
- Little formal physio
- Limit step counts (garment tracker / similar — monitored)
- If pain is high, check steps and reduce them
- Ice every hour, gentle walking only
Once early inflammation settles, exercises ramp up. The app also provides two-way messaging for non-urgent questions to surgeon, physio, or nurse (checked daily; physio available Sunday). The day after discharge, physio telehealth reviews walking, wound, and medicines. In-person visits still occur (~2–3 weeks wound check / suture removal; ~6 weeks review). Digital care builds confidence — it does not replace clinic.
Q&A: scars, PRP / nFlex, anterior vs posterior
Scar care
From about three weeks, patients use vitamin E cream or bio-oil with massage, plus a dressing that reduces tension on the wound.
PRP and nFlex for osteoarthritic knee
Wider trials were framed as showing roughly equivalent efficacy to regular anti-inflammatories, slightly better than steroids; about 75% of patients get some symptomatic benefit. Not disease-modifying — will not convert a patient destined for replacement in two years into a non-surgical course. Speaker did not see a large practical difference between PRP and nFlex in that framing.
Anterior vs posterior hip
Anterior: muscle-sparing (no muscle cut); purported slightly lower dislocation rate, but modern posterior dislocation rates are already low. Technically harder, smaller view, higher potential for intraoperative complications — robotics help reproducibility. Early recovery (getting in/out of bed) may be easier in the first 2–6 weeks; by six weeks differences fade. Wu: ~95% of his new hips anterior after ~500 cases. Posterior remains a workhorse approach but divides the short external rotators.
- Enhanced recovery in surgery (distinct seminar — otter e11FqH0rkEdjfW1h_U8A1moZtfM)
- Foot and ankle surgery seminar (same CPD afternoon — Dr Michael Feigen)