Writing for the Journal of Orthopaedic Research

Affiliation.

  • 1 Department of Biomechanics and Biomaterials, Hospital for Special Surgery, New York, New York 10021-4892, USA. [email protected]
  • PMID: 10459750
  • DOI: 10.1002/jor.1100170402
  • Orthopedics*

Medical Writing and Research Methodology for the Orthopaedic Surgeon

  • © 2018
  • Cyril Mauffrey   ORCID: http://orcid.org/0000-0003-2132-3418 0 ,
  • Marius M. Scarlat   ORCID: http://orcid.org/0000-0002-0347-299X 1

Associate Director of Service, Director of Orthopaedic Trauma and Research, Denver Health Medical Center, Denver, USA

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Departement Chirurgie Orthopédique, Clinique Chirurgicale St Michel, Toulon, France

  • Recipe-like approach to medical writing for orthopaedic surgeons
  • Get started with your study design
  • Tips and tricks for non English-natives

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Table of contents (10 chapters)

Front matter, fraud in publishing.

  • Andreas F. Mavrogenis, Georgios N. Panagopoulos, Cyril Mauffrey, Marius M. Scarlat

The Use of English and Its Editing

  • Andrew Quaile

Developing a Sound Research Methodology

  • Luca Pierannunzii

What Editors and Reviewers Look for: Tips for Successful Research Publication

  • Ryan Stancil, Seth S. Leopold, Adam Sassoon

Medical Writing: Systematic Reviews and Meta-analyses

  • Simon Tiziani, Hans-Christoph Pape

Epidemiological Studies

  • Charles M. Court-Brown, Stuart A. Aitken

Common Causes of Rejection

  • Fredric M. Pieracci

Tips and Tricks for Non-English Writers

  • Matthew P. Abdel, Matthieu Ollivier

Impact Factor and Altmetrics: What Is the Future?

  • Costas Papakostidis, Peter V. Giannoudis

Open-Access Journals: The Future of Scientific Publishing?

  • Philip F. Stahel, Todd VanderHeiden
  • Medical Writing in othopedics field
  • Research methodology
  • Dealing with rejected manuscripts
  • Impact factor
  • scientific fraud

About this book

This unique guide is designed to facilitate the complex task of getting a paper published in an orthopaedics journal. The editors have enlisted expert orthopaedic surgeons from prestigious academic institutions, who share essential advice on how to set up and write on your research. The book addresses fraud issues, the correct use of English and editing, how to develop a sound research methodology, and editors’ and reviewers’ expectations, along with the main reasons for rejection. The future of the Impact Factor, altmetrics and Open Access journals are also discussed, and will be of special interest to young faculty who are starting their research career. The chapters are structured in a reproducible and easy-to-follow format. In addition, the editors offer tips and tricks for non-native speakers writing in English.

As such, the book provides an accessible and comprehensive resource for all those seeking guidance on how to publish their research work in the fieldof orthopaedics.

Editors and Affiliations

Cyril Mauffrey

Marius M. Scarlat

About the editors

Cyril Mauffrey MD, FACS, FRCS is the Director of Orthopaedic Trauma at Denver Health Medical Center and an Associate Professor at the University of Colorado School of Medicine. He has a special interest in pelvic/acetabular fractures and the management of long bone infections/non unions. His research focuses on clinical trials in post-traumatic osteomyelitis and novel treatment strategies for this condition. Dr Mauffrey is Editor in Chief of the European Journal of Orthopaedic Surgery and Traumatology. He serves on the editorial board of several journals and has over 100 indexed orthopaedic publications. Further, he is actively involved in teaching medical writing through webinars and symposiums with the AAOS, SICOT and various other organisations.

Marius Scarlat MD is an Orthopaedic Surgeon specializing in shoulder and elbow surgery and arthroscopy. In addition to his busy clinical practice he is the Editor in Chief of International Orthopaedics, which receives several thousand submissions per year. Dr Scarlat has over a decade of experience in the medical writing/publishing world through numerous journals. He organises and chairs the yearly SICOT medical writing workshop and symposium.

Bibliographic Information

Book Title : Medical Writing and Research Methodology for the Orthopaedic Surgeon

Editors : Cyril Mauffrey, Marius M. Scarlat

DOI : https://doi.org/10.1007/978-3-319-69350-7

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer International Publishing AG 2018

Hardcover ISBN : 978-3-319-69349-1 Published: 24 January 2018

Softcover ISBN : 978-3-319-88760-9 Published: 06 June 2019

eBook ISBN : 978-3-319-69350-7 Published: 22 December 2017

Edition Number : 1

Number of Pages : X, 86

Number of Illustrations : 1 b/w illustrations, 6 illustrations in colour

Topics : Surgical Orthopedics , Medical Education , Language Education

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Writing for the Journal of Orthopaedic Research.

Author information, affiliations.

  • Wright TM 1

ORCIDs linked to this article

  • Buckwalter JA | 0000-0003-4308-7583

Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society , 01 Jul 1999 , 17(4): 459-466 https://doi.org/10.1002/jor.1100170402   PMID: 10459750 

Abstract 

Full text links .

Read article at publisher's site: https://doi.org/10.1002/jor.1100170402

References 

Articles referenced by this article (5)

Scientific credibility requires complete presentation of methods.

Buckwalter JA , Wright TM , Frank CB , Martin RB , Sandell LJ , Trippel SB

J Orthop Res, (2):161 1997

MED: 9167616

: The Elements of Style, 3rd ed, p 23. New York, Macmillan Publishing, 1979

Style manual committee, council of biology editors [eds]: scientific style and format: the cbe manual for authors, editors, and publishers, 6th ed. cambridge, cambridge university press, 1994, title not supplied.

J Orthop Res 1997

: Essentials of Writing Biomedical Research Papers. New York, McGraw-Hill, 1991

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Cited by: 1 article | PMID: 31115720 | PMCID: PMC6842086

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  • v.3(4); Oct-Dec 2013

How to Write a Case Report for Journal of Orthopaedic Case Reports– What do Editor and Reviewer want?

Ashok shyam.

1 Indian Orthopaedic Research Group, Thane, India

2 Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India

More than two years have passed since Journal of Orthopaedic Case Reports (JOCR) has started publication. Over this period of time a huge number of reviewers and Editorial Board Members have contributed to review the articles and send comments on improvement of various aspect of case reports. I have personally reviewed all articles that are published in the journal. During this course a lot of tips and tricks about writing a good case report were noted and I wished to share them with our authors and readers. Also with increase in number of submissions to JOCR, we come across many good case reports, which are poorly written. This leads to delay in publishing the reports and good formatting and content will significantly reduce the time to publication. These two intentions prompted me to write this Editorial giving a brief perspective on what the Editors and Reviewers want from the authors when they write a case report for JOCR. I shall cover the topic as per headings of the case report.

Title: the title of the case report should be descriptive and should contain broad details of the case. It should be appealing to the reader and should arose interest in the case report. A blanket title like ‘Aneurysmal bone cyst of calcaneum: a rare case report’ should be written in a more descriptive terms like 'Curettage and bone grafting for aneurysmal bone cyst of calcaneum in a young woman: Surgical decision making and outcome”

Abstract: a structured abstract is needed as per JOCR guidelines. The introduction part of abstract should clearly mention why the case is reported. The case report part should contain the salient features of the case and conclusions part should contain all the important learning points from the case. Keywords are essential and if possible do format them according to medical subject heading (Mesh) terminology from pubmed.

Introduction: Many authors try to give introduction of the disease, for example if they are describing a case of admantinoma, they try to write an introduction to admantinoma on a whole. This should not be done and introduction should be very specific. If your case is pathological fracture of tibia secondary to admantinoma, the introduction should start with pathological fractures in admantinoma and then move ahead. The purpose of introduction is to introduce the premise of your case and not to introduce the disease or pathology. The introduction should further clearly justify why you wish to report this case and to do this it should include a review of all similar cases reported in literature. I shall personally recommend all authors to include a table of literature review in introduction with details of patient demography, treatment method and results. The last line of introduction should mention, in unambiguous words, why the reported case is important and why the reader should read any further. Use references to justify every sentence in introduction and provide recent literature in review.

Case Report: Make this section succinate but at the same time include all relevant details. Describe everything in chronological manner. Provide detail description of history, symptoms and clinical findings. Include relevant pathological investigation. Discuss the differential diagnosis here in case report and what procedures were carried out to differentiate the said disease from other differentials. Some authors take it for granted that the reader is accepting the diagnosis and do not discuss the complete methodology for arriving on the diagnosis. I will request all authors to clearly describe the method of differential diagnosis and if possible include a flow chart. Describe the radiograph and other radiological investigations in details with figure numbers. Especially in MRI scans describe the T1 and T2 and other special frames in details and what exactly is seen in it [possibly with references]. The final decision about the management of the case should also be rationalized here. Details about clinical decision making concepts should be provided here and if possible in form of a flow chart. Again at times special implants or equipment’s are planned for surgery and these too should be included here. The surgical part of the case report should be described in great details along with approach, exposure and wherever possible intraoperative photographs should be included. Surgical tips and pearls will be very important and can be included in a small box. Any special improvisation required during surgery or any significant observation or event during surgery should be mentioned. Post-operative protocol should be provided in brief with details of radiographic assessment if applicable. At follow up the functional status of the patient should be mentioned in details along with clinical photographs. If serial follow ups are available, details can be included in a table. Complications or any other specific observations should be mentioned at the end of case report.

Discussion: This part is meant to put the current report in context with the literature. The literature review table in the introduction should be used here. The comparison can begin with demography and patient characteristics and should also include the intra-operative details and results. The peculiarity of the case should be discussed in details and important learning points should be backed with literature support. Differential diagnosis and different clinical management protocols can be discussed here with reference to the reported case. Approach to surgery and complications or potential complications should be discussed with rationalization on why certain approach was used or how a certain complication can be avoided. Focus on points that you find are different in your case as per literature but also cover the points that are common with literature. The end of the discussion should include a conclusion where all learning points should be included. This is followed by clinical message where clinical application of the learning points should be mentioned in one sentence.

References: Standard format of references is applicable can be directly taken from pubmed. Please include all recent references and a maximum of 25 -30 references can be included in case the literature review has more reports.

Figures / Legends: Provide good quality photographs of all picture separately [and not embedded in the word file] and provide legend for each photograph separately. Legends should be provided for every figure and table and should be more descriptive to help the reader understand the figures / tables without referring the manuscript

General comments: JOCR provides equal platform to evidence based medicine as well as personal experience and every case report should reflect both these important concepts. Both concepts i.e. the literature and personal experience have to be balanced and neither should be overdone. Write about practical concepts that can come to minds of readers and address them in your report. Place yourself in shoes of a reader who has a similar case. With this in mind provide details of differential diagnosis, clinical decision making and surgical procedure as if you are providing a blueprint for management of such cases. This may sound as a different concept to people who imagine case reports to be something rare or unusual to be reported. In JOCR the case report is also a case management blueprint where the case may not be unusual but the management may be different or the differentials may be confusing or surgical technique is improvised or a different unique learning point is seen in the case. Authors need to find these points in their case reports and highlight them. One major thing that should never be done is ‘Plagiarism’. I will request all authors to avoid plagiarism (copy and paste) from other journal articles at all cost. At JOCR we do use plagiarism check software and can easily detect plagiarized manuscript. Plagiarism will attract immediate rejection with blacklisting of authors for minimum 2 years.

I believe if these guidelines are followed, it will help authors to format good articles for JOCR. It will also help us editors and reviewers to make quick decisions and help facilitate publications. And most importantly it will help the reader to gain every bit of knowledge from the case and be confident that if such a case presents to them, they will be able to manage it appropriately. This will help in combining the concepts detailed in earlier four editorials which focused on creating a personalised journal [ 1 ], noting single observations [ 2 ] and combining wisdom of crowds [ 3 ] in creating avenues for pursuit of knowledge [ 4 ]. I will urge all authors to read all these past editorials along with present editorial [ 5 ] to have a complete idea of what is expected from them when they submit a case report.

JOCR is now well established and will further focus on improving the quality of articles and making it a more interesting read for our readers. Next whole year will focus on improving the quality of the journal and also making it more readable with the aim of making JOCR the most widely read journal in Orthopaedics.

Conflict of Interest: Nil

Source of Support: None

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Writing for the Journal of Orthopaedic Research. Academic Article

  • Wright, Timothy
  • Buckwalter, J A

publication date

  • July 1, 1999

published in

  • Journal of orthopaedic research : official publication of the Orthopaedic Research Society   Journal
  • Orthopedics

Scopus Document Identifier

Additional document info, has global citation frequency.

Photo of a person's hands typing on a laptop.

AI-assisted writing is quietly booming in academic journals. Here’s why that’s OK

writing for the journal of orthopaedic research

Lecturer in Bioethics, Monash University & Honorary fellow, Melbourne Law School, Monash University

Disclosure statement

Julian Koplin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Monash University provides funding as a founding partner of The Conversation AU.

View all partners

If you search Google Scholar for the phrase “ as an AI language model ”, you’ll find plenty of AI research literature and also some rather suspicious results. For example, one paper on agricultural technology says:

As an AI language model, I don’t have direct access to current research articles or studies. However, I can provide you with an overview of some recent trends and advancements …

Obvious gaffes like this aren’t the only signs that researchers are increasingly turning to generative AI tools when writing up their research. A recent study examined the frequency of certain words in academic writing (such as “commendable”, “meticulously” and “intricate”), and found they became far more common after the launch of ChatGPT – so much so that 1% of all journal articles published in 2023 may have contained AI-generated text.

(Why do AI models overuse these words? There is speculation it’s because they are more common in English as spoken in Nigeria, where key elements of model training often occur.)

The aforementioned study also looks at preliminary data from 2024, which indicates that AI writing assistance is only becoming more common. Is this a crisis for modern scholarship, or a boon for academic productivity?

Who should take credit for AI writing?

Many people are worried by the use of AI in academic papers. Indeed, the practice has been described as “ contaminating ” scholarly literature.

Some argue that using AI output amounts to plagiarism. If your ideas are copy-pasted from ChatGPT, it is questionable whether you really deserve credit for them.

But there are important differences between “plagiarising” text authored by humans and text authored by AI. Those who plagiarise humans’ work receive credit for ideas that ought to have gone to the original author.

By contrast, it is debatable whether AI systems like ChatGPT can have ideas, let alone deserve credit for them. An AI tool is more like your phone’s autocomplete function than a human researcher.

The question of bias

Another worry is that AI outputs might be biased in ways that could seep into the scholarly record. Infamously, older language models tended to portray people who are female, black and/or gay in distinctly unflattering ways, compared with people who are male, white and/or straight.

This kind of bias is less pronounced in the current version of ChatGPT.

However, other studies have found a different kind of bias in ChatGPT and other large language models : a tendency to reflect a left-liberal political ideology.

Any such bias could subtly distort scholarly writing produced using these tools.

The hallucination problem

The most serious worry relates to a well-known limitation of generative AI systems: that they often make serious mistakes.

For example, when I asked ChatGPT-4 to generate an ASCII image of a mushroom, it provided me with the following output.

It then confidently told me I could use this image of a “mushroom” for my own purposes.

These kinds of overconfident mistakes have been referred to as “ AI hallucinations ” and “ AI bullshit ”. While it is easy to spot that the above ASCII image looks nothing like a mushroom (and quite a bit like a snail), it may be much harder to identify any mistakes ChatGPT makes when surveying scientific literature or describing the state of a philosophical debate.

Unlike (most) humans, AI systems are fundamentally unconcerned with the truth of what they say. If used carelessly, their hallucinations could corrupt the scholarly record.

Should AI-produced text be banned?

One response to the rise of text generators has been to ban them outright. For example, Science – one of the world’s most influential academic journals – disallows any use of AI-generated text .

I see two problems with this approach.

The first problem is a practical one: current tools for detecting AI-generated text are highly unreliable. This includes the detector created by ChatGPT’s own developers, which was taken offline after it was found to have only a 26% accuracy rate (and a 9% false positive rate ). Humans also make mistakes when assessing whether something was written by AI.

It is also possible to circumvent AI text detectors. Online communities are actively exploring how to prompt ChatGPT in ways that allow the user to evade detection. Human users can also superficially rewrite AI outputs, effectively scrubbing away the traces of AI (like its overuse of the words “commendable”, “meticulously” and “intricate”).

The second problem is that banning generative AI outright prevents us from realising these technologies’ benefits. Used well, generative AI can boost academic productivity by streamlining the writing process. In this way, it could help further human knowledge. Ideally, we should try to reap these benefits while avoiding the problems.

The problem is poor quality control, not AI

The most serious problem with AI is the risk of introducing unnoticed errors, leading to sloppy scholarship. Instead of banning AI, we should try to ensure that mistaken, implausible or biased claims cannot make it onto the academic record.

After all, humans can also produce writing with serious errors, and mechanisms such as peer review often fail to prevent its publication.

We need to get better at ensuring academic papers are free from serious mistakes, regardless of whether these mistakes are caused by careless use of AI or sloppy human scholarship. Not only is this more achievable than policing AI usage, it will improve the standards of academic research as a whole.

This would be (as ChatGPT might say) a commendable and meticulously intricate solution.

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writing for the journal of orthopaedic research

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  • Open access
  • Published: 21 May 2024

Massage for rehabilitation after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

  • Ruinan Chen 1   na1 ,
  • Yaoyu Jin 1   na1 ,
  • Zhaokai Jin 1 ,
  • Yichen Gong 1 ,
  • Lei Chen 1 ,
  • Hai Su 1 &
  • Xun Liu 2  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  307 ( 2024 ) Cite this article

15 Accesses

Metrics details

This study aimed to evaluate the effectiveness of massage for postoperative rehabilitation after total knee arthroplasty (TKA).

Data sources

The PubMed, Web of Science, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases were systematically searched from inception to May 2024.

Study selection

Any randomized controlled trials on the use of massage for postoperative TKA rehabilitation were included.

Data extraction

A meta-analysis of outcomes, including postoperative pain, knee range of motion (ROM), postoperative D-dimer levels, and length of hospital stay, was performed. The Cochrane Risk of Bias Assessment Tool was used to assess the risk of bias, and the data for each included study were extracted independently by two researchers.

Data synthesis

Eleven randomized controlled clinical trials with 940 subjects were included. The results showed that compared with the control group, the massage group experienced more significant pain relief on the 7th, 14th and 21st days after the operation. Moreover, the improvement in knee ROM was more pronounced on postoperative days 7 and 14. In addition, the massage group reported fewer adverse events. However, there was no statistically significant difference in the reduction in postoperative D-dimer levels between the patients and controls. Subgroup analysis revealed that massage shortened the length of hospital stay for postoperative patients in China but not significantly for patients in other regions. Nevertheless, the heterogeneity of the studies was large.

Conclusions

Increased massage treatment was more effective at alleviating pain and improving knee ROM in early post-TKA patients. However, massage did not perform better in reducing D-dimer levels in patients after TKA. Based on the current evidence, massage can be used as an adjunctive treatment for rehabilitation after TKA.

Knee osteoarthritis (KOA) is a disease caused by the degeneration of articular cartilage. Knee pain and dysfunction are the main clinical symptoms occurring mostly in middle-aged and older adults [ 1 ]. As the disease progresses, it will eventually lead to the loss of knee function, and its expensive treatment costs will burden patients, families, and society [ 2 ]. As the world's population ages, more middle-aged and older adults are likely to develop KOA, and one study predicts that by 2032, the proportion of people over 45 years of age with KOA will increase to 15.7% [ 3 ].

Total knee arthroplasty (TKA) is widely accepted as an effective treatment for end-stage KOA [ 4 ]. After TKA, patients may experience several complications, including pain, swelling, decreased muscle strength, limited joint motion, and even deep vein thrombosis (DVT). These complications seriously affect postoperative rehabilitation and can subsequently seriously affect the recovery of limb function [ 5 ]. Therefore, timely and effective postoperative rehabilitation for TKA patients is essential for successful surgery [ 6 ].

Massage has a long history of treatment and has evolved throughout the world with different characteristic forms of manipulation, including pressure (gradual downward pressure with fingers or palms on the body surface), rubbing (circular strokes on the body surface), pinching (gentle grasping of soft tissues), vibration (shaking hands to move limbs), and plucking (plucking soft tissues back and forth like strings) [ 7 ].

To date, in comparison with traditional rehabilitation methods following TKA such as manual lymphatic drainage and continuous passive movement [ 8 ], massage exhibits unique characteristics and has demonstrated favorable efficacy across various disease fields [ 9 , 10 ]. Similarly, many randomized controlled clinical trials have investigated the effects of massage on postoperative rehabilitation after TKA, but the results are diverse, and there is no clear consensus [ 11 , 12 , 13 , 14 , 15 ]. In addition, no systematic reviews or meta-analyses of these studies have been reported. Therefore, this study collected randomized controlled trials of massage rehabilitation after TKA from different databases and performed a systematic review and meta-analysis to assess the effect of massage on the rehabilitation of patients undergoing TKA surgery.

Study registration

The protocol for this systematic review was registered with PROSPERO (registration number: CRD42023411680). This systematic review is reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 checklist [ 16 ].

Search strategy

Two reviewers (Jin YY, Chen RN) searched the PubMed, Web of Science, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases for related research from inception to May 2024. Strings such as “Arthroplasty, Replacement, Knee,” “Total Knee Arthroplasty,” “TKA,” “Massage,” “Massage Therapy,” and “Randomized Controlled Trials” were used. The search strategy is detailed in Supplementary Table S1 .

Selection criteria

This study screened the literature according to the principles of the PICOS.

① Participants:

Patients who underwent TKA for the first time. No restrictions were made on patient age, disease course or specific surgical procedure.

② Intervention:

Simple massage therapy or massage combined with routine rehabilitation therapy. In addition, there were no restrictions on the type of massage, duration, frequency, or intensity of the intervention.

③ Comparators:

Massage vs. other treatments, massage & other treatments vs. other treatments, massage vs. placebo.

④ Outcomes:

At least one index of the curative effect of postoperative rehabilitation.

⑤ Study design:

Randomized controlled trials (RCTs).

The literature was excluded if it met any of the following criteria:

① Articles not in English or Chinese; ② Incomplete or repeatedly published literature; ③ Documents required for statistical analysis that could not be integrated or obtained; ④ Full text could not be obtained; ⑤ Revision TKA, single compartment knee arthroplasty; ⑥ Continuous passive motion, manual lymphatic drainage; ⑦ Animal experimental studies, case reports, conference papers, dissertations.

Two researchers (Jin YY, Chen RN) independently screened all the retrieved literature based on the inclusion and exclusion criteria. An initial literature screening was performed first after reading the titles and abstracts, and then a final screening was performed after carefully reading the full texts of the remaining studies. In the process of literature screening and data extraction, any dissenting opinions were discussed by both parties or handed over to the third-party researcher for decision-making. Two researchers extracted the following information from the final included literature: name of the first author, year of publication, country, patient age and biological sex, sample size, type and duration of intervention, time point of assessment, primary outcomes, and adverse events.

Quality assessment

The Cochrane Risk of Bias Assessment Tool [ 17 ] was used to assess the quality of the included studies. The assessment included seven items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective reporting, and other biases. Each project risk level is divided into three levels: high risk, low risk, and unclear risk.

Statistical analysis

Review Manager 5.3 and Stata 16.0 software were used for the statistical analyses. All continuous variables were pooled by mean difference (MD) or standardized mean difference (SMD) with 95% confidence intervals (95% CI). Heterogeneity of the included studies was assessed using the Q statistic and I 2 indices, and meta-analysis was performed using a fixed-effects model when I 2  < 50% and a random-effects model when I 2  > 50%. Differences were also considered statistically significant when p  < 0.05. Subgroup analyses were performed based on country type to explore potential sources of heterogeneity between studies. Publication bias was assessed using Begg's and Egger's tests ( p  < 0.05, statistically significant difference).

A total of 554 articles were retrieved by searching each database; 135 articles were eliminated by EndNoteX9 software, 398 were deleted after reading titles and abstracts, and the remaining 21 were retained. After reading the full text, 10 articles were excluded, of which 1 was not an RCT, 2 were not available for full text, 1 did not have the correct intervention, 6 data could not be integrated, and were finally included in 11 articles. The flowchart of the literature selection process is shown in Fig.  1 .

figure 1

Flowchart of study selection

A total of 940 patients were included in the 11 articles [ 11 , 12 , 13 , 14 , 15 , 18 , 19 , 20 , 21 , 22 , 23 ]. Nine of the studies were from China, while the other two were from Turkey and Japan. The studies, published between 2008 and 2022, ranged in sample size from 30 to 168 people. Except for one study [ 14 ] in which the massage method was self-massaged under the guidance of a professional therapist, the massage method in other studies was administered by a professional therapist. And except for one study [ 20 ] that used the “massage vs. other treatments” model, the remaining studies used the “massage + other treatments vs. other treatments” model.

In addition, four studies [ 19 , 21 , 22 , 23 ] did not report the occurrence of adverse events. Table 1 summarizes the characteristics of the included studies.

Risk of bias

All included studies randomized the allocation of subjects. Nine studies [ 12 , 13 , 14 , 15 , 18 , 19 , 20 , 22 , 23 ] documented the randomization method in detail, and three [ 12 , 13 , 18 ] of them detailed the allocation concealment process. Two studies [ 12 , 13 ] were blinded to the outcome assessor. Moreover, only one study [ 18 ] described the blinding of subjects and therapists. The detailed results are shown in Fig.  2 .

figure 2

Risk of bias graph

Meta -analysis

Postoperative pain.

Three studies [ 11 , 12 , 23 ] , including 226, 140, and 110 patients , reported pain at 7 days after TKA, three [ 11 , 18 , 23 ] at 14 days after TKA, and two [ 11 , 20 ] at 21 days after TKA, respectively. A random effects model was used for the meta-analysis. The results showed that the degree of pain in the massage group (MG) was significantly lower than that in the control group (CG) at 7 [MD = -1.21 (95%: − 1.76, − 0.65), p  < 0.0001, I 2  = 68%];14 [MD = − 5.32 (95%: − 8.74, − 1.90), p  = 0.02, I 2  = 96%]; and 21 days [MD = − 2.14 (95%: − 3.10, − 1.17), p  < 0.0001, I 2  = 74%] after surgery (Fig.  3 ).

figure 3

Meta-analysis and forest plot for postoperative pain at different time points. a – c Pain on postoperative days 7, 14, and 21, respectively

Two studies [ 11 , 12 ] reported knee ROM at 7 days after TKA, including 84 patients in the MG and 82 in the CG. A fixed effects model was used for the meta-analysis. The results showed that the MG improved the knee ROM more than did the CG at 7 days after surgery, and the difference was statistically significant [MD = 6.39 (95%: 4.26,8.51), p  < 0.00001, I 2  = 38%]. Two studies [ 11 , 18 ] reported knee ROM at 14 days after TKA, including 40 patients in the MG and 40 in the CG. A random effects model was used for the meta-analysis. The results showed that the MG improved the knee ROM more than did the CG at 14 days after surgery, and the difference was statistically significant [MD = 11.98 (95%: 4.65, 19.31), p  = 0.001, I 2  = 80%] (Fig.  4 ).

figure 4

Meta-analysis and forest plot for knee ROM at different periods. a Knee ROM on the 7th day after surgery; b knee ROM on the 14th day after surgery

Postoperative D-dimer levels

Three studies [ 13 , 19 , 23 ] reported D-dimer levels at 14 days after TKA, including 105 patients in the MG and 106 in the CG. A random effects model was used for the meta-analysis. The results showed that the D-dimer level in the MG decreased more significantly than that in the CG at 14 days after surgery, and the difference was statistically significant [MD = -0.40 (95%: -0.75, -0.04), p  = 0.03, I 2  = 97%]. Two studies [ 15 , 21 ] reported D-dimer levels 15 days after TKA, including 58 patients in the MG and 58 in the CG. A random effects model was used for the meta-analysis. However, there was no significant difference in D-dimer levels between the massage and control groups at 15 days after surgery [MD = 0.02 (95%: − 0.12,0.15), p  = 0.80, I 2  = 96%] (Fig.  5 ).

figure 5

Postoperative D-dimer levels at different time points. a D-dimer level on the 14th day after surgery. b D-dimer level on the 15th day after surgery

Length of hospital stay

Five studies [ 11 , 14 , 15 , 18 , 22 ] reported the length of hospital stay after TKA, including 220 patients in the MG and 223 in the CG. A random effects model was used for the meta-analysis. The results showed that the length of hospital stay was significantly shorter in the MG than in the CG [MD = − 5.32 (95%: − 8.74, − 1.90), p  = 0.002, I 2  = 96%] (Fig.  6 ).

figure 6

Subgroup analyses

Due to the small number of studies included for the remaining outcomes, we performed subgroup analyses only for the outcome of length of hospital stay. To explore the sources of heterogeneity, we divided the analysis into two subgroups, China and other countries, according to country type. The results showed that massage treatment shortened the length of hospital stay for TKA patients in China [MD = − 3.79 (95%: − 4.36, 3.22), p  < 0.00001, I 2  = 0%] but not for TKA patients in other countries [MD = 0.08 (95%: − 0.17, 0.33), p  = 0.53, I 2  = 0%], and the heterogeneity between the two subgroups was significantly lower, confirming the country type as a source of heterogeneity (Fig.  7 ).

figure 7

Subgroup analysis of length of hospital stay

In addition, according to the Cochrane Handbook [ 24 ], sensitivity analysis was not performed in this study due to the small amount of literature included for each outcome.

Publication bias

In this study, we examined publication bias using Begg's and Egger's tests. The results showed potential publication bias in the outcome of postoperative day 14 pain according to Egger's test ( p  = 0.049), and no evidence of significant publication bias was found in the remaining included studies. ( p  > 0.05). In addition, Egger's test could not be performed for pain at postoperative day 21, knee ROM at postoperative day 7, knee ROM at postoperative day 14, or D-dimer level at postoperative day 15 because only two studies were included for each outcome. (Supplementary Table S2).

Adverse events

Seven studies [ 11 , 12 , 13 , 14 , 15 , 18 , 20 ] reported adverse events. In one study [ 11 ], one patient in the CG was reported to have DVT, and another study [ 15 ] reported adverse events in three patients in the CG, but the details were not available. No adverse events were reported in the remaining studies.

According to the evidence from this study, massage has certain therapeutic effects on reducing pain and improving ROM in patients with early-stage TKA, which may help patients leave the hospital earlier and return to normal life. At the same time, massage is safe and reliable. However, massage does not reduce the level of D-dimer in patients after surgery. The mechanism of massage is related to the following factors.

It has been shown that 10–34% of patients experience severe pain after TKA, often leading to chronic pain if not effectively treated [ 25 , 26 ]. Massage can reduce inflammatory cell infiltration and tissue necrosis in pain mechanisms, as well as the release of neuropeptides, thus preventing chronic pain caused by the constant sensitization of pain-sensing nerves [ 27 , 28 ].

Furthermore, we believe that these beneficial effects of massage are related to the complex interaction between the therapist and patient. Patients receiving massage receive more care and attention, which to some extent eliminates postoperative anxiety, thereby achieving pain relief. These effects cannot be achieved through routine rehabilitation or medication alone [ 29 ].

Quadriceps muscle strength plays an important role in knee function, but most patients fear exercise due to postoperative pain, leading to muscle wasting and decreased muscle strength, which in turn affects the recovery of knee ROM. In contrast, massage has been shown to improve muscle strength and increase knee ROM and stability [ 30 , 31 ]. The results of our statistical analysis showed that massage improved knee ROM in the early postoperative period after TKA.

D-dimer levels are clinically important indicators for monitoring the occurrence of lower extremity DVT after TKA [ 32 ]. There is evidence that massage can prevent DVT, but most studies strongly recommend that massage should be combined with anticoagulants, compression stockings, and pneumatic compression therapy to be effective for DVT prevention [ 33 ]. Our results suggest that the addition of massage therapy to routine rehabilitation was ineffective in reducing D-dimer levels after TKA.

The results of our subgroup analysis of the length of hospital stay showed that massage treatment was able to shorten the length of hospital stay for TKA patients in China but not for TKA patients in other countries. It is speculated that this may be related to the different types of massage manipulation and hospital management systems used in different regions.

The present study has several limitations. First, although we conducted as comprehensive a search as possible with no commercial interest involved, publication bias detection may indicate potential publication bias, indicating that some studies published in the gray literature may have been overlooked. Second, most of the included studies were conducted in China, which largely limits the generalizability of massage in post-TKA rehabilitation. The results should be further validated through multicenter and diverse clinical trials. Third, in terms of research design, the nature of massage made it difficult to implement the double-blind method in most studies, reducing the quality of the final evidence and resulting in the quality of the included studies being mostly low to moderate. Therefore, more rigorous scientific design, improved randomization, allocation concealment and blinding methods should be implemented in future research to improve the quality of evidence.

Fourth, muscle strength, knee swelling and quality of life scores are also important in assessing the outcome of TKA, and future studies should improve the collection of these indicators. In addition, in terms of adverse events, the included studies did not report the severity of adverse events. Therefore, the use of a special scale to evaluate the severity of adverse events or adverse events for statistical analysis is also an important direction for subsequent design.

Fifth, most meta-analyses showed great heterogeneity ( I 2  > 50%), which was strongly associated with different types, durations, frequencies or intensities of massage in the included studies because massage itself is a regional, individual, diverse characteristic of the treatment. Therefore, it is necessary to develop a set of standardized massage methods for post-TKA active clinical research.

Finally, due to the small number of studies included for each outcome, sensitivity analyses were not performed, which may have contributed to the lack of robustness of the results of the meta-analyses.

The present study is the first systematic review and meta-analysis to evaluate the efficacy of massage on postoperative rehabilitation in patients undergoing TKA. We conclude that low- to moderate-quality evidence suggests that massage can reduce early pain and improve early knee mobility in patients after TKA, but massage does not reduce D-dimer levels in patients after TKA. Therefore, based on the current evidence, we believe that massage can be used as an adjunctive treatment for postoperative rehabilitation after TKA. However, larger and higher-quality trials are needed to confirm these results in the future.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Knee osteoarthritis

Knee range of motion

  • Total knee arthroplasty

Deep vein thrombosis

Participants, intervention, comparators, outcomes and study design

Mean difference

Standardized mean difference

Confidence interval

Heterogeneity

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Ruinan Chen and Yaoyu Jin have contributed equally to this work and share first authorship.

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Zhejiang Chinese Medical University First Clinical Medical College, Hangzhou, 310053, China

Ruinan Chen, Yaoyu Jin, Zhaokai Jin, Yichen Gong, Lei Chen & Hai Su

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Chen R N and Liu X contributed to the study conception and design. Chen R N and Jin Y Y performed the data analysis and were major contributors to the writing of the manuscript. All the authors contributed to the interpretation of the data and the creation of the figures, tables and manuscript. All the authors have read and approved the final manuscript.

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Chen, R., Jin, Y., Jin, Z. et al. Massage for rehabilitation after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 19 , 307 (2024). https://doi.org/10.1186/s13018-024-04798-6

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To shift the gender dynamic in the practice and study of orthopaedic surgery, future orthopaedic surgeons Lulla Kiwinda and Dana Rowe co-led the creation of the inaugural Ruth Jackson Orthopaedic Society (RJOS) chapter at Duke University this year. The mission of RJOS is to promote the professional development of women in orthopaedics throughout all stages of their careers.

This was the first year the national organization allowed for medical school chapters, and female-identifying students at Duke interested in orthopaedic surgery were highly excited about the opportunity.

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  28. Meet the Inaugural Ruth Jackson Orthopaedic Society Chapter at Duke

    To shift the gender dynamic in the practice and study of orthopaedic surgery, future orthopaedic surgeons Lulla Kiwinda and Dana Rowe co-led the creation of the inaugural Ruth Jackson Orthopaedic Society (RJOS) chapter at Duke University this year. The mission of RJOS is to promote the professional development of women in orthopaedics throughout all stages of their careers.