A commentary on “Acupuncture for rehabilitation after total knee arthroplasty: a systematic review and network meta-analysis”

Dear Editor, We read with great interest the recent article by Li et al, titled “Acupuncture for rehabilitation after total knee arthroplasty: a systematic review and network meta-analysis.” The study addresses an innovative topic by exploring the specific efficacy of acupuncture in postoperative rehabilitation following total knee arthroplasty (TKA), highlighting the potential benefits of traditional medicine. After a thorough review, we believe the manuscript could be further strengthened in certain areas. Li et al analyzed 28 randomized controlled trials and concluded that acupuncture, particularly electroacupuncture, was effective in alleviating postoperative pain, improving joint mobility, and was associated with minimal adverse effects. However, while the study included a risk-of-bias assessment for the trials, it did not provide a comprehensive evaluation of the quality of evidence. We recommend the use of the GRADE framework to systematically assess the certainty of the evidence[1]. Our own GRADE-based analysis revealed that the overall quality of evidence was low (see Table 1). Future studies should aim to include high-quality trials in network meta-analyses and meta-analyses. We commend the authors for providing a comprehensive review of rehabilitation options after TKA, and we agree that further well-designed studies with large sample sizes and rigorous methodologies are essential to confirm the precise efficacy of acupuncture in this context. Table 1 - GRADE Score Sheet Quality assessment No. of patients Effect Quality Importance No. of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Acupuncture Routine treatment Relative (95% CI) Absolute Visual Analog Scale 16 randomised trials no serious risk of bias Seriousa No serious indirectness no serious imprecision reporting biasb - - - - ⊕⊕〇〇 0% - Low Hospital for Special Surgery 4 Randomized trials Seriousc Seriousa No serious indirectness Seriousd None - - - - ⊕〇〇〇 0% - Very low range of movement 4 Randomized trials Serious Seriousa No serious indirectness Seriousd None - - - - ⊕〇〇〇 0% - Very low Western Ontario and McMaster Universities Osteoarthritis Index 3 Randomized trials Seriousc Seriousa No serious indirectness Seriousd None - - - - ⊕〇〇〇 Very low 0% - aAtypia greater than 50%bThere is potential publication bias.cAllocation concealment was not described in three studies.dSmall sample size, wide confidence interval.