
==== Front
Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

38814310
IJS-D-24-02031
10.1097/JS9.0000000000001728
00117
3
Correspondence
Comment on: the efficacy and safety of hydrotherapy in patients with knee osteoarthritis: a meta-analysis of randomized controlled trials
Zhao Zhihu MD azhaozhihu@tju.edu.cn

Luo Wei PhD luoweidoc@tju.edu.cn
a
Ma Jianxong PhD bmjx909900@qq.com

Ma Xinlong PhD a*gukezzh@126.com

a Department of Orthopaedics, Tianjin Hospital, Hexi District
b Tianjin Institute of Orthopedics in Traditional Chinese and Western Medicine, Tianjin, People’s Republic of China
* Corresponding author. Address: Department of Orthopaedics, Tianjin Hospital, No. 406, Jiefangnan Road, Hexi District, Tianjin 300000, People’s Republic of China. Tel.: +86 022 022 6091 0301. E-mail: gukezzh@126.com (X. Ma).
9 2024
29 5 2024
110 9 59775978
14 5 2024
19 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0/

OPEN-ACCESSTRUE
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pmcComment

The meta-analysis conducted by Lei et al.1 provides a comprehensive evaluation of the effects of hydrotherapy on individuals with knee osteoarthritis (OA). The study’s systematic review methodology, well-defined inclusion/exclusion criteria, and extensive statistical analysis enhance its methodological robustness. Nonetheless, the lack of a trial sequence analysis (TSA) represents a significant limitation that may impact the interpretation of the findings.

Strengths

The study’s stringent inclusion and exclusion criteria contribute to a targeted and pertinent synthesis of the extant literature.

The thorough data extraction procedure, which incorporates independent reviewers and a third reviewer for resolving discrepancies, bolsters the credibility of the results.

The meta-analysis adeptly utilizes both fixed-effect and random-effects models in response to the observed heterogeneity, demonstrating a sophisticated methodology for data synthesis.

Weaknesses

The restricted number of randomized controlled trials (RCTs) included in the study may impede the generalizability of the results and diminish the statistical power of the analysis.

The recognized moderate to low quality of evidence implies that the conclusions should be interpreted with caution and highlights the necessity for additional, higher-quality research.

The existence of heterogeneity in certain analyses signifies diversity in study outcomes, potentially influencing the strength of the conclusions made.

Concerns regarding trial sequence analysis

Lack of TSA: The research lacks a trial sequence analysis, a statistical technique utilized to mitigate random errors in cumulative meta-analyses. TSA enables the estimation of the requisite evidence for drawing dependable conclusions and evaluates the adequacy of information gathered for making definitive determinations.

Implications for Reliability: In the absence of TSA, there exists a possibility that the results may be influenced by stochastic fluctuations, potentially leading to an exaggeration of the impact of hydrotherapy on knee osteoarthritis.

Recommendation for Future Research: Conducting a TSA in future updates of this meta-analysis could strengthen the reliability of the evidence base and provide a more accurate estimation of hydrotherapy’s efficacy and safety.

Suggestions for future research

Conducting long-term studies to assess the sustainability of hydrotherapy’s benefits for knee OA patients.

Performing subgroup analyses to identify patient characteristics that may predict better responses to hydrotherapy.

Expanding the search criteria to include a broader range of literature, including non-English and unpublished studies, to mitigate potential publication bias.

Conclusion

While Lei et al.’s meta-analysis offers preliminary evidence supporting hydrotherapy as a safe treatment option for knee OA, the lack of TSA is a significant omission. Incorporating TSA in future research could provide a more robust assessment of hydrotherapy’s true effect size and clinical significance.

Ethical approval

The comment does not necessitate ethical approval as it is a scholarly critique and does not involve experimental procedures.

Consent

None.

Source of funding

This study was sponsored by grants from the Technology Fund of Tianjin Hospital (TJYY2117), Tianjin Health Research Project (TJWJ2022QN051, TJWJ2022MS025), Tianjin Health Science and Technology Project (ZC20096 and ZC20191), Tianjin Municipal Science and Technology Bureau Project (22JCQNJC01060, 22ZYJDSY00110).

Author contribution

Z.Z. and W.L.: data collections, data analysis, and writing; J.M.: data collections and data analysis; X.M.: data analysis and writing.

Conflicts of interest disclosure

The authors declare that there are no conflicts of interest.

Guarantor

Xinlong Ma.

Research registration unique identifying number (UIN)

None.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

None.

Zhihu Zhao and Wei Luo contributed equally to this article and should be listed as co-first authors.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 29 May 2024
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Reference

1 Lei C Chen H Zheng S . The efficacy and safety of hydrotherapy in patients with knee osteoarthritis: a meta-analysis of randomized controlled trials. Int J Surg 2024;110 :1711–1722.38051935
