Early High-Intensity Versus Low-Intensity Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial

Resistance training in patients with total knee arthroplasty: A systematic review and meta-analysis

Background

Though popular after joint replacement surgery, progressive resistance training (PRT) has controversial safety and efficacy claims. Therefore, PRT's effect on early postoperative muscle strength and functional capacity following total knee arthroplasty (TKA) must be thoroughly investigated. Between May 12, 2020, and February 12, 2002, the Cochrane Library, Web of Science, and Medline databases containing pertinent literature were thoroughly reviewed for this investigation.

Methods

Out of 704 studies, 9 (TKA) met inclusion criteria for meta-analysis, involving 1021 adult patients. The analysis encompassed various post-TKA indicators at 1, 3, and 12 months, including the 6-Minute Walk Test (6-WMT), Stair Climbing Performance (SCP), leg extension strength, Timed Up and Go Test (TUG), and Sit-to-Stand (ST) repetitions.

Results

In TKA patients, 6-WMT within 1 month (95 % CI = -0.41, 1.53), 3 months (95 % CI = -0.27, 0.76), and 12 months (95 % CI = -0.29, 0.66) did not show any significant differences. There were no discernible changes in ST at various time intervals, SCP, leg extension strength, and TUG at 1 month (95 % CI = -1.75, 0.77), 3 months (95 % CI = -0.48, 0.33), and 12 months (95 % CI = -0.44, 0.35). There was no statistical difference in the incidence of adverse events between the two groups (95 % CI = -0.01, 0.10).

Conclusion

Early post-TKA PRT demonstrated no significant differences compared to Standard Rehabilitation (SR) regarding functional capacity, muscle strength recovery, and adverse event incidence. Therefore, PRT is a feasible option for promoting swift recovery post-total knee arthroplasty.

Predictors for the Knee Extension Strength at 2 Yrs After Total Knee Arthroplasty Using Regression Tree Analysis

OBJECTIVE

The aim of the study is to clarify the interactive combinations of clinical factors associated with knee extension strength 2 yrs after total knee arthroplasty.

DESIGN

A retrospective cohort study was conducted on 264 patients who underwent total knee arthroplasty. Knee extension strength was assessed preoperatively, 3 wks, and 2 yrs after total knee arthroplasty. Physical functions were measured with 10-m walking test, Timed Up and Go test, one-leg standing time, isometric knee flexion strength, knee joint stability, knee pain, femora-tibial angle, and passive knee extension and flexion angle before surgery as a baseline and 3 wks after total knee arthroplasty as acute phase. Regression tree analysis was conducted to clarify the interactive combinations that accurately predict the knee extension strength 2 yrs after total knee arthroplasty.

RESULTS

Operational side knee extension strength (>1.00 Nm/kg) at acute phase was the primal predictor for the highest knee extension strength at 2 yrs after total knee arthroplasty. Acute phase Timed Up and Go test (≤10.13 secs) and baseline 10-m walking test (≤11.72 secs) was the second predictor. Acute phase nonoperative side knee extension strength (>0.90 Nm/kg) was also selected as the predictor.

CONCLUSIONS

This study demonstrated that knee extension strength or Timed Up and Go test in the acute phase and 10-m walking test before total knee arthroplasty are useful for estimating the knee extension strength after total knee arthroplasty. The results will help determine specific postoperative rehabilitation goals and training options.

Cost and outcomes of Hospital-based Usual cAre versus Tele-monitor self-directed Rehabilitation (HUATR) in patients with total knee arthroplasty: A randomized, controlled, non-inferiority trial

OBJECTIVE

To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA).

DESIGN

In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points).

RESULTS

In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs.

CONCLUSIONS

In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup.

The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

High-Intensity Progressive Rehabilitation Versus Routine Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

This study aimed to compare the effectiveness of high-intensity progressive rehabilitation training with routine training in the early treatment of patients undergoing total knee arthroplasty.

METHODS

There were 78 patients who underwent total knee arthroplasty and were randomized into high-intensity progressive training and routine rehabilitation training groups (RRT). The primary outcome measures were the American Hospital for Special Surgery Knee Score (HSS), with secondary outcomes including patient satisfaction, visual analog pain score, first time of standing after surgery, 6-minute walk test, 36-Item Short Form Survey (SF-36), and length of hospital stay. The incidence of postoperative complications were recorded.

RESULTS

The HSS scores were higher in the intervention group at 2 weeks, 3 months, and 12 months postoperatively (P < .001). The RRT group had higher visual analog pain scores than the intervention group at 24 hours, 3 days, and 2 weeks after surgery (P < .001). The intervention group had an earlier the first time of standing after surgery and a longer 6-minute walk test distance (P < .001, P = .028, P < .001, P < .001). Patient satisfaction was higher in the intervention group, with a higher quality of life rating at 3 months postoperatively (P < .001). However, 1 year after surgery, the 2 groups had no significant differences in mental component summaries. The length of hospital stay was shorter in the intervention group than in the RRT group.

CONCLUSION

Compared to routine training, high-intensity progressive rehabilitation training is more effective. It reduces postoperative patient pain, accelerates recovery of joint function, increases patient satisfaction, improves quality of life, shortens hospital stays, and promotes rapid recovery.

[SOG-Special Orthopedic Geriatrics : First interim results of a randomized controlled study on integrated orthogeriatric care in elective hip and knee arthroplasty]

BACKGROUND

To date, there are no adequate care concepts for geriatric patients undergoing elective orthopaedic surgery in Germany. The Special Orthopaedic Geriatrics (SOG) study evaluates for the first time in Germany the impact of comprehensive orthogeriatric co-management on the outcome of elderly patients with elective hip and knee replacements compared to standard orthopaedic care.

METHODS

The interim analysis of the ongoing study included 174 patients; 87 patients were randomized to the intervention group and 87 to the control group. The SOG care model consists of screening, preoperative assessment with preoperative intervention, fast-track surgery and multimodal perioperative care in the orthogeriatric team. The control group received standard orthopaedic care. Mobility, complications, and patient-reported outcome measures after surgery were compared.

RESULTS

The SOG group showed a clinically relevant improvement in mobility postoperatively compared to the control group at all time points (p < 0.01). The evaluation of complications showed a significant risk reduction for minor complications (p < 0.01), as well as a clear trend towards a risk reduction for major complications. Patient-reported outcome measures showed a significant improvement in joint function and general health-related quality of life both in the SOG group and the control group.

CONCLUSION

Integrated orthogeriatric care models such as SOG could improve the care of geriatric patients in elective orthopaedic surgery in the future and, above all, make it safer.

Enhanced recovery after surgery combined with quantitative rehabilitation training in early rehabilitation after total knee replacement: a randomized controlled trial

BACKGROUND

The number of patients undergoing total knee replacement (TKR) is increasing yearly; however, there is still a relative lack of specific, individualized, and standardized protocols for functional exercise after TKR. Quantitative rehabilitation training was developed to improve the recovery of postoperative joint function, increase patient satisfaction, shorten the length of the hospital stay, improve the quality of life, and promote rapid patient recovery.

AIM

We aimed to compare the effectiveness of quantitative rehabilitation training based on the enhanced recovery after surgery (ERAS) concept with conventional rehabilitation training in the early rehabilitation of patients with TKR.

DESIGN

This was a single-centre, prospective, randomized controlled trial.

SETTING

Inpatient department.

POPULATION

Participants were patients who underwent unilateral total knee replacement.

METHODS

Based on the ERAS concept, a quantitative rehabilitation training program was developed for the quantitative group, and the control group underwent conventional rehabilitation training. Seventy-eight patients undergoing TKR were randomly divided into two blinded groups: the quantitative rehabilitation group and the conventional rehabilitation group. The analysis was performed according to per-protocol practice. The primary outcome metric was the Hospital for Special Surgery Knee Score (HSS Score), and secondary outcomes included patient satisfaction, Visual Analog Pain Score (VAS), time to get out of bed for the first time after surgery, 6-minute-walk test (6MWT), quality-of-life score (SF-36), and number of days in the hospital. The incidence of postoperative complications was also recorded.

RESULTS

There was no significant difference in HSS scores between the two groups before surgery (P=0.967), but the quantitative rehabilitation training group had significantly higher scores at two weeks (P=0.031), 3 months (P<0.01), and 12 months (P<0.01) after surgery than did the conventional rehabilitation training group, and both groups had higher HSS scores than before surgery. The quantitative training group had significantly higher VAS scores at 24 hours and three days postoperatively than the conventional training group (P<0.01), while there was no statistical significance at any other time points. The quantitative rehabilitation group had an earlier time to get out of bed for the first time after surgery (P<0.01), a longer 6MWT distance (P=0.028), and higher patient satisfaction and quality of life scores (SF-36) (P<0.01) that did the control group. The number of days in the hospital was lower in the quantitative training group than in the control group (P<0.001). There was no significant difference in the incidence of postoperative complications between the two groups.

CONCLUSIONS

Compared with conventional rehabilitation training, quantitative rehabilitation training based on the ERAS concept was found to be safe and effective and can accelerate the recovery of joint function after surgery, shorten hospitalization time, improve patient satisfaction, and promote rapid recovery.

CLINICAL REHABILITATION IMPACT

The quantitative rehabilitation training based on the ERAS concept provides a new program for rehabilitation exercises after total knee arthroplasty, which is safe and reliable, accelerates the recovery of joint function, and should be considered for clinical promotion.

Responsiveness of Isokinetic Dynamometry in Patients with Osteoarthritis after Knee and Hip Arthroplasty: A Prospective Repeated-Measures Cohort Study

Functional assessments are crucial for the evaluation of rehabilitation after total knee (TKA) and hip (THA) arthroplasty. Muscle strength, a key determinant of physical function (PF), is often measured with isokinetic dynamometry (ID), which is considered the gold standard. However, studies lack evaluations of responsiveness-the ability to detect changes over time. This study aims to determine the responsiveness of ID in measuring PF in TKA and THA rehabilitation-is muscle strength a valid indicator for assessing improvement in rehabilitation processes? The pre- and post-surgery PF of 20 osteoarthritis patients (age 55-82) was assessed, using ID, performance-based and self-reported measures. Responsiveness was evaluated by comparing the observed relationship of changes in ID and PF scores with the a priori defined expected relationship of change scores. While the performance-based and self-reported measures showed significant improvements post-surgery (Cohen's d [0.42, 1.05] p < 0.05), ID showed no significant differences. Moderate correlations were found between changes in some ID parameters and selected functional tests (r ≈|0.5|, p < 0.05). Responsiveness was solely found for the peak torque of knee extension at 180°/s on the operated side. Responsiveness is an often-overlooked psychometric property of outcome measurements. The findings suggest that ID may not be fully responsive to the construct of PF after TKA and THA, raising questions about its role and usefulness in this context and the need for more appropriate assessment methods.

Perioperative nursing care for hip arthroplasty patients with concomitant hypertension: A minireview

Hip replacement (HA) is mainly indicated for the elderly, who generally suffer from various underlying diseases such as hypertension. This article provides a review of the key points of perioperative nursing care for patients with hypertension undergoing HA. It analyzes the key points of care during the perioperative period (preoperative, intraoperative, and postoperative) and proposes directions for the development of perioperative nursing care for HA. The prognosis for patients can be improved through the modification of traditional medical approaches and the application of new technologies and concepts.

Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation

Background

The place of tonsillectomy in the management of sore throat in adults remains uncertain.

Objectives

To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways.

Design

This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation.

Setting

The study took place at 27 NHS secondary care hospitals in Great Britain.

Participants

A total of 453 eligible participants with recurrent sore throats were recruited to the main trial.

Interventions

Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity.

Main outcome measures

The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms.

Results

There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it.

Limitations

The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial.

Conclusions

The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective.

Trial registration

This trial is registered as ISRCTN55284102.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.

Distal Femur Megaprostheses in Orthopedic Oncology: Evaluation of a Standardized Post-Operative Rehabilitation Protocol

BACKGROUND AND OBJECTIVES

Megaprostheses are the most used reconstructive approach for patients who have undergone massive resection of their distal femurs due to bone tumors. Although the literature about their outcomes has flourished in recent decades, to date, a consensus on rehabilitative treatment is yet to be established. In this study, we report on our experience with our latest standardized rehabilitation program, evaluating our results in a mid-to-long-term scenario.

MATERIALS AND METHODS

We evaluated the functional results of all our oncologic patients treated between 2016 and 2022 who could follow our standardized post-operative rehabilitative approach, consisting of progressive knee mobilization and early weight-bearing.

RESULTS

Sixteen cases were included in our study. The average duration of the patients' hospitalization was 12.2 days. A standing position was reached on average 4.1 days after surgery, while assisted walking was started 4.5 days after surgery. After a mean post-operative follow-up of 46.7 months, our patients' mean MSTS score was 23.2 (10-30). Our data suggest that the sooner patients could achieve a standing position (R = -0.609; p = 0.012) and start walking (R = -0.623; p = 0.010), the better their final functional outcomes regarding their MSTS scores.

CONCLUSIONS

Rehabilitation should be considered a pivotal factor in decreeing the success of distal femur megaprosthetic implants in long-surviving oncologic patients. Correct rehabilitation, focused on early mobilization and progressive weight-bearing, is crucial to maximizing the post-operative functional outcomes of these patients.

Effect of Femoral Nerve Block with Different Concentrations of Chloroprocaine on Early Postoperative Rehabilitation Training After Total Knee Arthroplasty

BACKGROUND Patients experience severe pain in early postoperative rehabilitation after total knee arthroplasty (TKA). This study aimed to compare the effect of femoral nerve block with different concentrations of chloroprocaine on postoperative rehabilitation in patients with TKA. MATERIAL AND METHODS Ninety patients who only received unilateral TKA were randomly and equally divided into C1 (1% chloroprocaine 0.2 ml/kg), C2 (2% chloroprocaine 0.2 ml/kg), or NS (0.9% sodium chloride solution 0.2 ml/kg) groups. The patients received rehabilitation 3 times a day on days 3-6 after surgery, and femoral nerve block was performed with corresponding solution 10 min before each training session. We recorded the maximum knee flexion angles (MKFA) and maximum knee extension angles (MKEA) during active exercise on day 7 after surgery, as well as the incidence of MKFA ³100°, American knee society (AKS) scores, and postoperative rehabilitation satisfaction. Adverse effects after administration in each group were also recorded. RESULTS Compared with group NS, patients in group C1 and C2 had larger MKFA during active exercise on day 7 after TKA, and had better rehabilitation satisfaction (P<0.05). MKEA, the incidence of MKFA ≥100°, and AKS scores showed no significant differences in the 3 groups. There were more patients with decline of muscle strength in group C2 (P<0.05), and no other adverse reactions were recorded. CONCLUSIONS Chloroprocaine for femoral nerve block can be safely used in rehabilitation after TKA and to improve the knee flexion angle in the early postoperative period. Because they may have fewer adverse effects, 1% chloroprocaine 0.2 ml/kg may be preferred.

Anterior knee pain and sit-up tests predicts patients' satisfaction and improvement in quality of life after anterior stabilized total knee replacement without patellar resurfacing

PURPOSE

The purpose of this study was to assess patient satisfaction and identify risk factors for dissatisfaction after anterior stabilised conventional total knee arthroplasty (TKA) without patellar resurfacing, using the Goodman score.

METHODS

We conducted a cross-sectional study using data from our institutional database from 1 January 2018 to 1 March 2021. Patients who underwent TKA with the Vanguard® Cruciate Retaining Anterior Stabilized Knee System (Zimmer Biomet, Warsaw, Indiana, USA) without patellar replacement were included. Patients with other bearing surfaces (posterior stabilised or medial congruent) or diagnosed with infection or instability were excluded. Patients' reported outcomes, body mass index (BMI), passive range of motion, the timed up-and-go test, sit-up test, and algometry were assessed. Patients were also asked if they had anterior knee pain. Satisfaction was assessed using the Goodman scale, and logistic multivariate regression was used to identify variables associated with dissatisfaction and perceived improvement in quality of life.

RESULTS

A total of 131 TKA patients were included in the study. The median satisfaction score was 100 (interquartile range [IQR], 87.5 to 100), with the 75-point threshold at the 90th percentile according to Section A of Goodman. Section B of Goodman showed that 113 TKA patients (86.26%) reported "great improvement" or "more than I ever dreamed." Multivariate logistic regression revealed that anterior knee pain (OR 5.16, 95% CI 1.24 to 21.39), the sit-up test (OR 0.63, 95% CI 0.49 to 0.81), and BMI (OR 0.84, 95% CI 0.70 to 0.99) were significantly associated with patient dissatisfaction and a worse perceived improvement in quality of life. The receiver operating characteristics curve for the models had areas under the curve of 0.83 (95% CI 0.69 to 0.97) and 0.82 (95% CI 0.70 to 0.94), respectively.

CONCLUSION

Anterior stabilised TKA without patellar resurfacing can achieve 90% satisfaction and 86% improvement in quality of life. To improve these results, it is essential to prevent and treat anterior knee pain and enhance quadriceps strength.

LEVEL OF EVIDENCE

Level III (retrospective cohort study).

Do Interlimb Knee Joint Loading Asymmetries Persist throughout Stance during Uphill Walking Following Total Knee Arthroplasty?

The purpose of this study was to determine differences in total (TCF), medial compartment (MCF), and lateral compartment (LCF) tibiofemoral joint compressive forces and related muscle forces between replaced and non-replaced limbs during level and uphill walking at an incline of 10°. A musculoskeletal modeling and simulation approach using static optimization was used to determine the muscle forces and TCF, MCF, and LCF for 25 patients with primary TKA. A statistical parametric mapping repeated-measures ANOVA was conducted on knee compressive forces and muscle forces using statistical parametric mapping. Greater TCF, MCF, and LCF values were observed throughout the loading response, mid-stance, and late stance during uphill walking. During level walking, knee extensor muscle forces were greater throughout the first 50% of the stance during level walking, yet greater during uphill walking during the last 50% of the stance. Conversely, knee flexor muscle forces were greater through the loading response and push-off phases of the stance. No between-limb differences were observed for compressive or muscle forces, suggesting that uphill walking may promote a more balanced loading of replaced and non-replaced limbs. Additionally, patients with TKA appear to rely on the hamstrings muscle group during the late stance for knee joint control, thus supporting uphill walking as an effective exercise modality to improve posterior chain muscle strength.

Effects of strength training on functional ambulation following knee replacement: a systematic review, meta-analysis, and meta-regression

Strength training is recommended by the American Physical Therapy Association to improve muscle strength, mobility, and balance following knee replacement. Few studies have focused on the direct effects of strength training on functional ambulation, and potential dose-response relationships between strength training parameters and the effect remain unclear. The aim of this systematic review, meta-analysis, and meta-regression was to evaluate the effects of strength training on functional ambulation following knee replacement (KR). We also aimed to explore potential dose-response relationships between strength training parameters and performance in functional ambulation. A systematic literature search of eight online databases was performed on March 12, 2023, for randomized controlled trials evaluating the effects of strength training on functional ambulation by six-minute walk test (6MWT) or timed-up and go test (TUG) after KR. Data were pooled by random-effect meta-analyses and presented as weighted mean difference (WMD). A random-effect meta-regression was performed for four predetermined training parameters, namely, duration (weeks), frequency (sessions per week), volume (time per session), and initial time (after surgery) separately to explore dose-response relationships with WMD. Fourteen trials encompassing 956 participants were included in our study. Meta-analyses showed an improvement in 6MWT performance after strength training (WMD: 32.15, 95% CI 19.44-44.85) and a decrease in time to complete TUG (WMD: - 1.92, 95% CI - 3.43 to - 0.41). Meta-regression revealed a dose-response relationship only between volume and 6MWT, with a decreasing trend (P = 0.019, 95% CI - 1.63 to - 0.20). Increasing trends of improvement in 6MWT and TUG were observed with increasing training duration and frequency. A slight decreasing trend of improvement was observed in 6MWT with postponed initial time, while an opposite trend was observed in TUG. Based on existing studies, moderate-certainty evidence suggests that strength training could increase 6MWT distance, and low-certainty evidence shows that strength training could decrease the time to complete TUG after KR. Meta-regression results only suggested a dose-response relationship between volume and 6MWT with a decreasing trend.Registration: PROSPERO: CRD42022329006.

Health-related quality of life among patients with knee osteoarthritis in Guangzhou, China: a multicenter cross-sectional study

PURPOSES

To investigate health-related quality of life (HRQoL) of patients with knee osteoarthritis (KOA) in Guangzhou, China, and examine its association with selected sociodemographic characteristics as well as knee function.

METHODS

This multicenter cross-sectional study included 519 patients with KOA in Guangzhou from April 1 to December 30, 2019. Data on sociodemographic characteristics were obtained using the General Information Questionnaire. The disability was measured using the KOOS-PS, resting pain using the Pain-VAS, and HRQoL using the EQ-5D-5L. The association of selected sociodemographic factors, KOOS-PS and Pain-VAS scores with HRQoL (EQ-5D-5L utility and EQ-VAS scores) were analyzed using linear regression analyses.

RESULTS

The median (interquartile range [IQR]) of EQ-5D-5L utility and EQ-VAS scores were 0.744 (0.571-0.841) and 70 (60-80) respectively, lower than the average HRQoL in the general population. Only 3.661% of KOA patients reported no problems in all EQ-5D-5L dimensions, with Pain/Discomfort being the most frequently affected dimension (78.805%). The correlation analysis showed that the KOOS-PS score, Pain-VAS score and HRQoL were moderately or strongly correlated. Patients with cardiovascular disease, no daily exercise, and high KOOS-PS or Pain-VAS scores had lower EQ-5D-5L utility scores; and patients with body mass index (BMI) > 28 ,high KOOS-PS or Pain-VAS scores had lower EQ-VAS scores.

CONCLUSIONS

Patients with KOA had relatively low HRQoL. Various sociodemographic characteristics as well as knee function were associated with HRQoL in regression analyses. Providing social support and improving their knee function through methods such as total knee arthroplasty might be crucial to improve their HRQoL.

Neuromuscular electrical stimulation preserves muscle strength early after total knee arthroplasty: Effects on muscle fiber size

Loss of quadriceps strength after total knee arthroplasty (TKA) is most pronounced acutely but persists long-term, negatively impacting physical function in daily activities. Neuromuscular electrical stimulation (NMES) early after surgery is an effective adjuvant to standard of care rehabilitation (SOC) for attenuating strength loss following TKA, but the mechanisms whereby NMES maintains strength are unclear. This work aimed to determine the effects of early NMES on quadriceps strength and skeletal muscle fiber size 2 weeks after TKA compared to SOC. Patients scheduled for primary, unilateral TKA were enrolled and randomized into SOC (n = 9) or NMES plus SOC (n = 10) groups. NMES was started within 48 h of TKA, with 45-min sessions twice a day for 2 weeks. Isometric quadriceps strength was assessed preoperatively and 2 weeks following TKA. Vastus lateralis muscle biopsies of the involved leg were performed at the same time points and immunohistochemistry conducted to assess muscle fiber cross-sectional area and distinguish fiber types. Groups did not differ in age, body mass index, sex distribution, or preoperative strength. Both groups got weaker postoperatively, but the NMES group had higher normalized strength. After 2 weeks, the group receiving NMES and SOC had significantly greater MHC IIA and MHC IIA/IIX fiber size compared to SOC alone, with no group differences in MHC I fiber size. These results suggest that NMES mitigates early muscle weakness following TKA, in part, via effects on fast-twitch, type II muscle fiber size. This investigation advances our understanding of how adjuvant, early postoperative NMES aids muscle strength recovery.

Effectiveness and therapeutic validity of physiotherapeutic exercise starting within one year following total and unicompartmental knee arthroplasty for osteoarthritis: a systematic review

BACKGROUND

To determine the effectiveness and therapeutic validity of physiotherapeutic exercise after total and unicompartmental knee arthroplasty for osteoarthritis. It was hypothesized that interventions of high therapeutic validity result in superior functional recovery after total and unicompartmental knee arthroplasty versus interventions of low therapeutic validity.

METHODS

A systematic review incorporating a comprehensive database search of five major databases relevant to the topic was conducted. Randomized controlled trials were reviewed if they included studies that compared postoperative physiotherapeutic exercise with usual care or compared two types of postoperative physiotherapeutic interventions. All included studies were assessed for risk of bias (using the Cochrane Collaboration's tool) and therapeutic validity (using the Consensus on Therapeutic Exercise Training scale). The characteristics of the included articles and their results on joint and muscle function, functional performance, and participation were extracted.

RESULTS

Of the 4343 unique records retrieved, 37 articles were included. Six of them showed good therapeutic validity, suggesting low therapeutic validity in 31 studies. Three articles showed a low risk of bias, 15 studies scored some concerns for risk of bias and 19 studies scored high risk of bias. Only one article scored well on both methodological quality and therapeutic validity.

CONCLUSION

Due to heterogeneity of outcome measures and length of follow-up, as well as limited reporting of details of the physiotherapeutic exercises and control interventions, no clear evidence was found on effectiveness of physiotherapeutic exercises after total and unicompartmental knee arthroplasty. Homogeneity in intervention characteristics and outcome measures would enhance comparability of clinical outcomes between trials. Future studies should incorporate similar methodological approaches and outcome measures. Researchers are encouraged to use the Consensus on Therapeutic Exercise Training scale as a template to prevent insufficient reporting.

Surface electromyography characteristics of patients with anterior cruciate ligament injury in different rehabilitation phases

Background: Anterior cruciate ligament reconstruction (ACLR) is a common treatment for anterior cruciate ligament (ACL) injury. However, after ACLR, a significant proportion of patients do not return to pre-injury levels. Research on muscle function during movement has important implications in rehabilitation.

Methods: Sixty patients with unilateral ACL injury were recruited for this study and assigned into three groups: group A, individuals with an ACL injury before 6 months; group B, individuals with ACLR from 6 months to 1 year; and group C, individuals with ACLR 1 year later. Surface electromyography (SEMG) signals were collected from the bilateral rectus femoris (RF), vastus medialis (VM), vastus lateralis (VL), biceps femoris (BF), and semitendinosus (ST). The tasks performed during the experiment included straight leg raising (SLR) training at 30°, SLR training at 60°, ankle dorsiflexion, walking, and fast walking.

Results: In the maximum muscle strength test, the affected side of the BF in group A (199.4 ± 177.12) was significantly larger than in group B (53.91 ± 36.61, p = 0.02) and group C (75.08 ± 59.7, p = 0.023). In the walking test, the contralateral side of the RF in group B (347.53 ± 518.88) was significantly greater than that in group C (139.28 ± 173.78, p = 0.029). In the SLR training (60°) test, the contralateral side of the RF in group C (165.37 ± 183.06) was significantly larger than that in group A (115.09 ± 62.47, p = 0.023) and smaller than that in group B (226.21 ± 237.17, p = 0.046); In the ankle dorsiflexion training test, the contralateral side of the RF in group B (80.37 ± 87.9) was significantly larger than that in group C (45.61 ± 37.93, p = 0.046).

Conclusion: This study showed the EMG characteristics of patients with ACL injury helped to determine which muscle requires more training and which exercise model would be best suited for intervention.

The effect of a digital-assisted group rehabilitation on clinical and functional outcomes after total hip and knee arthroplasty-a prospective randomized controlled pilot study

BACKGROUND

The rising number of total hip and knee arthroplasties and the decreasing availability of physiotherapists require clinically and economically effective rehabilitation approaches. Therefore, the present pilot study investigated the effect of a novel digital-assisted individualized group rehabilitation program on clinical and functional outcomes after total hip and knee arthroplasty.

METHODS

In this randomized controlled pilot study, 26 patients undergoing total knee or hip replacement were randomly assigned to either the intervention group (IG, novel digital-assisted group therapy) or the control group (CG, standard postoperative physiotherapy currently carried out in Germany). The IG received the novel digital-assisted group therapy twice per week for a six-months period, while the CG received individual outpatient therapy depending on the prescription of the supervising physician. The number of therapy sessions was recorded. Moreover, subjective outcomes (EuroQol-5Dimensions (EQ-5D) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), functional outcome (30 s sit to stand test and timed up and go test (TUG)), as well as gait parameters were quantified preoperatively as well as at three and six months after surgery. Data were analyzed using an analysis of covariance with baseline-adjustment.

RESULTS

No patient-reported falls, pain, and hospital readmissions were recorded. On average, the IG received more therapy sessions. The clinical and functional outcomes were mainly not significantly different between groups at three- and six-months follow-up, but medium to large effect sizes for the differences in quality of life (EQ-5D) as well as pain, stiffness, and physical function (WOMAC), and TUG performance were observed in favor of the IG. However, the IG showed a higher variability of gait velocity after total joint replacement.

CONCLUSION

The digital-assisted rehabilitation had positive effects on quality of life, pain, stiffness, physical function, and TUG performance. Nevertheless, the therapy concept may be improved by adding exercises focusing on gait performance to reduce gait variability. The results indicate that the digital-assisted therapy concept is effective and safe. Therefore, a consecutive full-scaled randomized controlled clinical trial is recommended.

TRIAL REGISTRATION

This study was retrospectively registered on 14/02/2022 in the German Clinical Trial Register (DRKS00027960).

Rehabilitation approach in robot assisted total knee arthroplasty: an observational study

BACKGROUND

The purpose of this study is to evaluate the impact of total knee arthroplasty (TKA) with the aid of Navio Robot, comparing it with standard prosthetic surgery on the functional outcomes of patients after an intensive rehabilitation program.

METHOD

A case-control observational study was conducted on patients undergoing TKA for severe KOA. All patients underwent the same intensive hospital rehabilitation program of 14 daily sessions lasting 3 h. The following rating scales were administered: Numeric Rating Scale (NRS), Knee Society Score (KSS) and 12-Item Short Form Survey scale. Patient assessments were performed 1 week post-surgery (T0), 1 month post-surgery (T2), and 3 months post-surgery (T3). The primary outcomes were active knee extension and flexion and pain severity. The secondary outcomes were functional capacity and quality of life.

RESULTS

Using repeated measures ANOVA, we observed at T1 a statistically different difference for the treatment group compared to the control group about KSS (p < 0.05), pain (p < 0.05), and knee flexion (p < 0.05). No statistically significant difference between the two groups was observed for knee extension (p = 0.09) and the SF-12 scale (p = 0.52). At T2 instead, we observed a statistically significant difference for the treatment group compared to the control group as regards KSS (p < 0.05) and knee flexion (p < 0.05), while no statistically significant difference was observed for pain (p = 0.83), knee extension (p = 0.60), and the SF-12 scale (0.44).

CONCLUSIONS

Our study has demonstrated that robot-NAVIO assisted knee prosthesis surgery, associated with a specific intensive rehabilitation treatment, in the short and medium term, determines good pain control, better flexion recovery and a improvement of functional capacity.

Tibiofemoral compressive force during downhill walking in patients with primary total knee arthroplasty: A statistical parametric mapping approach

BACKGROUND

Downhill walking is a necessary part of daily life and an effective activity in post-operative rehabilitation following total knee arthroplasty. The purpose of this study was to determine differences in the behavior of total, medial, and lateral tibiofemoral compressive forces as well as knee extensor and flexor muscle forces between different limbs of patients with total knee arthroplasty (replaced, non-replaced) during downhill and level walking.

METHODS

Musculoskeletal modeling and simulation were implemented to determine muscle forces and tibiofemoral compressive forces in 25 patients with total knee arthroplasty. A 2 × 2 [Limb (replaced, non-replaced) × Slope (0°, 10°)] Statistical parametric mapping repeated measures analysis of variance was conducted on selected variables.

FINDINGS

Statistical parametric mapping did not identify any between-limb differences for compressive or muscle forces. Differences in joint compressive and muscle forces persisted throughout different intervals of stance-phase between level and downhill walking. Knee extensor muscle forces were distinctly greater during level walking for nearly all of stance phase. Knee flexor muscle force was greater during downhill walking for >60% of stance. Statistical parametric mapping did identify regions of significance between level and downhill walking that coincided temporally (near loading response and push off) with peak joint moment and joint compressive forces traditionally reported using discrete variable analyses.

INTERPRETATION

Downhill walking may be a safe and useful rehabilitation tool for post-knee arthroplasty rehabilitation that will not disproportionally load either the replaced or the non-replaced joint and where the quadriceps muscles can be strengthened during a gait-specific task.

Functional outcomes and length of stay with early and high-intensity rehabilitation after simultaneous bilateral total knee arthroplasty

BACKGROUND

Length of stay and functional outcomes after total knee arthroplasty (TKA) are related to the timing and intensity of post-operative rehabilitation.

OBJECTIVE

To determine the effectiveness of early and high-intensity rehabilitation after simultaneous bilateral TKA.

METHODS

Prospective cohort data of 156 patients (11 men and 145 women; average age 72.0 ± 5.6 years) who underwent simultaneous bilateral primary TKA were analyzed. The intervention group (n= 82) underwent a high-intensity rehabilitation (phase II) after early postoperative standard rehabilitation (phase I) between June 2019 and May 2021. The control group (n= 74) underwent a lower-intensity rehabilitation (phase II) after phase I rehabilitation between July 2017 and May 2019. The timed up-and-go (TUG) test, timed stair climbing test (SCT), 6-minute walk test, isometric knee extensor and flexor strength of both knees, knee flexion and extension range of motion, Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) for pain, stiffness, and functional levels, and the EuroQol five-dimension questionnaire were assessed preoperatively and 6 weeks after TKA.

RESULTS

The average length of hospital stay was shortened by 5.7 days (p< 0.001). Phase II rehabilitation started earlier in the intervention group than in the control group (7.7 ± 1.3 vs 13.5 ± 2.0, p< 0.001). Compared with the control group, the intervention group showed significant improvements in the measures of mobility (WOMAC-function and SCT) and strength (isometric strength of both knee extensors and flexors) 6 weeks after TKA by statistically controlling for age and preoperative functional status.

CONCLUSION

This study demonstrated that early and high-intensity rehabilitation could achieve functional improvement and shorten the length of hospital stay.

Effects of a home-based, exergaming intervention on physical function and pain after total knee replacement in older adults: a randomised controlled trial

Objectives

To investigate the effects of 4 months of customised, home-based exergaming on physical function and pain after total knee replacement (TKR) compared with standard exercise protocol.

Methods

In this non-blinded randomised controlled trial, 52 individuals aged 60-75 years undergoing TKR were randomised into an exergaming (intervention group, IG) or a standard exercising group (control group, CG). Primary outcomes were physical function and pain measured before and after (2 months and 4 months) surgery using the Oxford Knee Score (OKS) and Timed Up and Go (TUG) test. Secondary outcomes included measures of the Visual Analogue Scale, 10m walking, short physical performance battery, isometric knee extension and flexion force, knee range of movement and satisfaction with the operated knee.

Results

Improvement in mobility measured by TUG was greater in the IG (n=21) at 2 (p=0.019) and 4 months (p=0.040) than in the CG (n=25). The TUG improved in the IG by -1.9 s (95% CI, -2.9 to -1.0), while it changed by -0.6 s (95% CI -1.4 to 0.3) in the CG. There were no differences between the groups in the OKS or secondary outcomes over 4 months. 100% of patients in the IG and 74% in the CG were satisfied with the operated knee.

Conclusion

In patients who have undergone TKR, training at home with customised exergames was more effective in mobility and early satisfaction and as effective as standard exercise in pain and other physical functions. In both groups, knee-related function and pain improvement can be considered clinically meaningful.

Trial registration number

NCT03717727.

Rehabilitation for Total Knee Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral total knee arthroplasty for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. The team assessed strength of evidence. Evidence from 53 studies randomized controlled trials suggests that various rehabilitation programs after total knee arthroplasty may lead to comparable improvements in pain, range of motion, and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the postacute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period after total knee arthroplasty; risk of harms among various postacute rehabilitation programs seems comparable. All findings were of low strength of evidence. Evaluation of rehabilitation after total knee arthroplasty needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

Interval Time of at Least 6 Weeks Between Bilateral Total Knee Arthroplasties is Associated With Decreased Postoperative Complications

BACKGROUND

Staged, bilateral total knee arthroplasty (TKA) has an increased risk of complications if the second procedure is performed before physiologic recovery from the first. The aims of this study were to 1) determine whether there is a time-dependent relationship between TKA staging and rates of revisions and complications and 2) identify data-driven time intervals that reduce risk of revisions and complications.

METHODS

Data were collected from a national insurance database from 2015 to 2018. Staged intervals were initially assessed using fixed 6-week intervals. Stratum-specific likelihood ratio analyses were subsequently conducted to observe data-driven staging thresholds. Bivariate and multivariable regression analyses were conducted to determine the associations between the time intervals and 2-year rates of revision surgery and 90-day major complications. We included 25,527 patients undergoing staged bilateral TKA.

RESULTS

In comparison to the shortest fixed time interval (1-6 weeks), as the staging interval increased the odds of 2-year all-cause revision and 90-day major complications significantly decreased (P < .05 for all). Stratum-specific likelihood ratio analysis identified 3 data-driven staging categories 1-5, 6-17, and 18-24 weeks that maximized the difference in both 2-year rates of revision and 90-day major complications.

CONCLUSION

Our data showed a time-dependent relationship between the timing of TKA stages and complications. If staging is considered, a delayed interval of at least 6 weeks between procedures may significantly reduce revision and major complications.

LEVEL OF EVIDENCE

Level III Therapeutic Study.

Comparing "people-like-me" and linear mixed model predictions of functional recovery following knee arthroplasty

OBJECTIVE

Prediction models can be useful tools for monitoring patient status and personalizing treatment in health care. The goal of this study was to compare the relative strengths and weaknesses of 2 different approaches for predicting functional recovery after knee arthroplasty: a neighbors-based "people-like-me" (PLM) approach and a linear mixed model (LMM) approach.

MATERIALS AND METHODS

We used 2 distinct datasets to train and then test PLM and LMM prediction approaches for functional recovery following knee arthroplasty. We used the Timed Up and Go (TUG)-a common test of mobility-to operationalize physical function. Both approaches used patient characteristics and baseline postoperative TUG values to predict TUG recovery from days 1-425 following surgery. We then compared the accuracy and precision of PLM and LMM predictions.

RESULTS

A total of 317 patient records with 1379 TUG observations were used to train PLM and LMM approaches, and 456 patient records with 1244 TUG observations were used to test the predictions. The approaches performed similarly in terms of mean squared error and bias, but the PLM approach provided more accurate and precise estimates of prediction uncertainty.

DISCUSSION AND CONCLUSION

Overall, the PLM approach more accurately and precisely predicted TUG recovery following knee arthroplasty. These results suggest PLM predictions may be more clinically useful for monitoring recovery and personalizing care following knee arthroplasty. However, clinicians and organizations seeking to use predictions in practice should consider additional factors (eg, resource requirements) when selecting a prediction approach.

Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty

Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.

The preventive and therapeutic role of physical activity in knee osteoarthritis

The aim of this narrative review is to discuss the results of studies investigating the role of physical activity in knee osteoarthritis (OA). We also formulated two evidence-based exercise programs that could be prescribed to patients with symptomatic knee OA or after joint replacement. The PubMed and Google Scholar databases were searched for articles related to knee OA and physical activity. A total of 86 papers written in English and published from 1957 to 2021 were selected. Adapted physical activity, even at high intensity, does not appear to trigger or exacerbate knee OA; on the contrary, it may prevent obesity or lower limb muscle weakness, both of which are considered predisposing factors for the disease. In patients already diagnosed with knee OA, scientific evidence suggests that both land-based and aquatic activities combining aerobics, strength, and endurance programs are safe and effective. Physical interventions tailored to the patient may also accelerate recovery time after knee arthroplasty. Knee OA is a painful and disabling rheumatic disease that is very common in the elderly population. Pharmacotherapy has a modest effect in controlling disease progression, possibly due to the still limited understanding of OA pathogenesis. Non-pharmacologic interventions, including dietary and lifestyle changes and physical activity, may be more effective and safer than drugs in preventing or treating knee OA.

Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy.

Patient-Reported Quality of Life Before and After Total Knee Arthroplasty: A Multicenter Observational Study

PURPOSE

To compare patients' self-reported health-related quality of life (HRQoL) before and after total knee arthroplasty (TKA) and determine factors contributing to any heterogeneity in HRQoL.

PATIENTS AND METHODS

This prospective multicenter observational study included 404 patients with knee osteoarthritis who underwent TKA between April 1, 2019 and December 30, 2019 and whose HRQoL was assessed preoperatively and 7 days and 1, 3, and 6 months postoperatively. Sociodemographic characteristics were assessed using a General Information Questionnaire, disability using the Knee Injury and Osteoarthritis Outcome Score (KOOS-PS), resting pain using the visual analogue scale (Pain-VAS), and HRQoL using the European Quality of Life Five Dimension Five Level (EQ-5D-5L) scale. The growth mixture model was used to identify group heterogeneity in the developmental trajectories of KOOS-PS, Pain-VAS, and EQ5D5L. Logistic regression was used to explore the factors influencing the developmental trajectories of factors affecting the developmental trajectory of HRQoL.

RESULTS

The mean EQ-5D-5L score improved from 0.69 preoperatively to 0.90 at 6 months postoperatively. Longitudinal heterogeneity in HRQoL was observed in patients during recovery: 1) patients with a small and slow improvement in HRQoL and 2) patients who showed marked and rapid improvement in HRQoL. The main characteristics of the latter group were decreasing VAS pain scores, a monthly family income >2000 CNY (100 CNY equals approximately 14.9 USD), exercising for <30 min daily, and better knee function at baseline. Baseline knee function and change in knee function were significantly associated with the percentage change in HRQoL.

CONCLUSION

HRQoL improved considerably after TKA. However, there was heterogeneity in the changes in HRQoL depending on patients' socioeconomic status, exercise, and baseline knee function. Dynamic tracking of the HRQoL of TKA patients and timely provision of rehabilitation guidance will promote continuous improvement of the HRQoL of TKA patients.

Neighbors-based prediction of physical function after total knee arthroplasty

The purpose of this study was to develop and test personalized predictions for functional recovery after Total Knee Arthroplasty (TKA) surgery, using a novel neighbors-based prediction approach. We used data from 397 patients with TKA to develop the prediction methodology and then tested the predictions in a temporally distinct sample of 202 patients. The Timed Up and Go (TUG) Test was used to assess physical function. Neighbors-based predictions were generated by estimating an index patient's prognosis from the observed recovery data of previous similar patients (a.k.a., the index patient's "matches"). Matches were determined by an adaptation of predictive mean matching. Matching characteristics included preoperative TUG time, age, sex and Body Mass Index. The optimal number of matches was determined to be m = 35, based on low bias (- 0.005 standard deviations), accurate coverage (50% of the realized observations within the 50% prediction interval), and acceptable precision (the average width of the 50% prediction interval was 2.33 s). Predictions were well-calibrated in out-of-sample testing. These predictions have the potential to inform care decisions both prior to and following TKA surgery.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

Objective

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

Design: Scoping review

Literature search

A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

Study selection criteria

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

Data synthesis

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

Results

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

Conclusion

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

Pre-registration

OSF:https://osf.io/9ku8a/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04460-w.

What is the effect of supervised rehabilitation regime vs. self-management instruction following unicompartmental knee arthroplasty? - a pilot study in two cohorts

PURPOSE

The optimal rehabilitation strategy after a unicompartmental knee arthroplasty (UKA) is unclear. This study aims to compare the effect of transitioning from a supervised to a self-management rehabilitation regime by pilot study of patient outcomes subsequent to UKA surgery.

METHODS

Fifty consecutive patients scheduled to undergo unilateral UKA surgery at our institution between 22nd February 2016 and 18thof January 2017 were prospectively identified via local medical database and included. Performed UKAs were grouped into two cohorts, Supervised Cohort and Self-management Cohort, temporally separated by introduction of new rehabilitation. Self-management Cohort(n = 25) received an extensive inpatient rehabilitation regime along with outpatient referral to rehabilitation center. The Self-management Cohort(n = 25) were only instructed in use of crutches and free ambulation at own accord. Follow-up (F/U) was 1 year from receiving UKA. A range of outcomes were recorded, and between-cohort differences compared: knee joint range of motion, pain and functional limitations, length of stay (LOS), readmission rate, pain during activity and rest, and knee circumference.

RESULTS

Complete data was obtained for n = 45 patients. The mean between-cohort difference in ROM (range of motion) from preoperatively to discharge was 15.4 degrees (CI:5.2,25.8, p = 0.004), favoring the supervised regime, with no difference detected in any outcome at 3- or 12 months F/U. Median LOS was 1 day in both cohorts.

CONCLUSION

Transition to a simple rehabilitation regime following UKA surgery was associated with decreased ROM at discharge, which was not present at 3-month F/U. We found no other between-cohort differences for any other outcomes at 3- and 12-month F/U including functional limitations, although the study was likely underpowered for these outcomes. We encourage large-scale replication of these findings using randomized designs.

LEVEL OF EVIDENCE

Therapeutic level II.

Short-Term Effect of Peer Volunteers in Providing Inpatient Rehabilitative Exercises for Patients After Total Knee Arthroplasty

OBJECTIVE

To investigate the short-term outcomes at discharge of patients who receive additional postoperative rehabilitative exercises by peer volunteers after total knee arthroplasty (TKA).

DESIGN

Retrospective cohort study.

SETTING

Tertiary teaching hospital.

PARTICIPANTS

A total of 476 adult patients who had undergone a primary elective unilateral TKA (N=467).

INTERVENTIONS

An intervention group received a standardized postoperative rehabilitative exercise protocol taught and supervised by peer volunteers in additional to standard physiotherapy (n=309) compared with a control group receiving standard physiotherapy alone (n=167).

MAIN OUTCOME MEASURES

Discharge outcomes were the pain score using the Numeric Rating Scale pain score, passive knee flexion and extension range of motion (ROM), length of hospitalization, ability to perform an unassisted straight leg raise of the operated leg, ambulation distance, ability in independent walking, walking aids required, discharge destination, and adverse events.

RESULTS

On multivariate analysis, patients in the intervention group had an increased discharge passive knee flexion ROM of 7.89 degrees (95% confidence interval, 5.47-10.33; P<.001). There were no significant differences for the other outcome measures between the intervention and control group.

CONCLUSIONS

A rehabilitative exercise program by peer volunteers is feasible and safe after TKA in addition to standard physiotherapy and is associated with improved knee flexion ROM on discharge.

Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update

BACKGROUND

This article systematically summarizes the present evidences, published in the last 20 years, regarding the pre- and post-operative factors, which may influence recovery of the function of the quadriceps muscle group following total knee arthroplasty (TKA). We following the PRISMA methodology, including meta-analyses and high-level evidence studies (prospective trials, and, when unavailable, retrospective studies).

SOURCES OF DATA

Pubmed and Cochrane databases: 582 articles were identified and 54 of them were selected.

AREAS OF AGREEMENT

Tourniquets inflated at high pressure exert a detrimental effect on the quadriceps muscle group. Faster quadriceps recovery takes place using mini-invasive approaches, an eight-week rehabilitation period including balance training and the use of nutraceuticals.

AREAS OF DISAGREEMENT

Pre-habilitation and pre-operative factors, analgesic methods and different TKA implants.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Telerehabilitation seems a cost-effective tool for rehabilitation after TKA. Patients' optimization protocols before TKA should include standardized nutraceuticals intake.

Effects of dexmedetomidine on the function of distal organs and oxidative stress after lower limb ischaemia-reperfusion in elderly patients undergoing unilateral knee arthroplasty

Aims

This study aims to evaluate the effects of dexmedetomidine on organ function, inflammation response, and oxidative stress in elderly patients following iatrogenic lower limb ischaemia–reperfusion (IR) during unilateral total knee arthroplasty.

Methods

Following unilateral total knee arthroplasty, 54 elderly patients were randomized to receive either intraoperative intravenous injection of dexmedetomidine (n = 27) or equivalent volume of 0.9% saline (n = 27). Blood samples were harvested at 5 minutes before lower limb tourniquet release (baseline); and 1, 6 and 24 hours after tourniquet release. Surrogate markers of cardiac, pulmonary, hepatic and renal function, oxidative stress, inflammatory response, along with parasympathetic and sympathetic activity were recorded and analysed.

Results

The levels of blood xanthine oxidase, creatine kinase, lactic acid and respiratory index increased in patients following tourniquet‐induced lower limb IR injury. Dexmedetomidine administration decreased the respiratory index (P = .014, P = .01, and P = .043) and the norepinephrine level (P < .001) at 1, 6 and 24 hours; and decreased the xanthine oxidase level (P = .049, P < .001) at 6 and 24 hours after tourniquet release compared with the Control group. Other measurements, including creatine kinase isoenzyme, lactate dehydrogenase, creatinine, urea nitrogen, glutamic–oxalacetic transaminase, glutamic–pyruvic transaminase, malondialdehyde, interleukin‐1, interleukin‐6 and tumour necrosis factor‐α, were not statistically significantly different between the 2 groups.

Conclusions

Intraoperative dexmedetomidine administration in elderly patients dampens the deterioration in respiratory function and suppresses the oxidative stress response in elderly patients following iatrogenic lower limb IR injury.

Effects of progressive resistance training for early postoperative fast-track total hip or knee arthroplasty: A systematic review and meta-analysis

Progressive resistance training (PRT) is one of the most commonly used exercise methods after joint replacement, while its effectiveness and safety are still controversial. Therefore, it's vital to investigate the effect of PRT on muscle strength and functional capacity early postoperative total hip arthroplasty (THA) or total knee arthroplasty (TKA). Relevant studies were identified via a search of Medline, Web of science and Cochrane Library from 2002 to 12 May 2020. Fifteen of 704 studies which comprised 6 THAs and 8 TKAs, involving 1021 adult patients were eligible for inclusion in the meta-analysis. There were no significant differences between the two groups after TKA in the 6-min walk test (6-WMT) within 1 month (95% CI = -0.41, 1.53), within 3 months (95% CI = -0.27, 0.76), within 12 months (95% CI = -0.29, 0.66); climb performance in seconds (s) (SCP), leg extension power, timed up and go test in seconds (s) (TUG) within 1 month (95% CI = -1.75, 0.77), within 3 months (95% CI = -0.48, 0.33), within 12 months (95% CI = -0.44, 0.35), sit to stand, number of repetitions in 30s (ST). There was no difference in the incidence of adverse events (95% CI = -0.01, 0.10). Similarly, two groups were also no obvious distinction after THA in the 6-WMT, SCP, Leg extension power, ST. PRT early after THA or TKA did not differ significantly from SR in terms of functional capacity, muscle strength recovery and incidence of adverse events. PRT is one of the options for rapid rehabilitation after joint replacement.

Recovery trajectories over six weeks in patients selected for a high-intensity physiotherapy program after Total knee Arthroplasty: a latent class analysis

Background

Recovery trajectories differ between individual patients and it is hypothesizes that they can be used to predict if an individual patient is likely to recover earlier or later. Primary aim of this study was to determine if it is possible to identify recovery trajectories for physical functioning and pain during the first six weeks in patients after TKA. Secondary aim was to explore the association of these trajectories with one-year outcomes.

Methods

Prospective cohort study of 218 patients with the following measurement time points: preoperative, and at three days, two weeks, six weeks, and one year post-surgery (no missings). Outcome measures were performance-based physical functioning (Timed Up and Go [TUG]), self-reported physical functioning (Knee injury and Osteoarthritis Outcome Score-Activities of Daily Living [KOOS-ADL]), and pain (Visual Analogue Scale [VAS]). Latent Class Analysis was used to distinguish classes based on recovery trajectories over the first six weeks postoperatively. Multivariable regression analyses were used to identify associations between classes and one year outcomes.

Results

TUG showed three classes: “gain group” (n = 203), “moderate gain group” (n = 8) and “slow gain group” (n = 7), KOOS showed two classes: “gain group” (n = 86) and “moderate gain group” (n = 132), and VAS-pain three classes: “no/very little pain” (n = 151), “normal decrease of pain” (n = 48) and “sustained pain” (n = 19). The” low gain group” scored 3.31 [95% CI 1.52, 5.09] seconds less on the TUG than the “moderate gain group” and the KOOS “gain group” scored 11.97 [95% CI 8.62, 15.33] points better than the “moderate gain group” after one year.

Patients who had an early trajectory of “sustained pain” had less chance to become free of pain at one year than those who reported “no or little pain” (odds ratio 0.11 [95% CI 0.03,0.42].

Conclusion

The findings of this study indicate that different recovery trajectories can be detected. These recovery trajectories can distinguish outcome after one year.

Comparison of two different models of rehabilitation programs following total knee replacement operations

Background

Total knee replacement operation (TKR) is the treatment of choice in severe knee osteoarthritis (OA). Rehabilitation post-TKR is still not well studied. The aim of this study was to compare between the high-intensity (HI) rehabilitation program and the low-intensity (LI) rehabilitation program following TKR.

Results

At 1 month following the TKR operations, significant improvements were found in the first group compared to the second group in all the measured parameters except for the knee range of motion (ROM). At 3 and 12 months follow-up periods, there were statistically significant differences between both groups in all the evaluated parameters except for the numeric pain rating scale and the knee ROM.

Conclusions

Both high-intensity and low-intensity rehabilitation programs are effective; however, HI program had superior functional gain and patient-reported outcomes compared to the LI program. Moreover, HI group has a long-term functional gain.

Psychometric properties of the 4-meter walk test after total knee arthroplasty

OBJECTIVE

To determine the reliability, responsiveness, and convergent validity of the Four-Meter Walk Test (4mWT) compared to the Six-Minute Walk Test (6MWT) surrounding total knee arthroplasty (TKA).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Research laboratory.

PARTICIPANTS

One hundred sixty-two patients (aged 63.5 ± 7.4 (mean ± sd) years; 89 females) undergoing TKA participated.

MAIN OUTCOME MEASURES

4mWT (usual and fastest) and 6MWT were measured 1-2 weeks preoperatively, and 1, 2, 3, 6 and 12 months post-operatively.

RESULTS

4mWT demonstrated excellent test-retest reliability with Interclass Correlation Coefficients (ICC's) ranging from 0.80 to 0.93 s. 4mWT also demonstrated small measurement error with Standard Error of Measurement (SEM) ranging from 0.15 to 0.35 s. 4mWT (fastest) demonstrated similar responsiveness to 6mWT in the first 2 months after surgery and better responsiveness from 2 to 3 months after surgery. Convergent validity between 6MWT and 4mWT (fastest) was high, with Pearson correlation coefficients ranging from 0.73 to 0.81.

CONCLUSIONS

The 4mWT (fastest) has excellent test-retest reliability, shows high responsiveness sufficient for clinical outcomes in the immediate postoperative time periods, and exhibits high convergent validity with 6MWT. Given space and time requirements to conduct each test, 4mWT may be preferred for routine clinical assessment.IMPLICATIONS FOR REHABILITATIONWalking ability•Walking is an important functional ability for patients who undergo total knee arthroplasty (TKA).•While the Six-Minute Walk Test is a validated measure of walking ability in the TKA population, its clinical utility is limited by the space and time it takes to perform the test.•The Four-Meter Walk Test (fastest speed) is a valid, reliable, and responsive alternative to the 6MWT and is recommended for routine clinical use after TKA.

Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial

Importance

Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA).

Objective

To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol.

Design, Setting, and Participants

This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019.

Interventions

The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation.

Main Outcomes and Measures

Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy.

Results

Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60).

Conclusions and Relevance

This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02426190.

Effectiveness of early high-intensity balance training for early home life independence after total knee arthroplasty: a pseudo-randomized controlled trial

OBJECTIVE

In Japan, the number of elderly individuals living alone is increasing, leading to an increase in hospital medical expenses attributed to total knee arthroplasty (TKA). Improvement in balance and functional performance is a priority in the early postoperative stages after TKA. However, there are no reports on the effectiveness of balance training (BT) for inpatients in the early postoperative period. Thus, we aimed to evaluate the effectiveness of early high-intensity BT for early home-life independence after TKA.

METHOD

This pseudo-randomized controlled trial included 49 inpatients who underwent TKA and had osteoarthritis. Inpatients were categorized into the BT or typical training (TT) group. The BT program began on post-TKA day 4, with 12-14 sessions between day 7 and 10 (i.e., 1-2 sessions per day). The effect of the intervention was assessed using balance ability as the main outcome. Sub-outcomes included evaluation of motion function. The differences in each variable before and after intervention were compared, including covariance analysis adjusted for age and sex.

RESULTS

The mean (standard deviation) balance ability indexes in the left and right directions were BT, pre 4.5 (0.8) and post 4.4 (0.8); TT, pre 4.8 (0.9) and post 4.4 (0.8), and those in the forward and backward directions were BT, pre 4.7 (1.7) and post 5.1 (2.1); TT, pre 6.3 (2.6) and post 5.9 (2.0). No significant differences were found between the preoperative and postintervention scores in the two groups for any measured outcome.

CONCLUSION

BT did not appear to improve balance ability or functional performance.

Efficacy and Safety of Lower Limb Progressive Resistance Exercise for Patients With Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy and safety of progressive resistance exercise (PRE) for patients with total knee arthroplasty (TKA) in a meta-analysis.

DATA SOURCES

PubMed, MEDLINE, Cochrane's Library, and EMBASE databases.

STUDY SELECTION

Randomized controlled trials evaluating the effect of PRE on mobility and function in patients with TKA.

DATA EXTRACTION

A random-effects model was applied if significant heterogeneity was detected; otherwise, a fixed-effects model was applied.

DATA SYNTHESIS

Seven randomized controlled trials. Compared with a rehabilitation program without PRE, physiotherapy including PRE was associated with improvements in the 6-minute walking test (weighed mean difference [WMD], 19.22m; P=.04) with a wide confidence interval (CI, 0.48∼37.95). However, sensitivity analysis by omitting 1 study with preoperative rehabilitation revealed nonsignificant results (WMD, 15.15m; P=.16). Moreover, PRE did not significantly improve the maximal walking speed (WMD, 0.05m/s, 95% CI, 0.00∼0.11; P=.05). However, PRE was associated with improved knee strength of extension (standardized mean difference [SMD], 0.72; 95% CI, 0.47∼0.96; P<.001) and flexion (SMD, 0.47; 95% CI, 0.19∼0.74; P<.001) but not self-reported physical function (SMD, -0.17; 95% CI, -0.37∼0.03; P=.10) or changes in pain score (SMD, 0.11; 95% CI, -0.15∼0.37; P=.40). PRE did not increase the risk of adverse events (risk ratio, 1.19; 95% CI, 0.52∼2.71; P=.68).

CONCLUSIONS

PRE may lead to improvements in physical function among patients receiving a TKA. PRE leads to higher ultimate strength in the surgical knee and is safe to perform.

Physical Therapist Management of Total Knee Arthroplasty

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

Return to Sport after Anatomic and Reverse Total Shoulder Arthroplasty in Elderly Patients: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the rate of return to sport in elderly patients who underwent anatomic (ATSA) and reverse (RTSA) total shoulder arthroplasty, to assess postoperative pain and functional outcomes and to give an overview of postoperative rehabilitation protocols. A systematic search in Pubmed-Medline, Cochrane Library, and Google Scholar was carried out to identify eligible randomized clinical trials, observational studies, or case series that evaluated the rate of return to sport after RTSA or ATSA. Six retrospective studies, five case series, and one prospective cohort study were included in this review. The overall rate of return to sport was 82% (95% CI 0.76–0.88, p < 0.01). Patients undergoing ATSA returned at a higher rate (90%) (95% CI 0.80–0.99, p < 0.01) compared to RTSA (77%) (95% CI 0.69–0.85, p < 0.01). Moreover, the results showed that patients returned to sport at the same or a higher level in 75% of cases. Swimming had the highest rate of return (84%), followed by fitness (77%), golf (77%), and tennis (69%). Thus, RTSA and ATSA are effective to guarantee a significative rate of return to sport in elderly patients. A slightly higher rate was found for the anatomic implant.