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Huang G, Su B, Liang C. Letter to the editor concerning "Effect of joint immobilization using extension splint immediately after total knee arthroplasty on post-operative knee function and pain: a randomized clinical trial". INTERNATIONAL ORTHOPAEDICS 2023; 47:893-894. [PMID: 36547702 DOI: 10.1007/s00264-022-05667-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Guilan Huang
- Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, 214515, Jiangsu, China
| | - Bin Su
- Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, 214515, Jiangsu, China
| | - Chengpan Liang
- Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, 214515, Jiangsu, China.
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Kaseb MH, Moharrami A, Mirghaderi SP, Fallah E, Razzaghof M, Moazen Jamshidi MM, Poopak A, Mortazavi SMJ. Effect of joint immobilization using extension splint immediately after total knee arthroplasty on post-operative knee function and pain: a randomized clinical trial. INTERNATIONAL ORTHOPAEDICS 2022; 46:1749-1759. [PMID: 35587284 DOI: 10.1007/s00264-022-05428-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/01/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Investigate the effect of semirigid extension bracing after total knee arthroplasty (TKA) on articular pain and function. METHODS The present randomized clinical trial included 72 patients undergoing unilateral primary TKA. Patients in the case group received eight days of post-operative semirigid extension-locked knee bracing, whereas controls did not. The outcomes assessed preoperatively and on the first, ninth, 30th day, and one year post-operatively included the knee society score (KSS), functional KSS (FKSS), VAS pain score, amount of postoperative opiate painkiller usage (tablet oxycodone 5mg), and knee ROM. RESULTS The case group had a significantly lower flexion ROM on postoperative day nine compared to the control group (95.3° vs. 100.8°, p=0.03), while it became significantly higher 1 month (114.1° vs. 104.7°, p=0.03) and one year post-operative (128.0° vs. 120.5°, p=0.002). Also, FKSS was significantly higher in the case group than in the controls in the one month post-operative assessment (37.0 vs. 32.6, p=0.009) but not in the one year post-operative assessment. The case group patients had a significantly lower pain than the controls on days one (5.8 vs. 7.2, p=0.02) and nine post-operative (4.1 vs. 5.2, p=0.048), but not at later assessments. The amount of one month post-operative opium (oxycodone) consumption was significantly lower in the brace group (12.4 vs. 14.1 tablets, p=0.03). The KSS were not significantly different between the groups after the surgery. CONCLUSION Extension-locked splinting immediately after TKA is a noninvasive, non-pharmacological, and inexpensive intervention with possible promising effects on knee ROM, short-term functional improvement, and acute post-operative pain management.
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Affiliation(s)
- Mohammad Hasan Kaseb
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | - Alireza Moharrami
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | | | - Ehsan Fallah
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
| | | | - Amirhossein Poopak
- Joint Reconstruction Research Center, Tehran University Of Medical Sciences, Tehran, Iran
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Wang HY, Yu GS, Li JH, Zhang SX, Lin YB. An updated meta-analysis evaluating limb management after total knee arthroplasty-what is the optimal method? J Orthop Surg Res 2019; 14:97. [PMID: 30971262 PMCID: PMC6457036 DOI: 10.1186/s13018-019-1140-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 03/28/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose Postoperative knee flexion protocol has been widely recognized as a highly attractive, simple, and cost-effective tactic to improve patient’s outcomes after primary total knee arthroplasty (TKA). However, optimal knee position and duration of knee flexion are still controversial. The purpose of this meta-analysis was to compare the effectiveness of different postoperative knee flexion protocols, as an aid to find out optimal limb management strategy following TKA. Methods We conducted a meta-analysis to identify the available and relevant randomized controlled trials (RCTs) with regard to the influence of different postoperative knee positions on clinical outcomes after primary TKA in electronic databases, including PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI, Wanfang Med Online, and VIP, up to May 2018. In this meta-analysis, three major subgroups based on diverse postoperative knee flexion protocols were considered: long-term (≥ 24 h) high flexion (> 30°), short term (< 24 h) high flexion (> 30°), and long-term (≥ 24 h) mild flexion (≤ 30°). The statistical analysis was performed using the Review Manager (RevMan) version 5.3 software. Results A total of 16 trials were finally included in this meta-analysis. The result of subgroup analysis indicated that keeping the knee in high flexion (> 30°) postoperatively for a long time (≥ 24 h) significantly reduced total blood loss (P < 0.00001), hidden blood loss (P < 0.00001), and transfusion requirements (P = 0.003) and led to a significant improvement in range of motion (ROM) at 1 week after operation (P < 0.00001); keeping the knee in high flexion (> 30°) postoperatively for a short time (< 24 h) significantly reduced total blood loss (P = 0.006) and hidden blood loss (P < 0.00001) but not significantly improved ROM at 1 week after operation (P = 0.34) and reduced transfusion requirements (P = 0.62); and keeping the knee in mild flexion (≤ 30°) postoperatively for a long time (≥ 24 h) significantly reduced total blood loss (P = 0.02) and transfusion requirements (P = 0.02) and improved ROM at 1 week after operation (P < 0.00001) but not significantly reduced hidden blood loss (P = 0.11). Furthermore, there was no significant difference with respect to the rates of wound-related infection and DVT between the three knee flexion subgroups. Conclusions This meta-analysis showed that the long-term (≥ 24 h) high flexion (> 30°) protocol could be an optimal limb management to reduce blood loss and blood transfusion requirements and facilitate early postoperative rehabilitation exercises in patients after primary TKA without increasing in complication rate.
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Affiliation(s)
- Hai-Yang Wang
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Guang-Shu Yu
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Jie-Hui Li
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Shou-Xiong Zhang
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China
| | - Yan-Bin Lin
- Department of Orthopedics, Fuzhou the Second Hospital Affiliated to Xiamen University, 47 Shangteng Road, Fuzhou, 350,007, Fujian, People's Republic of China.
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De Fine M, Traina F, Giavaresi G, Leo E, Sanzarello I, Perna F, Dattola R, Faldini C. Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2972-2977. [PMID: 27056697 DOI: 10.1007/s00167-016-4119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE A consistent limb position strategy could be an attractive and easier alternative to reduce blood loss and increase range of motion following total knee arthroplasty. The aim of this study was to understand the proper amount of flexion required to improve functional outcomes with limited patients' discomfort. METHODS Eighty-five patients undergoing total knee arthroplasty were randomly assigned to receive mild (30° of knee flexion) or high-flexion protocol (70° of knee flexion), 48 h after surgery. The same daily rehabilitation scheme was followed. Total blood loss, hidden blood loss, haemoglobin and haematocrit levels, fixed flexion deformity, range of motion and limb circumference at the superior patellar pole were evaluated preoperatively and 7 days after surgery. RESULTS Demographics, blood parameters and preoperative range of motion did not show any significant difference between the two groups. No complications were recorded in both groups. High-flexion group had greater rate of dropout due to excessive patients' discomfort. A significantly lower Hb at day 1 was found in the high-flexion group. No differences were recorded regarding the remaining parameters. CONCLUSION No significant differences were found between the high-flexion and mild-flexion protocols; however, mild-flexion protocol was better tolerated by patients. We therefore recommend a 30° flexion protocol to be routinely used 48 h postoperatively after total knee arthroplasty. This is an easy strategy to improve functional outcomes, which is a fundamental issue considering the steady increase in knee prostheses utilization. LEVEL OF EVIDENCE Randomized controlled trial, Level II.
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Affiliation(s)
- Marcello De Fine
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy.
| | - Francesco Traina
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopedic Institute, Bologna, Italy
- Laboratory of Tissue Engineering - Innovative Technology Platforms for Tissue Engineering, Rizzoli Orthopedic Institute, Palermo, Italy
| | - Eugenio Leo
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Ilaria Sanzarello
- Section of Orthopaedics and Traumatology, Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Fabrizio Perna
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
| | - Roberto Dattola
- Rehabilitation Service, University of Messina, Messina, Italy
| | - Cesare Faldini
- General Orthopaedic Surgery, Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, km 246, Bagheria, PA, Italy
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Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. J Physiother 2017; 63:67-75. [PMID: 28433236 DOI: 10.1016/j.jphys.2017.02.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 11/24/2022] Open
Abstract
QUESTION Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions? DESIGN A Cochrane Systematic Review with meta-analyses of randomised trials. PARTICIPANTS People with or at risk of contractures. INTERVENTION Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way. OUTCOME MEASURES The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE. RESULTS Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses. CONCLUSION Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy 63: 67-75].
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Affiliation(s)
- Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, Sydney School of Medicine, University of Sydney
| | - Owen M Katalinic
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, Sydney School of Medicine, University of Sydney
| | | | - Anne M Moseley
- The George Institute for Global Health, Sydney Medical School, University of Sydney
| | - Natasha A Lannin
- School of Allied Health, Department of Community and Clinical Allied Health, Occupational Therapy, College of Science, Health and Engineering, La Trobe University, Melbourne
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Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev 2017; 1:CD007455. [PMID: 28146605 PMCID: PMC6464268 DOI: 10.1002/14651858.cd007455.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review. OBJECTIVES The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events. SEARCH METHODS In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries. SELECTION CRITERIA We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE. MAIN RESULTS Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds' phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data. AUTHORS' CONCLUSIONS There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.
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Affiliation(s)
- Lisa A Harvey
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchRoyal North Shore HospitalSt LeonardsNSWAustralia2065
| | - Owen M Katalinic
- Telstra HealthEmerging Systems18/9 Hoyle AvenueCastle HillNSWAustralia2154
| | - Robert D Herbert
- Neuroscience Research AustraliaBarker StreetRandwickSydneyAustralia2031
| | - Anne M Moseley
- The George Institute for Global Health, Sydney Medical School, The University of SydneyPO Box M201Missenden RdSydneyNSWAustralia2050
| | - Natasha A Lannin
- La Trobe UniversityOccupational Therapy, Department of Community and Clinical Allied Health, School of Allied Health, College of Science, Health and EngineeringMelbourneVictoriaAustralia
| | - Karl Schurr
- Bankstown HospitalPhysiotherapy DepartmentLocked Bag 1600BankstownNSWAustralia2200
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Wu Y, Yang T, Zeng Y, Si H, Li C, Shen B. Effect of different postoperative limb positions on blood loss and range of motion in total knee arthroplasty: An updated meta-analysis of randomized controlled trials. Int J Surg 2016; 37:15-23. [PMID: 27913236 DOI: 10.1016/j.ijsu.2016.11.135] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/16/2016] [Accepted: 11/27/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative limb positioning has been reported to be an efficient and simple way to reduce blood loss and improve range of motion following total knee arthroplasty (TKA). This meta-analysis was designed to compare the effectiveness of two different limb positions in primary TKA. MATERIALS AND METHODS A meta-analysis of the PubMed, CENTRAL, Web of Science, EMBASE and Google Search Engine electronic databases was performed. In this meta-analysis, two postoperative limb positions were considered: mild-flexion (flexion less than 60°) and high-flexion (flexion at 60° or more). The subgroups were analysed using RevMan 5.3. RESULTS Nine RCTs were included with a total sample size of 913 patients. The mild- and high-flexion positions significantly reduced postoperative total blood loss (P = 0.04 and P = 0.01; respectively). Subgroup analysis indicated that knee flexion significantly reduced hidden blood loss when the knee was fixed in mild-flexion (P = 0.0004) and significantly reduced transfusion requirements (P = 0.03) and improved range of motion (ROM) (P < 0.00001) when the knee was fixed in high-flexion. However, the rates of wound-related infection, deep venous thrombosis (DVT) and pulmonary embolism (PE) did not significantly differ between the two flexion groups. CONCLUSION This meta-analysis suggests that mild- and high-flexion positions have similar efficacy in reducing total blood loss. In addition, subgroup analysis indicates that the mild-flexion position is superior in decreasing hidden blood loss compared with high-flexion; the high-flexion position is superior to mild-flexion in reducing transfusion requirements and improving postoperative ROM. Thus, the use of the high-flexion position is a viable option to reduce blood loss in patients following primary TKA without increasing the risk of wound-related infection, DVT or PE.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Timin Yang
- Department of Orthopaedic Surgery, People's Hospital of Tibet Autonomous Region, Lasa, 850000, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Canfeng Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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Fu X, Tian P, Li ZJ, Sun XL, Ma XL. Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Curr Med Res Opin 2016; 32:771-8. [PMID: 26783114 DOI: 10.1185/03007995.2016.1142431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIM Postoperative leg position has been reported as an efficient and convenient technique to minimize blood loss and improve early recovery following total knee arthroplasty (TKA); however, no single study was large enough to definitively determine optimal leg position. Therefore, we performed a meta-analysis pooling the results from randomized controlled trials (RCTs) to evaluate the effect of postoperative leg position on blood loss and range of motion (ROM) in TKA. METHODS Potential academic articles were identified from the Cochrane Library, Medline (1966-October 2015), PubMed (1966-October 2015), Embase (1980-October 2015), ScienceDirect (1985-October 2015) and other databases. Gray studies were identified from the references of included literature reports. The pooling of data was analyzed by RevMan 5.1. RESULTS Ten RCTs were included in the meta-analysis. There were significant differences in the total blood loss (mean difference [MD] = -130.66, 95% CI: -198.74 to -62.57, P = 0.0002), hidden blood loss (MD = -73.27, 95% CI: -117.57 to -28.96, P = 0.001), blood transfusion requirement (risk difference [RD] = -0.10, 95% CI: -0.19 to -0.22, P = 0.02), postoperative hemoglobin level (MD = 0.73, 95% CI: 0.42 to 1.04, P < 0.00001) and range of motion (MD = 3.79, 95% CI: 1.43 to 6.14, P = 0.002) between the flexion group and extension group. No significant differences were found regarding length of hospital stay, deep vein thrombosis (DVT) and wound infection between the two groups. CONCLUSIONS This meta-analysis indicated that the postoperative flexion position of the leg in TKA was effective and safe, significantly decreasing total blood loss, hidden blood loss and blood transfusion requirement. In addition, the postoperative range of motion is significantly improved by the flexion position of the leg.
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Affiliation(s)
- Xin Fu
- a Tianjin Hospital , Tianjin , China
| | - Peng Tian
- a Tianjin Hospital , Tianjin , China
| | - Zhi-jun Li
- b General Hospital of Tianjin Medical University , Tianjin , China
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Yang Y, Yong-Ming L, Pei-jian D, Jia L, Ying-ze Z. Leg position influences early blood loss and functional recovery following total knee arthroplasty: A randomized study. Int J Surg 2015; 23:82-6. [PMID: 26407829 DOI: 10.1016/j.ijsu.2015.09.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 09/17/2015] [Accepted: 09/19/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hidden blood loss is a major factor influencing functional recovery and quality of life in patients undergoing total knee arthroplasty. Special hip and knee flexion positions after have been reported to have promising results with respect to reducing perioperative blood loss. The purpose of this study was to determine the effect of postoperative leg position on blood loss and functional recovery after total knee arthroplasty. METHODS We enrolled 46 consecutive patients with degenerative osteoarthritis of the knee in this prospective, randomized study. The patients were randomly allocated to a flexion or an extension group. In the flexion group, the affected leg was elevated by 60° at the hip, and the knee was flexed by 60°, while in the extension group, the affected knee was fully extended postoperatively. Blood loss, hemoglobin level, knee circumference and range of motion (ROM) were recorded to determine the influence of postoperative leg position on clinical outcomes. RESULTS Although the transfusion rate was similar between the two groups (P > 0.05), other parameters related to blood loss (including calculated blood loss, hidden blood loss and postoperative knee circumference) were significantly lower in the flexion group than in the extension group (P < 0.05). After 6 weeks of rehabilitation, patients from the flexion group had gained a better ROM in the affected knee than had patients from the extension group (P = 0.04). At 6 months, however, the ROM of the affected knee was similar in both groups. The hospital stay was 1.9 days shorter in the flexion group than in the extension group. Wound infection rates were similar in both groups, and no proven case of deep vein thrombosis was observed in either group. CONCLUSIONS Elevation of the hip by 60° with 60° knee flexion is an effective and simple method to reduce blood loss after primary unilateral total knee arthroplasty, and contributes to better recovery of the functional ROM in the early postoperative period.
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Affiliation(s)
- Yang Yang
- Hebei Medical University, Shijiazhuang 050017, PR China
| | - Lv Yong-Ming
- The Affiliated Hospital of Chengde Medical Collage, Orthopedic Department, Chengde 067700, PR China
| | - Ding Pei-jian
- The Affiliated Hospital of Chengde Medical Collage, Orthopedic Department, Chengde 067700, PR China
| | - Li Jia
- The Affiliated Hospital of Chengde Medical Collage, Orthopedic Department, Chengde 067700, PR China
| | - Zhang Ying-ze
- Third Hospital of Hebei Medical University, Department of Orthopedics, Institute of Biomechanical Science, Biomechanical Key Laboratory of Hebei Province, Shijiazhuang 050051, PR China.
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Liu J, Li YM, Cao JG, Wang L. Effects of knee position on blood loss following total knee arthroplasty: a randomized, controlled study. J Orthop Surg Res 2015; 10:69. [PMID: 25982235 PMCID: PMC4443627 DOI: 10.1186/s13018-015-0213-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 05/04/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Blood loss following total knee arthroplasty is a serious side-effect of surgery and impacts on patient recovery and quality of life. The aim of this study was to assess the effect of postoperative knee position during recovery on blood loss and range of motion. METHODS One hundred consecutive patients, with stage III or IV degenerative osteoarthritis, were enrolled in the study and randomized equally between two treatment groups: flexion and extension. In the flexion group, the affected leg was elevated postoperatively by 45° at the hip, with 45° flexion at the knee, while patients in the extension group had the knee extended fully. Blood loss, pre- and postoperative hemoglobin levels, and range of motion were recorded together with duration of hospital stay and complications. RESULTS Calculated blood loss, hidden blood loss, and postoperative hemoglobin levels between the two groups were significantly different, with patients in the flexion group experiencing lower blood loss than those in the extension group (P < 0.05). After 6-week rehabilitation, patients from both groups attained a similar range of motion in the joint. Duration of hospital stay was shorter in the flexion group by 1.6 days. Wound infection rates were similar in both groups, and we observed no proven deep vein thrombosis. CONCLUSIONS Postoperative elevation of the hip by 45°, with 45° knee flexion, is an effective and simple method of reducing blood loss and hospital stay following unilateral primary total knee arthroplasty.
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Affiliation(s)
- Jun Liu
- Tianjin Medical University, 30070, Tianjin, China. .,Center for Joint Diseases, Tianjin Hospital, 300211, Tianjin, China.
| | - Yao-min Li
- Tianjin Medical University, 30070, Tianjin, China. .,Department of Rehabilitation, Tianjin Hospital, 300211, Tianjin, China.
| | - Jian-Gang Cao
- Center for Joint Diseases, Tianjin Hospital, 300211, Tianjin, China.
| | - Lei Wang
- Center for Joint Diseases, Tianjin Hospital, 300211, Tianjin, China.
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Post-operative limb position can influence blood loss and range of motion after total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23:852-9. [PMID: 24682489 DOI: 10.1007/s00167-013-2732-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE A consistent post-operative limb positioning regime could be an attractive, simple and cost-effective alternative to improve patient's outcomes after total knee arthroplasty (TKA). The aim of this study was to perform a systematic review of the available literature in order to understand whether a consistent post-operative limb positioning regime could affect blood loss and range of motion (ROM) after TKA. METHODS A search was performed using the keywords "total knee replacement/knee prosthesis" in combination with "post-operative management", "blood loss", "range of motion", "leg position", "flexion", "extension" and "splinting" regardless of the year of publication. The scientific databases have been accessed in order to identify papers dealing with post-operative limb positioning regimes after TKA. RESULTS Seven articles matching the inclusion criteria were selected. Blood loss and ROM were both investigated in all but one paper, in which only blood loss was evaluated. There were six randomized controlled trials and one prospective comparative study. A 48-72 h post-operative knee flexion protocol seems to be effective in reducing blood loss and increasing ROM following TKA. We did also find no benefit in using extension splints in the immediate post-operative period. CONCLUSIONS Based on the studies undertaken to date, a 48-72 h post-operative knee flexion protocol should be implemented as an easy and inexpensive method of reducing blood loss and increasing ROM following TKA. Shorter flexion regimes failed to influence these parameters.
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Pinsornsak P, Chumchuen S. Can a modified Robert Jones bandage after knee arthroplasty reduce blood loss? A prospective randomized controlled trial. Clin Orthop Relat Res 2013; 471:1677-81. [PMID: 23307631 PMCID: PMC3613516 DOI: 10.1007/s11999-013-2786-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 01/02/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND A bulky compression dressing (Robert Jones bandage) is commonly used after TKA to reduce blood loss, pain, and swelling. However, it is unclear whether these dressings in fact reduce blood loss. QUESTIONS/PURPOSES We compared postoperative blood loss, pain, knee swelling, and postoperative complications in two types of postoperative dressings after TKA: a modified Robert Jones dressing (MRJB) and a conventional wound dressing. METHODS We conducted a prospective, randomized, controlled trial of 60 patients who underwent a unilateral primary TKA at our institution between November 2010 and July 2011. After wound closure, the patients were allocated into two groups. Thirty patients had the MRJB applied for 24 hours (Group 1) and 30 patients had a conventional wound dressing applied (Group 2). Postoperative hemorrhages in the vacuum drain, units of transfused blood, postoperative pain, knee swelling, and complications were assessed at 24 and 48 hours postoperatively. RESULTS We found no differences in the mean postoperative blood loss between the groups (Group 1, 418 mL versus Group 2, 467 mL). Blood transfusion amounts, postoperative pain, and knee swelling also were similar. Three patients in Group 1 experienced bruising and two patients in Group 2 also had bruising. One patient in Group 1 had a blister. CONCLUSIONS Although previous studies have shown reduced blood loss, pain, and knee swelling after application of a MRJB, we found no benefit of this bandage. Our data suggest a postoperative compression dressing is not necessary after primary TKAs.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120 Thailand
| | - Sukanis Chumchuen
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120 Thailand
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13
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The effect of knee position on blood loss and range of motion following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012; 20:594-9. [PMID: 21811855 DOI: 10.1007/s00167-011-1628-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 07/14/2011] [Indexed: 01/31/2023]
Abstract
PURPOSE This study prospectively assessed the effects of knee position on blood loss and range of motion after primary total knee arthroplasty (TKA). METHODS One hundred and ten consecutive TKA patients were randomized into flexion group and extension group. Both groups had the leg elevated 30° at the hip over an inactive CPM for 72 h postoperatively. The flexion group had the knee flexed to 30° during this period. The extension group had the knee extended fully. Perioperative blood loss, hidden blood loss, knee swelling, ecchymosis, analgesia requirements, range of motion (ROM), fixed flexion deformity (FFD), straight-leg raising action, and postoperative complications within 6 weeks of surgery were measured for evaluation and comparison. RESULTS The postoperative hidden blood loss, knee swelling, and scope of ecchymosis were significantly lower in the flexion group than in the extension group, and ROM and straight-leg raising action were significantly higher during the early period after operation. No significant difference was observed in perioperative blood loss, the amount of morphine used, or FFD in the early postoperative period or in ROM and FFD at 6 weeks postoperatively. CONCLUSIONS The findings of this study indicate that flexion of the knee to 30° with the leg elevated 30° at the hip after total knee arthroplasty may mitigate knee swelling and provide other beneficial results during the early rehabilitation following TKA. LEVEL OF EVIDENCE Prospective comparative study, Level I.
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14
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Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev 2010:CD007455. [PMID: 20824861 DOI: 10.1002/14651858.cd007455.pub2] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Contractures are a common complication of neurological and musculoskeletal conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. OBJECTIVES To determine the effects of stretch on contractures in people with, or at risk of, contractures. SEARCH STRATEGY Electronic searches were conducted on CENTRAL, DARE, HTA (The Cochrane Library); MEDLINE; CINAHL; EMBASE; SCI-EXPANDED; and PEDro (April 2009). SELECTION CRITERIA Randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, and assessed risk of bias. The primary outcomes of interest were joint mobility and quality of life. The secondary outcomes were pain, spasticity, activity limitation and participation restriction. Outcomes were evaluated immediately after intervention, in the short term (one to seven days) and in the long term (> one week). Effects were expressed as mean differences or standardised mean differences with 95% confidence intervals (CI). Meta-analyses were conducted with a random-effects model. MAIN RESULTS Thirty-five studies with 1391 participants met the inclusion criteria. No study performed stretch for more than seven months. In people with neurological conditions, there was moderate to high quality evidence to indicate that stretch does not have clinically important immediate (mean difference 3 degrees ; 95% CI 0 to 7), short-term (mean difference 1 degrees ; 95% CI 0 to 3) or long-term (mean difference 0 degrees ; 95% CI -2 to 2) effects on joint mobility. The results were similar for people with non-neurological conditions. For all conditions, there is little or no effect of stretch on pain, spasticity, activity limitation, participation restriction or quality of life. AUTHORS' CONCLUSIONS Stretch does not have clinically important effects on joint mobility in people with, or at risk of, contractures if performed for less than seven months. The effects of stretch performed for periods longer than seven months have not been investigated.
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Affiliation(s)
- Owen M Katalinic
- Rehabilitation Studies Unit, Northern Clinical School, Sydney Medical School, The University of Sydney, PO Box 6, Ryde, NSW, Australia, 1680
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Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2008; 2008:CD004957. [PMID: 18425906 PMCID: PMC8859927 DOI: 10.1002/14651858.cd004957.pub3] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement. OBJECTIVES To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF). DATA COLLECTION AND ANALYSIS Four authors independently extracted data and assessed methodological quality of included trials. MAIN RESULTS Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only. AUTHORS' CONCLUSIONS Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.
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Affiliation(s)
- F Khan
- University of Melbourne, Department of Rehabilitation Medicine, Poplar Road, Parkville, Melbourne, Victoria, Australia, 3052.
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Ma T, Khan RJK, Carey Smith R, Nivbrant B, Wood DJ. Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion -- a randomised controlled trial. Knee 2008; 15:15-9. [PMID: 17997100 DOI: 10.1016/j.knee.2007.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 09/13/2007] [Accepted: 09/21/2007] [Indexed: 02/02/2023]
Abstract
Previous published research has shown promising results with flexion splinting post total knee arthroplasty. Before instituting this practice, we conducted a randomised controlled trial to confirm any benefits over splinting in extension. Five patients were recruited into the trial. 5 were excluded. The flexion group consisted of 49 patients who had their knee placed in 70 degrees of flexion over an inactive CPM machine for 24 h post operation. The extension group consisted of 46 patients who were splinted in full extension for the first 24 h post operation. We assessed post-operative day 1 drain volume, haemoglobin and haematocrit, blood transfusions, duration of inpatient stay, range of motion and complications within 6 weeks of surgery. There was no significant difference between the two groups among any of the outcomes measured. As such, we have been unable to demonstrate any benefit with splintage in flexion post total knee arthroplasty and have not adopted it as part of our post-operative management.
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Affiliation(s)
- T Ma
- Sir Charles Gairdner Hospital, Western Australia, Australia
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