Total knee arthroplasty: does ultra-early physical therapy improve functional outcomes and reduce length of stay? A retrospective cohort study

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) Society recommends that after total knee arthroplasty (TKA), patients should be mobilized early. However, there is no consensus on how early physical therapy should be commenced. We aim to investigate whether ultra-early physical therapy (< 12 h postoperatively) leads to better outcomes.

METHODS

This is a retrospective cohort study of 569 patients who underwent primary TKA from August 2017 to December 2019 at our institution. We compared patients who had undergone physical therapy either within 24 h or 24-48 h after TKA. Further subgroup analysis was performed on the < 24 h group, comparing those who had undergone PT within 12 h and within 12-24 h. The outcomes analyzed include the Oxford Knee Scoring System score, Knee Society Scores, range of motion (ROM), length of stay (LOS) and ambulatory distance on discharge. A student's t test, chi-squared test or Fisher's exact test was used where appropriate, to determine statistical significance of our findings.

RESULTS

LOS in the < 24 h group was shorter compared to the 24-48 h group (4.87 vs. 5.34 days, p = 0.002). Subgroup analysis showed that LOS was shorter in the ultra-early PT (< 12 h) group compared to the early PT (12-24 h) group (4.75 vs. 4.96 days, p = 0.009). At 3 months postoperatively, there was no significant difference in ROM, ambulatory distance or functional scores between the < 24 h group and 24-48 h group, or on subgroup analysis of the < 24 h group.

CONCLUSION

Patients who underwent physical therapy within 24 h had a shorter length of stay compared to the 24-48 h group. On subgroup analysis, ultra-early (< 12 h) physical therapy correlated with a shorter length of stay compared to the 12-24 h group (4.75 vs. 4.96 days, p = 0.009) - however, the difference is small and unlikely to be clinically significant. Ultra-early (< 12 h) physical therapy does not confer additional benefit in terms of functional scores, ROM or ambulatory distance. These findings reinforce the importance of early physical therapy after TKA in facilitating earlier patient discharge.

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.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

Patients' Perceptions of Remote Monitoring and App-based Rehabilitation Programs: A Comparison of Total Hip and Knee Arthroplasty

BACKGROUND

Remote monitoring rehabilitation programs are new technologies growing in popularity for patients undergoing lower extremity total joint arthroplasty. The purpose of this study was to assess the patients' perceptions of these technologies.

METHODS

Patients who underwent total hip (THA), knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) from September 2020 to February 2022 and participated in a clinical study utilizing remote monitoring and an app-based rehabilitation program were given a questionnaire three months postoperatively to assess their perceptions of these technologies. There were 166 patients who completed the survey (42 THA; 106 TKA; 18 UKA).

RESULTS

There were 92% of patients who found the technology easy to use. A majority of patients felt the technologies motivated them. The TKA/UKA patients felt more strongly that these technologies allowed the surgeon to monitor their recovery closely (81.9% v. 65.9%; P=0.009). There were 85% of THA patients and 94.5% of TKA/UKA patients recommended these technologies. The THA patients felt more strongly that digital rehabilitation could completely replace in-person physical therapy compared to TKA/UKA patients (85.4% v. 41.3%; P<0.001). A majority (83%) of patients recommended a combination of inpatient and technology-assisted rehabilitation (THA 90.2%; 84.4% TKA/UKA).

CONCLUSIONS

The THA and TKA/UKA patients found remote monitoring rehabilitation easy to use, increased motivation, and recommend it to other patients undergoing lower extremity arthroplasty. They recommend a combination of technology and in-person rehabilitation postoperatively. The THA patients felt these technologies could replace in-person rehabilitation programs.

Non-drainage Offers Faster Proprioceptive and Functional Recovery, and More Clinical Benefits for Patients following Primary Total Knee Arthroplasty Compared to Drainage

BACKGROUND

Although a non-drainage procedure following total knee arthroplasty (TKA) is becoming more acceptable in enhanced recovery after surgery, postoperative drainage is still commonly used in TKA surgeries. This study aimed to compare the non-drainage to the drainage during the early postoperative stage regarding proprioceptive and functional recovery, and postoperative outcomes of TKA patients.

MATERIAL AND METHODS

A prospective, single-blind, randomized, controlled trial was carried out on 91 TKA patients, who were randomly allocated into the non-drainage group (NDG) or the drainage group (DG). Patients were evaluated regarding knee proprioception, functional outcomes, pain intensity, range of motion, knee circumference, and anesthetic consumption. Outcomes were assessed at the time of charge, at postoperative 7th day, and at postoperative 3rd month.

RESULTS

There were no differences between groups at baseline (p > 0.05). During the inpatient period, the NDG experienced superior pain relief (p < 0.05), had a higher Hospital for Special Surgery knee score (p = 0.001), demanded lower assistance from a sitting position to a standing position (p = 0.001) and walking for 4.5 m (p = 0.034), and performed the Timed Up and Go test in a shorter duration (p = 0.016) compared to the DG. The NDG gained the actively straight leg raise earlier (p = 0.009), needed lower anesthetic consumption (p < 0.05), and showed improved proprioception (p < 0.05) compared to the DG during the inpatient period.

CONCLUSIONS

Our findings support that a non-drainage procedure would be a better option to provide a faster proprioceptive and functional recovery, and beneficial results for patients following TKA. Therefore, the non-drainage procedure should be the first choice in TKA surgery rather than drainage.

Pre- and postoperative physiotherapy using a digital application decreases length of stay without reducing patient outcomes following total knee arthroplasty

Introduction

Total Knee Arthroplasty (TKA) for both patients and the surgical team is a journey spanning many months, rather than purely a hospital episode of care. To improve patient outcomes and reduce costs in TKA, greater emphasis should be placed on the pre- and postoperative periods as, historically, innovation has focused on the intraoperative execution of the surgery. The purpose of this study was to determine if a pre- and postoperative physiotherapy program delivered via a digital application could reduce hospital length of stay (LOS) without compromising patient outcomes.

Methods

A retrospective series of 294 patients who underwent TKA from a single-surgeon in a single-centre was examined. This included 232 patients who underwent a pre- and postoperative physiotherapist-led program delivered via a digital application and 62 patients who underwent a conventional pre- and postoperative protocol. 2:1 nearest neighbour propensity score matching was performed to establish covariate balance between the cohorts. Data collected included pre- and postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS), KOOS for Joint Replacement (KOOS, JR), and acute, rehabilitation, and total LOS.

Results

No significant difference in KOOS or KOOS, JR scores was observed at 12-month follow-up. A significantly reduced rehabilitation (P = 0.014) and total LOS (P = 0.015) was observed in the patients who received the digital physiotherapy program.

Conclusions

There may be significant economic benefits to a pre- and postoperative physiotherapy program delivered via a digital application. Our results suggest that a digital physiotherapist-led patient program may reduce the need for inpatient rehabilitation services without compromising patient outcomes.

The number of stairs into home do not impact discharge disposition and patient reported outcomes after total joint arthroplasty

INTRODUCTION

The purpose of this study is to report on the association between the number of stairs to enter home and length of stay (LOS), discharge disposition, and patient reported outcome measures (PROMs) among patients who underwent primary total joint arthroplasty (TJA).

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent primary total hip or knee arthroplasty between January 2016 and March 2020. Only patients with documentation of the number of stairs to enter their homes were included in the study. The two cohorts were separated into four groups: none, 1-10, 11-20, and > 20 stairs. Collected variables included demographic data, LOS, discharge disposition, and PROMs. Chi-square and ANOVA were utilized to determine significance.

RESULTS

Of the 1116 patients included, 510 underwent THA, and 606 underwent TKA. There was no statistical difference in LOS (THA: p = 0.308; TKA: p = 0.701) and discharge disposition (THA: p = 0.371; TKA: p = 0.484) in both cohorts regardless the number of stairs. There was no statistical difference in FJS-12 scores at 3 months (THA: p = 0.590; TKA: p = 0.206), 12 months (THA: p = 0.217; TKA: p = 0.845), and 21 months (THA: p = 0.782; TKA: p = 0.296) postoperatively for both cohorts. There was no statistical difference in HOOS, JR scores preoperatively (p = 0.278) and at 3 months postoperatively (p = 0.527) for the THA cohort, as well as KOOS, JR scores preoperatively and at 3 and 12 months postoperatively (p = 0.557; p = 0.522; p = 0.747) for the TKA cohort.

CONCLUSION

We found no statistical differences in LOS, discharge disposition, and PROMs in patients who underwent TJA, irrespective of the number of stairs negotiated to enter their home. These findings can aid surgeons to provide preoperative education and reassurance to patients who have concerns with their discharge planning due to the walk-up stairway at their residence.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

The Time Course of Quadriceps Strength Recovery After Total Knee Arthroplasty Is Influenced by Body Mass Index, Sex, and Age of Patients: Systematic Review and Meta-Analysis

Introduction

For patients with osteoarthritis who have undergone total knee arthroplasty (TKA), quadriceps strength is a major determinant of general physical function regardless of the parameters adopted for functional assessment. Understanding the time course of quadriceps strength recovery and effectiveness of different rehabilitation protocols is a must. Therefore, the aim of this study was to: (i) determine the magnitude of maximal voluntary strength (MVS) loss and the time course of recovery of the quadriceps muscle following TKA, (ii) identify potential moderators of strength outcomes, and (iii) investigate whether different rehabilitation practices can moderate the strength outcomes following TKA, respectively.

Design

General scientific databases and relevant journals in the field of orthopedics were searched, identifying prospective studies that investigated quadriceps’ MVS pre-to post-surgery.

Results

Seventeen studies with a total of 832 patients (39% males) were included. Results showed that in the early post-operative days, the involved quadriceps’ MVS markedly declined, after which it slowly recovered over time in a linear fashion. Thus, the greatest decline of the MVS was observed 3 days after TKA. When compared to pre-operative values, the MVS was still significantly lower 3 months after TKA and did not fully recover up to 6 months following TKA. Furthermore, a meta-regression analysis identified that the variables, time point of evaluation, patient age, sex, and BMI, significantly moderate the MVS of the quadriceps muscle.

Conclusion

The analyzed literature data showed that the decrease in strength of the involved quadriceps muscles following TKA is considerable and lasts for several months post-surgery. Therefore, we recommend to specifically target the strengthening of knee extensor muscles, preserve motor control, and apply appropriate nutrition to ensure a holistic quadriceps muscle recovery. Since age, sex, and BMI were found to be moderating factors in patients’ recovery, further research should include specific analyses considering these moderators.

Effect of Local Infiltration Analgesia on Functional Outcomes in Total Knee Arthroplasty: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Local infiltration analgesia (LIA) is a simple, surgeon-administered technique for the treatment of postoperative pain after total knee arthroplasty (TKA). The aim of the study was to investigate the efficacy of LIA and its effects on functional outcomes in TKA. A total of 135 patients with primary TKA were recruited and randomized either to receive LIA or to receive placebo injection (PI). Pain, active range of motion (ROM), knee function score, functional activities, and hospital length of stay (LOS) were assessed before surgery and from postoperative day (POD) 1 to at discharge. Lower pain scores at rest were recorded on POD1 and POD2 in the LIA group (p = 0.027 and p = 0.020, respectively). Lower pain score on walking was recorded on POD1 in the LIA group (p = 0.002). There was a statistically significant difference in active knee flexion between groups on POD1 (p = 0.038). There was a significant difference in LOS between LIA and PI groups. Shorter stay was seen in LIA group. There were no statistically significant differences between the groups in terms of knee function score and functional outcomes. LIA technique is effective for pain management in the early postoperative period. LIA added benefit for knee function in terms of active knee flexion ROM after TKA. A shorter hospital LOS was observed in LIA group. However, we did not find any differences in groups in terms of functional assessment such as ability to rise from a chair and walking capacity.The level of evidence is randomized controlled trial, level I.

Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery

OBJECTIVE

The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models.

METHODS

A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65 years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics.

RESULTS

Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66).

CONCLUSION

Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery.

IMPACT

In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.

Comparing ERAS-outpatient versus standard-inpatient hip and knee replacements: a mixed methods study exploring the experience of patients who underwent both

BACKGROUND

Optimizing patients' total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs.

METHODS

We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients' characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together.

RESULTS

The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients' THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36-0.66], p-value < 0.01).

CONCLUSION

Whatever the perioperative program, the key to improving patients' THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients' experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients' THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients

BACKGROUND

Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients.

METHODS

167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m²) and severely diseased patients (ASA≥3).

RESULTS

TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12).

CONCLUSION

Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.

Effects of knee extension exercise starting within 4 h after total knee arthroplasty

PURPOSE

To determine the beneficial effects of knee extension exercise applied from 4 h after TKA.

METHODS

Patients undergoing TKA for osteoarthritis were assigned to early rehabilitation (n = 41) and control rehabilitation (n = 39) groups. Rehabilitation of knee extension exercise was started within 4 h postoperative in the early group and 2 days after surgery in the control group. Joint range of motion and pain were assessed before surgery and at 3 days to 12 months after surgery. Muscle strength and gait parameters were assessed before and 3 weeks after surgery.

RESULTS

Extension range of motion was significantly increased in the early group than the control at 3 days, 3 weeks and 6 months after surgery. In gait parameters, peak knee flexion and extension angles during stance phase were significantly improved in the early group than the control group at 3 weeks after surgery. Flexion range of motion was increased in the early group than the control at 12 months after surgery.

CONCLUSION

Starting knee extension exercise within 4 h after TKA reduced the early loss of extension range of motion and improved gait pattern and seemed to contribute to be better functional outcome one year after surgery.

Benefits of Early Ambulation in Elderly Patients Undergoing Lumbar Decompression and Fusion Surgery: A Prospective Cohort Study

Objective

To evaluate the effects of early ambulation on elderly patients’ postoperative physical functional outcomes, complications, 90‐day readmission rate, and the length of postoperative hospital stay.

Methods

This is a prospective cohort study conducted between June 2019 and December 2019. The study enrolled 86 elderly patients (39 males) with newly diagnosed lumbar degenerative disease undergoing single‐segment decompression and fusion surgerywere enrolled. Of all 86 patients, 39 voluntarily joined the early ambulation group, and 47 joined the regular ambulation group. The early ambulation group included patients ambulated within 4 h postoperatively, whereas the regular ambulation group included patients who were ambulatory at a minimum of 24 h after surgery. Participants’ baseline characteristics, surgical information, ambulation ability, degree of pain, functional scores, postoperative complications, 90‐day readmission rate, and length of postoperative hospital stay were recorded.

Results

Participants’ baseline demographic characteristics were balanced between the early ambulation group and the regular ambulation group. The operative time and blood loss were similar between groups. The time before the first‐time ambulation was 4 ± 0.5 h in the early ambulation group and 28 ± 4.5 h in the regular ambulation group. Ambulating distance was significantly longer in the early ambulation group compared with the regular ambulation group on the 1st (63 ± 45 vs 23 ± 60 m), the 2nd (224 ± 100 vs 101 ± 130 m), and the 3rd (280 ± 102.5 vs 190 ± 170 m) ambulation days based on generalized estimating equation analyses. Generalized estimating equation analyses also demonstrated that the ambulating time was longer in the early ambulation group compared with the regular ambulation group on the 1st (10 ± 5 vs 10 ± 5 min), the 2nd (19 ± 7 vs 15 ± 5 min), and the 3rd (22 ± 16.5 vs 27 ± 12 min) ambulation days. Patients in the regular ambulation group experienced a higher degree of pain than the early ambulation group patients, with an odds ratio of 1.627 (P = 0.002). Short‐term functional independence was superior in the early ambulation group, with a lower Roland–Morris disability questionnaire score (P = 0.008) and Oswestry disability index (P < 0.001). The incidences of postoperative urinary retention (early ambulation group: 7.7%, regular ambulation group: 25.5%, P = 0.030) and ileus (early ambulation group: 0%, regular ambulation group: 12.8%, P = 0.030) were significantly higher in the regular ambulation group. The prevalence of at least one complication rate was significantly lower in the early ambulation group than in the regular ambulation group (early ambulation group, 23.1%; regular ambulation group, 46.8%, P = 0.022). The duration of indwelling of the drainage catheter was shorter in the early ambulation group (early ambulation group, 68 ± 24 h; regular ambulation group, 78 ± 20 h, P = 0.001), and the length of the postoperative hospital stay was also shorter in the early ambulation group (early ambulation group, 4 ± 0 days; regular ambulation group: 5 ± 2 days, P < 0.001). However, there was no statistical difference in the 90‐day readmission rate between groups.

Conclusion

Early ambulation improved patients’ postoperative functional status, decreased the incidence of complications, and shortened postoperative hospital stay in elderly patients undergoing lumbar decompression and fusion surgery.

Mobilization after joint arthroplasty surgery: who benefits from standing within 12 hours?

BACKGROUND

Early mobilization following joint arthroplasty surgery has been shown to be beneficial for patients, but it is unclear whether it is associated with a shorter length of stay (LOS) for both hip and knee arthroplasty (KA) patients.

METHODS

We undertook a retrospective observational study, reviewing the case notes of 386 patients admitted to an enhanced recovery programme for total hip (THA) or total/unicompartmental KA. We evaluated the influence of early mobilization on LOS, adjusting for possible confounders, stratifying by surgery type.

RESULTS

THA patients first mobilized within 12 h of returning to the acute orthopaedic ward following surgery had a significantly shorter mean LOS (mean = 3.6, standard deviation = 1.1) than THA patients who first mobilized 12 or more hours (mean = 4.1, standard deviation = 1.2), P = 0.004. There was no statistical significant difference in the mean LOS between the KA patients mobilized earlier or later.

CONCLUSION

Early mobilization as part of an enhanced recovery programme was associated with decreased LOS for patients having THA; however, this was not the case for KA patients.

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project: Phase I Outcomes

BACKGROUND

This study aimed to improve institutional value-based patient care processes, provider collaboration, and continuous process improvement mechanisms for primary total hip arthroplasties and total knee arthroplasties through establishment of a perioperative orthopedic surgical home.

METHODS

On June 1, 2017, an institutionally sponsored initiative commenced known as the orthopedic surgery and anesthesiology surgical improvement strategy project. A multidisciplinary team consisting of orthopedic surgeons, anesthesiologists, advanced practice providers, nurses, pharmacists, physical therapists, social workers, and hospital administration met regularly to identify areas for improvement in the preoperative, intraoperative, and post-anesthesia care unit, and postoperative phases of care.

RESULTS

Mean hospital length of stay decreased from 2.7 to 2.2 days (P < .001), incidence of discharge to a skilled nursing facility decreased from 24% to 17% (P = .008), and the number of patients receiving physical therapy on the day of surgery increased from 10% to 100% (P < .001). Press-Ganey scores increased from 74.9 to 75.8 (94th percentile), while mean and maximum pain scores, opioid consumption, and hospital readmission rates remained unchanged (lowest P = .29). Annual total hip arthroplasty and total knee arthroplasty surgical volume increased by 11.4%. Decreased hospital length of stay and increased surgical volume yielded a combined annual savings of $2.5 million across the 9 involved orthopedic surgeons.

CONCLUSION

Through application of perioperative surgical home tools and concepts, key advances included phase of care integration, enhanced data management, decreased length of stay, coordinated perioperative management, increased surgical volume without personnel additions, and more efficient communication and patient care flow across preoperative, intraoperative, and postoperative phases.

LEVEL OF EVIDENCE

III Therapeutic.

A randomised controlled trial of laser acupuncture improves early outcomes of osteoarthritis patients' physical functional ability after total knee replacement

BACKGROUND AND PURPOSE

Total knee replacement is the most effective intervention for late-stage osteoarthritis; however, a major concern is postoperative recovery of physical function. This randomised controlled trial evaluated the effects of acupuncture with low-level laser therapy (ALLLT) on early outcomes of physical function after total knee replacement.

MATERIALS AND METHODS

Eighty-two osteoarthritis patients were recruited and randomly assigned to the experimental group receiving ALLLT or the control group receiving sham ALLLT without laser beam output. Physical function was evaluated by assessing knee joint flexion and stiffness on days 1, 2, and 3 after total knee replacement.

RESULTS

Generalised estimating equations revealed a significant difference between the two groups in joint flexion. The experimental group displayed better joint flexion and less stiffness on days 2 and 3 than did the control group.

CONCLUSION

ALLLT can facilitate the recovery of physical function, as evidenced by knee joint flexion and stiffness, in patients receiving total knee replacement.

Impact of Perioperative Pain Control on Knee Range of Motion and Development of Arthrofibrosis Following Primary Total Knee Arthroplasty

BACKGROUND

Inadequate pain control following total knee arthroplasty (TKA) has been postulated to negatively impact knee range of motion (ROM). We sought to determine the association between perioperative pain levels and knee ROM at 3-month follow-up or need for manipulation under anesthesia (MUA).

METHODS

We retrospectively reviewed 2243 primary TKAs performed from 2002 to 2019 at a single academic center using an institutional total joint registry. Mean age was 68, mean body mass index was 32.8, and 59% were female. Knee ROM was measured preoperatively and 3 months postoperatively. Change in knee ROM, rates of soft tissue contracture, and MUA were assessed in relation to in-hospital 10-point pain visual analog scale (VAS) measurements.

RESULTS

Overall, 44% had improved ROM at 3-month follow-up, 29% had no change in ROM, and 27% had worsened ROM. There was no significant difference in mean VAS scores of patients with improved, unchanged, or worsened ROM postoperatively (3.0 vs 2.8 vs 3.0; P = .068). There was no significant difference in mean VAS scores of patients who developed a soft tissue contracture or required MUA vs those who did not develop these complications (2.7 vs 2.9; P = .24). Similarly, no significant relationship with these outcomes was identified when maximum and discharge VAS scores were analyzed.

CONCLUSION

Comparable ROM and rates of MUA based on in-hospital pain levels were observed in this large series of primary TKA patients. While significant early pain may limit participation in ROM exercises initially, this does not appear to have a marked impact on ROM-related complications for most patients.

LEVEL OF EVIDENCE

III, Therapeutic.

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

BACKGROUND

Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care.

METHOD

A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol.

RESULTS

Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles.

CONCLUSION

Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Predictors of farther mobilization on day of surgery and shorter length of stay after total joint arthroplasty

BACKGROUND

Mobilization on the day of total joint arthroplasty (TJA) is associated with shorter length of stay. The question of whether incrementally farther mobilization on the day of surgery (POD0) contributes to shorter length of stay has not been widely studied. The purpose of this study was to determine if farther mobilization on POD0 led to shorter length of stay and to identify the predictors of farther mobilization and length of stay.

METHODS

A retrospective chart review was undertaken using data for patients who had a primary TJA and mobilized on POD0. Patients were categorized into the following 4 mobilization groups: sat on the bedside (Sat), stood by the bed or walked in place (Stood), walked in the room (Room) and walked in the hall (Hall). The primary outcome was length of stay. Predictors of farther mobilization on POD0 and length of stay were identified using regression analyses.

RESULTS

The sample comprised 283 patients. The Hall group had significantly shorter length of stay than all other groups. There were sex differences across the mobilization groups. Simultaneous regression analysis showed that farther mobilization was predicted by younger age, male sex, lower body mass index, spinal anesthesia and fewer symptoms limiting mobilization. Hierarchical regression showed that shorter length of stay was predicted by male sex, lower body mass index, lower American Society of Anaesthesiologists physical status classification score, less pain/stiffness and farther mobilization on POD0.

CONCLUSION

Understanding the modifiable and nonmodifiable predictors of mobilization after TJA and length of stay can help identify patients more likely to mobilize farther on the day of surgery, which would contribute to better resource allocation and discharge planning. Focusing on symptom management could increase opportunities for farther mobilization on POD0 and thereby decrease length of stay.

Analgesic effectiveness of Local Infiltrative Analgesia alone versus combined single dose adductor canal block with Local Infiltrative Analgesia: A single centre case control study

BACKGROUND

Both adductor canal block (ACB) and of Local Infiltrative Analgesia (LIA) have been shown to reduce pain after total knee arthroplasty (TKA). The efficacy of combining ACB and LIA remains controversial. The objective of this study is to analyse the effect of LIA + single dose ACB compared to LIA alone on early post-operative pain and mobilization in TKA.

METHODS

This Cohort Prospective study analyses the Visual Analogue Score (VAS) pain scores and rehabilitation milestones at 24 h between LIA alone and LIA + single dose ACB in unilateral TKA operated by a single surgeon between August 2014 and February 2019.

RESULTS

VAS at rest and on movement were significantly better in the combined LIA + ACB group (n = 151) compared to LIA (n = 120) alone at 24 h. All patients were able to achieve the desired milestones of sitting, standing by the bedside and walking with the help of a walker within 24 h of the surgery.

CONCLUSION

Though the VAS scores were statistically significant, the actual scores at rest and on movement in both groups were significantly better than preoperative scores with excellent pain relief. All patients in both groups were able to ambulate within 24 h. LIA alone significantly improved the pain scores and enabled early mobilization. Addition of single dose ACB to LIA did not significantly alter the milestones.

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.

Initiating range of motion exercises within 24 hours following total knee arthroplasty affects the reduction of postoperative pain: A randomized controlled trial

Background

Postoperative limitations in the range of motion (ROM) after TKA may occur occasionally and restrict a patient's ADL. Although ROM exercise is a means of increasing the ROM after TKA, the optimal time of initiating ROM exercise is still unclear. The purpose of this study is to examine different initiation timings of postoperative ROM exercises after TKA and to compare the results in terms of postoperative pain, swelling, and ROM improvement to determine the optimal time of initiating ROM exercises following TKA.

Methods

This was a prospective, single-center, single-blinded randomized controlled trial involving 109 patients scheduled for unilateral TKA. All patients underwent the physiotherapist assisted passive and active same rehabilitation program that only differed in the starting time of ROM exercise on postoperative day 1 or day 7. Postoperative assessment was performed with all attending personnel blinded to group assignment. Visual analog scale (VAS) of pain, ROM, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and adverse outcomes were compared between groups on postoperative days within 2 years after surgery.

Results

VAS scores during the postoperative period from 18 to 72 h were significantly lower in the group with starting time of ROM exercise on postoperative day 1. The ROM, laboratory data, thigh girth, WOMAC and the incidence of complications did not differ between the two groups at any postoperative time-point.

Conclusions

The results of this study suggested that ROM exercises beginning in the early postoperative stage are advantageous in reducing the postoperative pain after TKA.

Simplified Measurement of Maximum Strength After Knee Surgery: Application-Based Knee-Training Device Compared to Isokinetic Testing

Context

Isokinetic testing is used as a standard tool in measuring strength in professional athletes. It is often used to evaluate improvement during rehabilitation. The disadvantages of isokinetic testing include its costs, the fact that it is not portable, and its risk of injury, which makes it not suitable for early postoperative rehabilitation.

Hypothesis

The aim of this study was to investigate the relationship between the results of the isokinetic testing and the measurements of an application-based knee-training device.

Study Design

Exploratory diagnostic study.

Methods

In this monocentric study, 100 subjects performed an isokinetic maximum strength examination and an assessment on the application-based knee-training device in a randomized order. The isokinetic testing was based on the Swiss Olympic protocol with 3 sets of 5 repetitions of maximum strength testing for flexion and extension. The subjects consisted of 50 healthy professional athletes and 50 healthy recreational athletes, half male and half female, between the ages of 18 to 30 years old.

Results

No medical or technical issues were reported. The analysis of the relationship between application-based knee-training device and extension showed a Pearson correlation coefficient of r=0.667 for the left knee and r=0.604 for the right knee. For flexion, the Pearson correlation coefficient was r=0.640 for the left side and r=0.673 for the right side. When strength measured by the application-based knee-training device was adjusted for height and weight of the subjects, the Pearson correlation was even stronger (extension left: r=0.727, right: r=0.689; flexion left: r=0.641, right: r=0.711).

Conclusion

The study shows a moderate to high correlation between isokinetic testing and the application-based knee-training device. These results suggest that the application-based knee-training device is effective for early strength rehabilitation without the risk of injury.

Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial

This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26, P=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83, P=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [Orthopedics. 2020; 43(1):e47-e53.].

Angiotensin receptor blockade mimics the effect of exercise on recovery after orthopaedic trauma by decreasing pain and improving muscle regeneration

KEY POINTS

Our tibial fracture orthopaedic injury model in mice recapitulates the major manifestations of complex trauma, including nociceptive sensitization, bone fracture, muscle fibrosis and muscle fibre loss. Delayed exercise after complex orthopaedic trauma results in decreased muscle fibrosis and improved pain Losartan, an angiotensin-receptor blocker with anti-fibrotic abilities, recapitulates the effect of exercise on post-injury recovery and may provide an enhanced recovery option for those who are unable to exercise after injury ABSTRACT: Chronic pain and disability after limb injury are major public health problems. Early mobilization after injury improves functional outcomes for patients, although when and how to implement rehabilitation strategies remains a clinical challenge. Additionally, whether the beneficial effects of exercise can be reproduced using pharmacological tools remains unknown and may benefit patients who are unable to exercise as a result of immobilization. We developed a murine model of orthopaedic trauma combining tibia fracture and pin fixation with muscle damage. Behavioural measures included mechanical nociceptive thresholds and distances run on exercise wheels. Bone healing was quantified using microcomputed tomagraphic scanning, and muscle fibre size distribution and fibrosis were followed using immunohistochemistry. We found that the model provided robust mechanical allodynia, fibrosis and a shift to smaller average muscle fibre size lasting up to 5 weeks from injury. We also observed that allowing 'late' (weeks 1-2) rather than 'early' (weeks 0-1) exercise after injury resulted in greater overall running activity and greater reversal of allodynia. In parallel, the late running paradigm was associated with reduced muscle fibrosis, earlier increase in muscle fibre diameter and a short-term benefit in reducing callus volume. Providing the anti-fibrotic angiotensin receptor blocker losartan to mice in drinking water reduced both allodynia and muscle fibrosis. Combining losartan and late exercise provided no additional benefit. We conclude that early healing after orthopaedic trauma must be allowed prior to the initiation of exercise to achieve optimal pain, functional and physiological outcomes and that losartan is a viable candidate for translational studies.

Comparison of Adductor Canal Block and Femoral Nerve Block for Early Ambulation After Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Purpose: The purpose of this study was to assess the efficacy of adductor canal block (ACB) as compared to femoral nerve block (FNB) in ambulation distance, opioid consumption, and physical therapy participation on postoperative days (PODs) 1 and 2 after total knee arthroplasty (TKA). We hypothesized ACB would have increased the ambulation distance and decreased the opioid consumption in comparison to FNB.

Methods: All elective TKAs at a single institution, age 18 and older, without existing neurologic or anatomic deficit in the operative limb, were considered. Participants were randomized 1:1 to receive either an ACB (AC group) or a FNB (FN group), in addition to standard care. Visual analog pain scores (VAS) and oral morphine equivalents (OMEs) were recorded preoperatively, in post-anesthesia care unit (PACU), and on PODs 1 and 2. Postoperative ambulation distance was recorded on PODs 1 and 2. Patient satisfaction with analgesia and physical therapist-rated participation in therapy sessions was obtained as well. 

Results: From 2014 to 2015, 84 participants were recruited: 41 in FN, and 43 in AC. On POD 1, mean ambulation distances in AC and FN were 70.2 and 48.5 ft, respectively (p = 0.045). On POD 2, mean ambulation distances in AC and FN were 129.0 and 106.4 ft, respectively (p = 0.225). VAS, OME, satisfaction, and physical therapy participation were not significantly different.

Conclusions: Ambulation after TKA is superior with ACB on the first POD, but there is no difference in VAS scores, OME, patient satisfaction, or ambulation on POD 2.

Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption

BACKGROUND

Early ambulation with physical therapy (PT) following total knee arthroplasty (TKA) has demonstrated benefits in the literature. However, the impact of early PT on rehabilitation performance and opioid consumption has not been elucidated. We evaluate the effect of same-day PT on inhospital functional outcomes and opioid consumption.

METHODS

We retrospectively identified 2 cohorts of primary TKA patients from July 2016 to December 2017: PT0 (n = 295) received PT on the day of surgery, and PT1 (n = 392) received PT on postoperative day (POD) 1. Outcomes studied included number of feet walked on POD0-3, visual analog scale pain scores, morphine equivalents (ME) consumed, length of stay, and discharge disposition. Analysis was conducted using the Student t-test and Fisher exact test.

RESULTS

In comparison to the PT1 group, the PT0 group walked significantly more steps on POD1 (347.6 vs 167.4 ft, P < .0001), POD2 (342.1 vs 203.5 ft, P < .0001), and POD3 (190.3 vs 128.9 ft, P = .00028). There was no difference between the 2 groups for visual analog scale. The PT0 group also consumed significantly fewer total ME when compared to the PT1 group (149.0 vs 200.3 mg, P = .0002). The PT0 group had a significantly shorter length of stay when compared to the PT1 group (2.7 vs 3.2 days, P = .00075). More patients were discharged home in the PT0 group (81.7% vs 54.8%, P < .0001).

CONCLUSION

We observed that initiation of PT on POD0 led to better PT performance, reduced ME during hospitalization, and more patients discharged home.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

PT Achievement in Public Hospitals and Its Effect on Outcomes

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

Analgesia effect of premixed nitrous oxide/oxygen during the rehabilitation after total knee arthroplasty: a study protocol for a randomized controlled trial

Background

The morbidity of knee arthritis is increasing among aged people and total knee arthroplasty has been its mainstream treatment to date. Postoperative rehabilitation is an important part of the procedure. However, the intense pain during the functional exercise involved has always been a challenge for both patients and health care professionals. The aim of this study is to test the analgesic effect of a mixture of nitrous oxide/oxygeb (1:1) inhalation for patients who are doing functional exercise 1 month after total knee arthroplasty.

Methods/design

This double-blind, randomized, placebo-controlled study will be implemented in the Rehabilitation Department in the General Hospital of Ningxia Medical University. Patients aged between 50 and 75 years who underwent a primary unilateral total knee arthroplasty are eligible for inclusion. The key exclusion criteria include: epilepsy, pulmonary embolism, intestinal obstruction, aerothorax. The treatment group (A) will receive a pre-prepared nitrous oxide/oxygen mixture plus conventional treatment (no analgesics), and the control group (B) will receive oxygen plus conventional treatment (no analgesics). Patients, physicians, therapists, and data collectors are all blind to the experiment. Assessments will be taken immediately after functional exercise begins (T0), 5 min (T1) after functional exercise begins, and 5 min after functional exercise has finished (T2). Patients will be randomly allocated between a treatment group (A) and a control group (B) in a ratio of 1:1. Primary outcome, including pain severity in the procedure, will be taken for each group. Secondary outcomes include blood pressure, heart rate, oxygen saturation, side effects, knee joint range of motion, Knee Society Score (KSS), rescue analgesia need, and satisfaction from both therapists and patients.

Discussion

This study will focus on exploring a fast and efficient analgesic for patients who are doing functional exercise after total knee arthroplasty. Our previous studies suggested that the prefixed nitrous oxide/oxygen mixture was an efficacious analgesic for the management of burn-dressing pain and breakthrough cancer pain. The results of this study should provide a more in-depth insight into the effects of this analgesic method. If this treatment proves successful, it could be implemented widely for patients doing functional exercise in the rehabilitation department.

Trial registration

ChiCTR-INR-17012891. Registered on 6 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3472-7) contains supplementary material, which is available to authorized users.

Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Comparison of knee sonography and pressure pain threshold after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players

Objective

The aim of this study was to compare the pressure pain threshold and muscle architecture after an anatomic single bundle reconstruction with quadriceps tendon and hamstring tendon autografts of the anterior cruciate ligament in competitive soccer players. We hypothesized that both procedures will obtain similar outcomes.

Methods

Fifty-one participants were enrolled in this secondary analysis of a randomized controlled trial and were categorised into two groups: quadriceps tendon (QT) group (23 men and 3 women; mean age 18.7 ± 3.6; BMI 23.0 ± 2.2) or hamstring tendon (HT) group (16 men and 9 women; mean age 19.2 ± 3.6 BMI 23.5 ± 3.5). Both groups followed the same rehabilitation staged protocol. Pressure pain threshold (PPT), as a measure of perceived pain, was obtained in several points of quadriceps and hamstring muscles. Ultrasound imaging measurements were obtained in quadriceps tendon and knee cartilage thickness. Four measurements were taken in this study: baseline, 1, 3, 6, and 12 months after the anterior cruciate ligament (ACL) reconstruction.

Results

The analysis of PPT did not find significant differences in both groups × interaction time in the points evaluated: epicondyle (QT = 421.1 ± 184.1 vs HT = 384.7 ± 154.1 kPa), vastus lateralis (QT = 576.2 ± 221.3 vs HT = 560.1 ± 167.7 kPa), vastus medialis (QT = 544.7 ± 198.8 vs HT = 541.1.1 ± 181.77 kPa), patellar tendon (QT = 626.3 ± 221.1 vs HT = 665.0 ± 205.5 kPa), QT (QT = 651.1 ± 276.9 vs HT = 660.0 ± 195.2 kPa).

(QT = 667.8 ± 284.7 vs HT = 648.2 ± 193.4 kPa) injured knee (all P > 0.05). The results of ultrasound imaging did not show significant differences in both groups × interaction time in the thickness of the QT (QT = 9.9 ± 2.4 vs HT = 9.4 ± 1.7 kPa) and patellar cartilage (QT = 3.2 ± 0.6 vs HT = 3.2 ± 0.4 kPa) (P > 0.05).

Conclusion

A QT autograft produces similar results to a HT autograft in ACL reconstructions in terms of pressure pain threshold and ultrasound muscle architecture during the 1-year follow-up.

Level of Evidence

Level I, Therapeutic Study.

Physical Therapy on Postoperative Day Zero Following Total Knee Arthroplasty: A Randomized, Controlled Trial of 394 Patients

BACKGROUND

Surgeons have increasingly emphasized early mobilization as a way to facilitate discharge following total knee arthroplasty (TKA). The purpose of this study was to determine whether starting formal physical therapy (PT) the afternoon of postoperative day (POD) 0, instead of starting PT the morning of POD 1, could shorten hospital length of stay (LOS).

METHODS

Patients undergoing elective TKA with a planned minimum 1-night hospital stay were randomized to start formal PT the afternoon following surgery or the morning of POD 1. LOS in hours was the primary outcome. An a priori sample size calculation suggested that 394 patients were required to show a 4-hour difference between groups.

RESULTS

Out of 394 patients enrolled and randomized, 378 (95.9%) completed the study. The observed difference in hospital LOS was not large enough to be of clinical significance (intention-to-treat analysis: median of 32.0 hours for POD 0 PT vs 31.0 hours for POD 1 PT, P = .65; as-treated analysis: median of 31.0 hours for POD 0 PT vs 32.0 hours for POD 1 PT, P = .12). Similarly, the observed differences in satisfaction with inpatient PT (10.0 vs 10.0, P = .77), patient-reported readiness for discharge at time of discharge (10.0 vs 10.0, P = .97), and POD 0 pain (3.3 vs 4.0, P = .79) were not large enough to be of clinical significance.

CONCLUSION

While PT on the day of surgery has been suggested as one method to facilitate discharge following TKA, this randomized trial did not demonstrate clinically meaningful differences in hospital LOS or patient satisfaction when PT is initiated on the day of surgery vs on the morning after surgery.

Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty

BACKGROUND

There is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined.

METHODS

From July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT).

RESULTS

Overall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026).

CONCLUSIONS

We recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications.

LEVEL OF EVIDENCE

Level III.

Factors Influencing Discharge Readiness After Total Knee Replacement

Total knee replacement (TKR) surgery has been found to achieve positive outcomes for many patients such as reduced pain and increased function. However, some patients experience suboptimal outcomes including falls, readmission to hospital, and reduced functional performance. Preparation for discharge after TKR surgery is often defined related to pain control, walking, knee function, and ability to climb stairs. These measures may not fully encompass aspects of recovery that impact patients' readiness for discharge after surgery. The purpose of this article is to review discharge readiness following TKR surgery and discuss factors that are known to impact preparedness for discharge.

Immediate Physical Therapy following Total Joint Arthroplasty: Barriers and Impact on Short-Term Outcomes

Background

Recent evidence suggests benefit to receiving physical therapy (PT) the same day as total joint arthroplasty (TJA), but relatively little is known about barriers to providing PT in this constrained time period. We address the following questions: (1) Are there demographic or perioperative variables associated with receiving delayed PT following TJA? (2) Does receiving immediate PT following TJA affect short-term outcomes such as length of stay, discharge disposition, or 30-day readmission? Methods. Primary TJA procedures at a single center were retrospectively reviewed. Immediate PT was defined as within eight hours of surgery. Demographic and perioperative variables were compared between patients who received immediate PT and those who did not. We identified an appropriately matched control group of patients who received immediate PT. Postoperative length of stay, discharge disposition, and 30-day readmissions were compared between matched groups.

Results

In total, 2051 primary TJA procedures were reviewed. Of these, 226 (11.0%) received delayed PT. These patients had a higher rate of general anesthesia (25.2% versus 17.8%, p=0.006), later operative start time (13:26 [11:31-14:38] versus 9:36 [8:24-11:16], p<0.001), longer operative time (1.8 [1.5-2.2] versus 1.6 [1.4-1.8] hours, p=0.002), and higher overall caseload on the day of surgery (6 [4-9] versus 5 [4-8], p=0.002). A matched group of patients who received immediate PT was identified. There were no differences in postoperative length of stay or discharge disposition between matched immediate and delayed PT groups, but delayed PT (OR 4.54; 95% CI 1.61-12.84; p=0.004) was associated with a higher 30-day readmission rate.

Conclusion

Barriers to receiving immediate PT following TJA included general anesthesia, later operative start time, longer operative time, and higher daily caseload. These factors present potential targets for improving the delivery of immediate postoperative PT. Early PT may help reduce 30-day readmissions, but additional research is necessary to further characterize this relationship.

Association between disease-specific anxiety at discharge and functional outcome in patients after total knee arthroplasty

BACKGROUND

Patients who undergo total knee arthroplasty (TKA) may experience disease-specific problems, including decline in motor function and intense pain, which may result in disease-specific anxiety. This study aimed to investigate disease-specific anxiety at discharge, and any association between anxiety and functional outcomes following TKA.

METHODS

The study prospectively included 129 patients who had undergone TKA. Each patient's disease-specific anxiety about wounds, pain, gait, and falling was assessed at discharge using a numerical rating scale, in which 0 represented no anxiety and 10 represented the highest level of anxiety. In addition, patient-reported outcomes (PROs) were evaluated using the Knee Society Score (KSS) at six-months postoperatively. The effects of disease-specific anxiety at discharge were evaluated with the KSS at six-months postoperatively and analyzed separately using multiple regression analysis.

RESULTS

The median score for anxiety about wounds, pain, and gait was 4.0 (IQR 2.0-5.0) at discharge five days after surgery. The median score for anxiety about falling was also 4.0 (IQR 2.0-6.0). The level of anxiety regarding wounds, pain, gait, and falling was negatively associated with the KSS six-months postoperatively after adjusting for all confounding factors (wounds: β = -2.8, 95% CI -4.3 to -1.3; pain: β = -3.4, 95% CI -4.9 to -1.9; gait: β = -4.3, 95% CI -5.8 to -2.9; falling: β = -2.5, 95% CI -3.9 to -1.1).

CONCLUSION

Patients reported similar levels of anxiety regarding wounds, pain, gait, and falling at discharge after TKA. The severity of anxiety symptoms at discharge was negatively associated with PROs six-months postoperatively.

Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total knee arthroplasty is a treatment option for debilitating arthritis. In the postoperative period, patients experience moderate to severe pain affecting the rehabilitation, hospital stay, and patient satisfaction. This study aims at utilizing current best evidence to determine whether adductor canal block (ACB) or periarticular injection (PAI) is a better modality for managing short-term postoperative pain and opioid consumption.

METHODS

Embase, MEDLINE, HealthStar, Emcare, and PubMed were searched for randomized controlled trials from 1946 to August 2018, for literature addressing the comparison of ACB and PAI for pain management in the setting of total knee arthroplasty. A systematic review and meta-analysis were performed.

RESULTS

Six studies were included in our meta-analysis. When examining the combined visual analog scale (VAS) pain values for each group, analysis demonstrated greater reduction in scores for the PAI group, and the difference was statistically significant (P = .001). When comparing the VAS scores of subgroups analyzed at specific periods in time, there was a trend toward lower VAS scores in subgroups analyzed at 24 hours and 48 hours postoperatively (at rest and at movement) in the PAI group. Overall opioid consumption was lower in the PAI group, with demonstrated statistical significance (P = .03). When comparing the postoperative subgroups, there was a trend toward decreased opioid use in the PAI group, with 13.25% less opioid use at 48 hours and 9.5% less opioid use at 24 hours.

CONCLUSION

PAI could significantly improve postoperative pain and opioid consumption when compared with ACB. Additional, high-quality studies are required to further address this topic.

Influence of early mobilization program on pain, self-reported and performance based functional measures following total knee replacement

BACKGROUND

Total knee replacement (TKR) is an optimal treatment for persons with severe knee joint pain and disability, who were unsuccessful with conservative management. Early mobilization can be defined as moving out of bed and/or walking quickly after the surgery for reducing the risks allied with bed rest. There is a paucity of studies on effects of early mobilization on a performance-based measure of timed up and go test (TUG), six-minute walk test (SMWT) and a self-reported disease-specific measure of a knee injury and Osteoarthritis outcome score (KOOS) following TKR.

METHODS

A prospective pre-post-trial was conducted at Manipal Hospital, Bangalore, India. Participants underwent early (POD '0') mobilization on the same postoperative day within 7 h post-TKR surgery. Outcome measures were recorded by an independent blinded observer. The statistical significance level was set at 'p' value < 0.05. The difference between pre-operative and post-operative outcome measure at 1 month and 3 months post-intervention were analyzed using repeated measures of ANOVA.

RESULTS

The study included a total of 78 participants (59 Females; 19 Males) and the mean age of the included participants was 64.1 ± 7 years. Amongst, 78 participants, 53 underwent unilateral TKR, 25 underwent bilateral TKR. There were three dropouts in the study due to post-operative complications. Significant improvements from pre-operative to one month were observed following POD '0' mobilization on NPRS (7.35 ± 1.2 to 4.3 ± 1.7), SMWT (169 ± 70 to 236.7 ± 80.7). KOOS subscales of pain, symptom, and quality of life showed significant changes at one month and 3 months. TUG, Knee strength, Knee ROM and KOOS ADL subscale shown improvements only at 3 months post-intervention.

CONCLUSION

Our study findings suggest that POD '0' (early) mobilization can result in reduced pain and an increase in walking speed at 1 month. Significant changes were observed in pain, Knee strength, Knee ROM, TUG, SMWT and KOOS subscales at 3 months following total knee replacement.

Effectiveness and weakness of local infiltration analgesia in total knee arthroplasty: a systematic review

Local infiltration analgesia has been widely used for pain relief in patients undergoing total knee arthroplasty. However, the effectiveness and major weakness of this technique have not been clarified; therefore, improvements in the technique have been limited. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and conducted a meta-analysis of randomized controlled trials comparing local infiltration analgesia with placebo infiltration in patients undergoing total knee arthroplasty. Fourteen trials involving 1305 knees were eligible. The results showed that local infiltration analgesia significantly reduced early perioperative pain and total narcotic consumption. However, postoperative functional outcomes were not significantly different between local infiltration analgesia and placebo. The pain-relieving effect of local infiltration analgesia was found to be strong but short in duration. In the future, modified delivery methods and formulas with longer durations of action and analgesia may provide a better environment for patients and therefore improve their function outcomes.

The Robustness of Trials That Guide Evidence-Based Orthopaedic Surgery

BACKGROUND

The fragility index (FI) may prove to be a powerful metric of trial robustness. The FI is the minimum number of patient events that would need to become nonevents in order to nullify a significant result. The fragility quotient (FQ) is the FI divided by the total sample size. This study evaluates the robustness of the 20% of orthopaedic clinical trials that were cited as having strong evidence in the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines and that could be analyzed with these indices.

METHODS

From the AAOS recommendations with strong evidence, we extracted the randomized controlled trials that were cited as having supporting evidence that could be analyzed with the FI. Each trial's FI was calculated using the fragility calculator (http://www.fragilityindex.com). With use of the Cochrane Risk of Bias Tool 2.0, we evaluated the likelihood of bias. We also performed a post hoc power analysis of eligible studies.

RESULTS

The median FI for the 72 trials was 2 events, and the median FQ was 0.022. Of the 72 trials, only 3 (4.2%) were at a low risk of bias, and 35 (48.6%) were at a high risk of bias. Thirty-eight (53%) of the trials were underpowered. We identified a strong correlation between a trial's FI or FQ and the trial's power.

CONCLUSIONS

Our study found that trials that provided strong evidence for orthopaedic surgery guidelines were largely fragile, underpowered, and at risk of bias.

Comparison of Periarticular Local Infiltration Analgesia With Femoral Nerve Block for Total Knee Arthroplasty: a Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total knee arthroplasty (TKA) is accompanied by moderate-to-severe postoperative pain. Postoperative pain will hamper functional recovery and lower patients' satisfaction with surgery. Recently, periarticular local infiltration analgesia (LIA) has been widely used in TKA. However, there is no definite answer as to the efficacy and safety of LIA compared with femoral nerve block (FNB).

METHOD

Randomized controlled trials about relevant studies were searched from PubMed (1996 to July 2017), Embase (1980 to July 2017), and Cochrane Library (CENTRAL, July 2017). Ten studies which compared LIA with FNB methods were included in our meta-analysis.

RESULTS

Ten studies containing 950 patients met the inclusion criteria. Our pooled data indicated that LIA was as effective as the FNB in terms of visual analog scale score for pain at 24 hours (P = .52), 48 hours (P = .36), and 72 hours (P = .27), and total morphine consumption (P = .27), range of motion (P = .45), knee society score (P = .51), complications (P = .81), and length of hospital stay (P = .75).

CONCLUSIONS

Our current meta-analysis results demonstrated that there were no differences in efficacy between the FNB and LIA method.

Continuous Adductor Canal Blocks Provide Superior Ambulation and Pain Control Compared to Epidural Analgesia for Primary Knee Arthroplasty: A Randomized, Controlled Trial

BACKGROUND

Adductor canal blocks (ACBs) are an alternative to femoral nerve blocks that minimize lower extremity weakness. However, it is unclear whether this block will provide analgesia that is equivalent to techniques, such as epidural analgesia. The purpose of this randomized controlled trial was to compare continuous ACBs with epidural analgesia for primary total knee arthroplasty.

METHODS

Following institutional review board approval, 145 patients were randomized to 1 of 3 groups: combined spinal-epidural (CSE), spinal + continuous ACB (CACB), or general + CACB. Epidural analgesia was used postoperatively in the CSE group, and an adductor canal catheter was used in the CACB groups. Power analysis determined that 84 patients per group were needed to demonstrate a 35% increase in ambulation with an alpha of 0.05 at a power of 90%.

RESULTS

At interim analysis, 13 patients were removed for protocol deviations, leaving 45 in CSE, 41 in spinal + CACB and 46 in general + CACB groups. Patient demographics were similar in all comparisons suggesting appropriate randomization. Patients in the CACB groups walked further on postoperative day 1, 2, and 3 (P = .02). Mean daily pain scores were lower in the CACB groups (4.1 CSE, 3.0 spinal + CACB, 3.4 general + CACB, P = .009). There was no significant difference in total opioid consumption between groups (158 morphine equivalents CSE, 149 spinal + CACB, and 172 general + CACB). More patients reported being "very satisfied" in CACB groups (68% general + CACB, 63% spinal + CACB, and 36% CSE; P = .001).

CONCLUSION

Continuous adductor analgesia provides superior ambulation, lower pain scores, faster discharge, and greater patient satisfaction when compared to epidural analgesia for primary total knee arthroplasty.