Michael J. Bade

Outcomes Before and After Total Knee Arthroplasty Compared to Healthy Adults

STUDY DESIGN Prospective cohort study. OBJECTIVES To measure changes in muscle strength, range of motion, and function from 2 weeks before to 6 months after total knee arthroplasty (TKA) and compare outcomes with data from a control group consisting of healthy adults. BACKGROUND Total knee arthroplasty successfully alleviates pain from knee osteoarthritis, but deficits in function can persist long term. How impairments and functional limitations change over the first 6 months after TKA, compared to data from healthy adults, has not been well reported in the literature. METHODS Twenty-four patients who underwent a primary unilateral TKA were compared to healthy adults (n = 17). All patients participated in a standardized rehabilitation program following surgery. Isometric quadriceps torque was assessed using an electromechanical dynamometer. Range of motion was measured actively and passively. Functional performance was assessed using the stair-climbing test, timed up-and-go test, 6-minute walk test, and single-limb stance time. Patients underwent testing at 2 weeks preoperatively and at 1, 3, and 6 months postoperatively. RESULTS Compared to healthy older adults, patients performed significantly worse at all times for all measures (P<.05), except for single-limb stance time at 6 months (P>.05). One month postoperatively, patients experienced significant losses from preoperative levels in all outcomes. Patients recovered to preoperative levels by 6 months postoperatively on all measures, except knee flexion range of motion, but still exhibited the same extent of limitation they did prior to surgery. CONCLUSION The persistent impairments and functional limitations 6 months after TKA with standard rehabilitation suggest that more intensive therapeutic approaches may be necessary to restore function of patients following TKA to the levels of healthy adults.

Early High-Intensity Rehabilitation Following Total Knee Arthroplasty Improves Outcomes

STUDY DESIGN Prospective cohort study with an age-matched and sex-matched control group. OBJECTIVES To assess the clinical outcomes of a high-intensity rehabilitation program (HI) compared to those of a group of age-matched and sex-matched controls who underwent a lower intensity rehabilitation program. BACKGROUND Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis; but deficits in function can persist long term. Despite these well-known deficits, there is little evidence supporting the use of rehabilitation interventions following TKA. METHODS Eight patients, who participated in the HI program, were compared to 8 age-matched and sex-matched patients who participated in a lower intensity rehabilitation program (control group). Patients were assessed preoperatively, and at 3.5, 6.5, 12, 26, and 52 weeks postoperatively. Assessment of patients included measures of pain, range of motion (ROM), functional performance, and quadriceps strength and activation. RESULTS There were no differences in knee ROM and pain between the HI and control groups at any postoperative time point. At the 3.5-week and 12-week (end of rehabilitation) time points, the HI group had better functional performance and quadriceps strength compared to the control group (P<.05). At the 52-week time point, the HI group continued to demonstrate better functional performance compared to the control group (P<.05), along with greater quadriceps strength (P = .08). CONCLUSION A HI program leads to better short- and long-term strength and functional performance outcomes compared to a lower intensity rehabilitation program. The HI program did not impair knee ROM and did not result in any musculoskeletal injuries in this small group of patients. LEVEL OF EVIDENCE Therapy, level 2b.

Restoration of physical function in patients following total knee arthroplasty: an update on rehabilitation practices.

Purpose of reviewPrevious studies on rehabilitation following total knee arthroplasty (TKA) demonstrated limited efficacy in increasing long-term outcomes. More recently, several rehabilitation approaches have demonstrated greater efficacy for increasing long-term strength and functional performance outcomes following TKA. Recent findingsNeuromuscular electrical stimulation (NMES), applied to the surgical limbs quadriceps muscle for the first 6 weeks following surgery, has been shown to improve the speed of recovery from TKA and leads to long-term increases in strength and functional performance. Rehabilitation programs that incorporate higher intensity, progressive resistive exercises that target all major muscle groups of the lower extremity have demonstrated superior long-term strength and functional gains compared with lower intensity programs. Finally, although the greatest strength and functional losses occur immediately after surgery, there is emerging evidence that strength and functional gains can be made after the acute postoperative recovery period with programs focusing on the use of progressive aquatic exercise or eccentric exercise. SummaryFunctional recovery following TKA can be enhanced by the use of NMES and utilization of a comprehensive, higher intensity strength training program in conjunction with traditional rehabilitation approaches.

Predicting functional performance and range of motion outcomes after total knee arthroplasty.

ObjectiveThe aim of this study was to assess the predictive value of functional performance and range of motion measures on outcomes after total knee arthroplasty. DesignThis is a secondary analysis of two pooled prospective randomized controlled trials. Sixty-four subjects (32 men and 32 women) with end-stage knee osteoarthritis scheduled to undergo primary total knee arthroplasty were enrolled. Active knee flexion and extension range of motion, Timed Up and Go (TUG) test time, and 6-min walk test distance were assessed. ResultsPreoperative measures of knee flexion and extension were predictive of long-term flexion (&bgr; = 0.44, P < 0.001) and extension (&bgr; = 0.46, P < 0.001). Acute measures of knee flexion and extension were not predictive of long-term flexion (&bgr; = 0.09, P = 0.26) or extension (&bgr; = 0.04, P = 0.76). Preoperative TUG performance was predictive of long-term 6-min walk performance (&bgr; = −21, P < 0.001). Acute TUG performance was predictive of long-term functional performance on the 6-min walk test, after adjusting for the effects of sex and age (P = 0.02); however, once adjusted for preoperative TUG performance, acute TUG was no longer related to long-term 6-min walk performance (P = 0.65). ConclusionsAcute postoperative measures of knee range of motion are of limited prognostic value, although preoperative measures have some prognostic value. However, acute measures of functional performance are of useful prognostic value, especially when preoperative functional performance data are unavailable.

Minimally invasive total knee arthroplasty improves early knee strength but not functional performance: a randomized controlled trial.

A prospective, randomized investigation compared early clinical outcomes of total knee arthroplasty (TKA) using conventional or minimally invasive surgical (MIS) approaches (n = 44). Outcome measures included isometric quadriceps and hamstrings strength, quadriceps activation, functional performance, knee pain, active knee range of motion, muscle mass, the Short Form-36, and Western Ontario and McMaster University Osteoarthritis Index, assessed preoperatively and 4 and 12 weeks after TKA. Four weeks after TKA, the MIS group had greater hamstring strength (P = .02) and quadriceps strength (P = .07), which did not translate to differences in other outcomes. At 12 weeks, there were no clinically meaningful differences between groups on any measure. Although MIS may lead to faster recovery of strength in patients undergoing TKA, there was no benefit on longer-term recovery of strength or functional performance.

Predicting Poor Physical Performance after Total Knee Arthroplasty

The purpose of this study was to develop a preliminary decision algorithm predicting functional performance outcomes to aid in the decision of when to undergo total knee arthroplasty (TKA). One hundred and nineteen patients undergoing primary unilateral TKA were evaluated before and 6 months after TKA. A regression tree analysis using a recursive partitioning function was performed with the Timed Up and Go (TUG) time, Six‐Minute Walk (6MW) distance, and Stair Climbing Test (SCT) time as measured 6 months after TKA as the primary outcomes. Preoperative measures of functional performance, joint performance, anthropometrics, demographics, and self‐reported status were evaluated as predictors of the primary outcomes 6 months after surgery. Individuals taking ≥10.1 s on the TUG and aged 72 years or older before surgery had the poorest performance on the TUG 6 months after surgery. Individuals walking <314 meters on the 6MW before surgery had the poorest performance on the 6MW test 6 months after surgery. Individuals taking ≥17 s to complete the SCT and scoring <40 on the SF‐36 mental component score before surgery had the poorest performance on the SCT 6 months after surgery. Poorer performance preoperatively on the 6MW, SCT, and TUG, was related to poorer performance in the same measure after TKA. Age and decreased mental health were secondary predictors of poorer performance at 6 months on the TUG and SCT, respectively. These measures may help further develop models predicting thresholds for poor outcomes after TKA.

Arthrofibrosis Associated With Total Knee Arthroplasty

BACKGROUND Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patients ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Factors predicting weight-bearing asymmetry 1 month after unilateral total knee arthroplasty: A cross-sectional study

UNLABELLED Factors predicting weight-bearing asymmetry (WBA) after unilateral total knee arthroplasty (TKA) are not known. However, identifying modifiable and non-modifiable predictors of WBA is needed to optimize rehabilitation, especially since WBA is negatively correlated to poor functional performance. The purpose of this study was to identify factors predictive of WBA during sit-stand transitions for people 1month following unilateral TKA. METHODS Fifty-nine people were tested preoperatively and 1month following unilateral TKA for WBA using average vertical ground reaction force under each foot during the Five Times Sit-to-Stand Test. Candidate variables tested in the regression analysis represented physical impairments (strength, muscle activation, pain, and motion), demographics, anthropometrics, and movement compensations. RESULTS WBA, measured as the ratio of surgical/non-surgical limb vertical ground reaction force, was 0.69 (0.18) (mean (SD)) 1month after TKA. Regression analysis identified preoperative WBA (β=0.40), quadriceps strength ratio (β=0.31), and hamstrings strength ratio (β=0.19) as factors predictive of WBA 1month after TKA (R(2)=0.30). CONCLUSION Greater amounts of WBA 1month after TKA are predicted by modifiable factors including habitual movement pattern and asymmetry in quadriceps and hamstrings strength.

Minimally Invasive Total Knee Arthroplasty: Surgical Implications for Recovery

BACKGROUND Despite growing interest in minimally invasive surgery (MIS) techniques for total knee arthroplasty (TKA), few randomized controlled trials have compared MIS and conventional TKA using a combination of functional performance, knee pain, knee range of motion (ROM), and surgical and radiographic outcomes. METHODS A prospective, randomized investigation comparing early outcomes of TKA using conventional or MIS approaches (n = 44). Patients were assessed preoperatively, 48 hours, 4 and 12 weeks postoperatively by blinded evaluators. Outcome measures included timed-up-and-go, 100-ft walk, knee pain, passive knee ROM, Knee Society Score, blood loss, tourniquet time, hospital length of stay, surgical complications, and radiographic outcomes. RESULTS No significant differences in functional performance, knee pain, knee ROM, surgical, or radiographic outcomes were observed between groups at 48 hours, 4 or 12 weeks postoperatively. CONCLUSION While surgical and radiographic outcomes were not compromised with MIS surgery, there were also no improvements in pain, ROM, or functional performance with MIS TKA.

Effects of Weight-Bearing Biofeedback Training on Functional Movement Patterns Following Total Knee Arthroplasty: A Randomized Controlled Trial.

STUDY DESIGN Randomized controlled trial. OBJECTIVES To examine the effects of weight-bearing biofeedback training on weight-bearing symmetry and functional joint moments following unilateral total knee arthroplasty. BACKGROUND Individuals after unilateral total knee arthroplasty place more weight on the nonsurgical limb compared to the surgical limb during function. It is unknown whether targeted intervention can improve function in the surgical limb and resolve altered movement patterns. METHODS Twenty-six patients were randomly assigned to 2 groups (reload or control). The reload group had a standard-of-care rehabilitation augmented with weight-bearing biofeedback training, and the control group had a dose-matched standard-of-care rehabilitation. Lower-limb weight-bearing ratios were measured preoperatively and 6 and 26 weeks after total knee arthroplasty during a 5-time sit-to-stand test (FTSST) and walking. Secondary outcomes were FTSST time, walking speed, and lower-limb joint moments during the FTSST and walking. RESULTS No between-group differences were found in weight-bearing ratios. Five-time sit-to-stand test time improved in the reload group compared to the control group at 6 (P = .021) and 26 weeks (P = .021). There were no between-group differences in knee extension moment during the FTSST. Surgical-limb knee extension moments during walking increased from baseline to 26 weeks in the reload group and decreased in the control group (P = .008). CONCLUSION Weight-bearing biofeedback training had no effect on functional weight-bearing symmetry or knee extension moments during the FTSST. However, the biofeedback training resulted in increases of knee extension moments during gait and improved FTSST times. Trial registered at ClinicalTrials.gov (NCT01333189). Level of Evidence Therapy, level 2b.