Neil Artz

Physiotherapy Provision Following Discharge after Total Hip and Total Knee Replacement: A Survey of Current Practice at High‐Volume NHS Hospitals in England and Wales

BACKGROUND Total hip replacement (THR) and total knee replacement (TKR) are two common elective orthopaedic procedures, and the provision of physiotherapy for patients after discharge is variable, with evidence for best practice remaining uncertain. AIMS AND OBJECTIVES To determine the standard physiotherapy service offered to patients following discharge after THR and TKR. METHODS A telephone survey was carried with clinicians at 24 high-volume NHS orthopaedic centres in England and Wales. Information was gathered on standard physiotherapy provision and categorized into; no routine physiotherapy, outpatient physiotherapy (including one-to-one and group), home-based physiotherapy or other physiotherapy (including telephone consultation and drop-in services). RESULTS No centres surveyed referred patients to outpatient physiotherapy as a routine pathway of care following THR. Eleven centres provided group physiotherapy to patients after discharge following TKR compared with five centres providing one-to-one outpatient physiotherapy. CONCLUSION The provision of physiotherapy following discharge after TKR is a more common practice than after THR, where ongoing physiotherapy is provided depending upon clinical need. Group exercises are the favoured destination for patients following TKR in high-volume centres.

Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial reporting outcomes up to 2 year follow up.

BACKGROUND We present a prospective, randomised, multi-surgeon, controlled trial comparing minimally invasive (MIS) and standard approach total knee arthroplasty (TKA). METHODS Participants underwent unilateral TKA. Patients were randomised to Bristol, quadriceps sparing MIS or standard medial parapatellar approaches. Length of stay with secondary outcome measures including knee range of movement, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and American Knee Society Score (KSS) up to 2 years. Radiographic and post operative assessment was blinded. RESULTS 86 patients (92 knees) participated in the study. Mean operative time between MIS and control groups was 95.5 (95% CI 90.0-101.0) and 94.8 (95% CI 88.2-101.4) minutes respectively. Mean readiness for discharge was shorter in the MIS group 4.5±1.5 (95% CI, 4.1-4.9) days versus 5.9±2.7 (95% CI, 5.1-6.7) days amongst controls (p=0.004). Patients in the MIS group had fewer complications (p=0.003). One patient developed a deep vein thrombosis (DVT) and one required revision surgery, both in the control group. 83 patients completed follow up to 2 years (40 MIS, 43 controls). Range of movement and other outcome measures improved up to 1 year post-operatively with no statistically significant differences between MIS and controls. We found no evidence of radiographic loosening in either group at the 2 year follow up. CONCLUSIONS MIS offers reduced length of stay and fewer complications for patients following TKR without evidence of component mal-alignment. Our findings of fewer systemic complications in MIS TKR patients warrant further future study. LEVEL OF EVIDENCE Level 1.

Effectiveness and cost-effectiveness of a group-based pain self-management intervention for patients undergoing total hip replacement: feasibility study for a randomized controlled trial

BackgroundTotal hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times can be considerable. A pain self-management intervention may provide patients with skills to more effectively manage their pain and its impact during their wait for surgery. This study aimed to evaluate the feasibility of conducting a randomized controlled trial to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR.MethodsPatients listed for a THR at one orthopedic center were posted a study invitation pack. Participants were randomized to attend a pain self-management course plus standard care or standard care only. The lay-led course was delivered by Arthritis Care and consisted of two half-day sessions prior to surgery and one full-day session after surgery. Participants provided outcome and resource-use data using a diary and postal questionnaires prior to surgery and one month, three months and six months after surgery. Brief telephone interviews were conducted with non-participants to explore barriers to participation.ResultsInvitations were sent to 385 eligible patients and 88 patients (23%) consented to participate. Interviews with 57 non-participants revealed the most common reasons for non-participation were views about the course and transport difficulties. Of the 43 patients randomized to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and feedback highlighted that patients enjoyed the group format. Retention of participants was acceptable (83% of recruited patients completed follow-up) and questionnaire return rates were high (72% to 93%), with the exception of the pre-operative resource-use diary (35% return rate). Resource-use completion rates allowed for an economic evaluation from the health and social care payer perspective.ConclusionsThis study highlights the importance of feasibility work prior to a randomized controlled trial to assess recruitment methods and rates, barriers to participation, logistics of scheduling group-based interventions, acceptability of the intervention and piloting resource use questionnaires to improve data available for economic evaluations. This information is of value to researchers and funders in the design and commissioning of future research.Trial registrationCurrent Controlled Trials ISRCTN52305381.

Sensorimotor function of the cervical spine in healthy volunteers

Background Sensorimotor mechanisms are important for controlling head motion. However, relatively little is known about sensorimotor function in the cervical spine. This study investigated how age, gender and variations in the test conditions affect measures of position sense, movement sense and reflex activation in cervical muscles. Methods Forty healthy volunteers (19M/21F, aged 19–59 years) participated. Position sense was assessed by determining repositioning errors in upright and flexed neck postures during tests performed in 25%, 50% and 75% cervical flexion. Movement sense was assessed by detecting thresholds to passive flexion and extension at velocities between 1 and 25°s− 1. Reflexes were assessed by determining the latency and amplitude of reflex activation in trapezius and sternocleidomastoid muscles. Reliability was evaluated from intraclass correlation coefficients. Findings Mean repositioning errors ranged from 1.5° to 2.6°, were greater in flexed than upright postures (P = 0.006) and in people aged over 25 years (P = 0.05). Time to detect head motion decreased with increasing velocity (P < 0.001) and was lower during flexion than extension movements (P = 0.002). Reflexes demonstrated shorter latency (P < 0.001) and greater amplitude (P = 0.009) in trapezius compared to sternocleidomastoid, and became slower and weaker with age. None of the measures were influenced by gender. Reliability was good for movement sense measures, but was influenced by the test conditions when assessing position sense. Interpretation Increased repositioning errors and slower reflexes in older subjects suggest that sensorimotor function in the cervical spine becomes impaired with age. In position sense tests, reliability was influenced by the test conditions with mid-range flexion movements, performed in standing, providing the most reliable measurements.

Patient Reported Kneeling Ability in Fixed and Mobile Bearing Knee Arthroplasty

Kneeling is an important function of the knee joint required for many daily activities. Bearing type is thought to influence functional outcome following UKA and TKA. Self-reported kneeling ability was recorded in 471 UKA and 206 TKA patients with fixed or mobile bearing implants. Kneeling ability was recorded from the Oxford Knee Score question 7. The self-reported ability to kneel was similar in patients with fixed and mobile bearing UKA implants following surgery. In TKA, greater proportions of patients were able to kneel in the fixed compared to the mobile bearing groups up to two years after surgery indicating that self-reported kneeling ability is enhanced in fixed compared to mobile bearing TKA.

Comparison of group-based outpatient physiotherapy with usual care after total knee replacement: a feasibility study for a randomized controlled trial

Objective: To evaluate the feasibility of conducting a randomized controlled trial comparing group-based outpatient physiotherapy with usual care in patients following total knee replacement. Design: A feasibility study for a randomized controlled trial. Setting: One secondary-care hospital orthopaedic centre, Bristol, UK. Participants: A total of 46 participants undergoing primary total knee replacement. Interventions: The intervention group were offered six group-based exercise sessions after surgery. The usual care group received standard postoperative care. Participants were not blinded to group allocation. Outcome measures: Feasibility was assessed by recruitment, reasons for non-participation, attendance, and completion rates of study questionnaires that included the Lower Extremity Functional Scale and Knee Injury and Osteoarthritis Outcome Score. Results: Recruitment rate was 37%. Five patients withdrew or were no longer eligible to participate. Intervention attendance was high (73%) and 84% of group participants reported they were ‘very satisfied’ with the exercises. Return of study questionnaires at six months was lower in the usual care (75%) than in the intervention group (100%). Mean (standard deviation) Lower Extremity Functional Scale scores at six months were 45.0 (20.8) in the usual care and 57.8 (15.2) in the intervention groups. Conclusion: Recruitment and retention of participants in this feasibility study was good. Group-based physiotherapy was acceptable to participants. Questionnaire return rates were lower in the usual care group, but might be enhanced by telephone follow-up. The Lower Extremity Functional Scale had high responsiveness and completion rates. Using this outcome measure, 256 participants would be required in a full-scale randomized controlled trial.