Otto Schnell Husby

Early Maximal Strength Training Is an Efficient Treatment for Patients Operated With Total Hip Arthroplasty

UNLABELLED Husby VS, Helgerud J, Bjørgen S, Husby OS, Benum P, Hoff J. Early maximal strength training is an efficient treatment for patients operated with total hip arthroplasty. OBJECTIVE To compare muscle strength, work efficiency, gait patterns, and quality of life in patients undergoing total hip arthroplasty (THA) randomly assigned to either maximal strength training or a conventional rehabilitation program. DESIGN A randomized controlled study. SETTING Research laboratory, rehabilitation center, and physical therapy clinic. PARTICIPANTS Patients (N=24) with osteoarthritis as the main reason for THA were randomly assigned to perform maximal strength training (n=12) or conventional rehabilitation (n=12). INTERVENTIONS The maximal strength training group (STG) performed maximal strength training in leg press and abduction with the operated leg only 5 times a week for 4 weeks in addition to the conventional rehabilitation program. The conventional rehabilitation group (CRG) received supervised physical therapy 3 to 5 times a week for 4 weeks. MAIN OUTCOME MEASURES 1-repetition maximum (1RM) leg press strength, 1RM abduction strength, rate of force development (RFD), work efficiency, gait patterns, and quality of life. RESULTS 1RM increased in the bilateral leg press (P<.002) and in the operated leg separately (P<.002) in the STG compared with the CRG. 1RM abduction strength in the operated leg (P<.002) and the healthy leg (P<.002) increased in the STG compared with the CRG. RFD increased in the STG compared with the CRG (P(g)=.030), followed by a trend towards increased peak force in the STG (P(g)=.053) (P(g) = probability for differences between groups). Work efficiency tended to improve in the STG compared with the CRG (P=.065). No differences in gait patterns were revealed between the groups after the training intervention. CONCLUSIONS Early maximal strength training 1 week postoperatively is feasible and an efficient treatment to regain muscular strength for patients who have undergone THA, demonstrated by a significantly larger increase in muscular strength and a trend towards a better work efficiency in the STG compared with the CRG.

1–year follow–up of 920 hip and knee arthroplasty patients after implementing fast–track

Background — Fast–track has become a well–known concept resulting in improved patient satisfaction and postoperative results. Concerns have been raised about whether increased efficiency could compromise safety, and whether early hospital discharge might result in an increased number of complications. We present 1–year follow–up results after implementing fast–track in a Norwegian university hospital. Methods — This was a register–based study of 1,069 consecutive fast–track hip and knee arthroplasty patients who were operated on between September 2010 and December 2012. Patients were followed up until 1 year after surgery. Results — 987 primary and 82 revision hip or knee arthroplasty patients were included. 869 primary and 51 revision hip or knee patients attended 1–year follow–up. Mean patient satisfaction was 9.3 out of a maximum of 10. Mean length of stay was 3.1 days for primary patients. It was 4.2 days in the revision hip patients and 3.9 in the revision knee patients. Revision rates until 1–year follow–up were 2.9% and 3.3% for primary hip and knee patients, and 3.7% and 7.1% for revision hip and knee patients. Function scores and patient–reported outcome scores were improved in all groups. Interpretation — We found reduced length of stay, a high level of patient satisfaction, and low revision rates, together with improved health–related quality of life and functionality, when we introduced fast–track into an orthopedic department in a Norwegian university hospital.

Early postoperative maximal strength training improves work efficiency 6-12 months after osteoarthritis-induced total hip arthroplasty in patients younger than 60 years.

Husby VS, Helgerud J, Bjørgen S, Husby OS, Benum P, Hoff J: Early postoperative maximal strength training improves work efficiency 6–12 months after osteoarthritis induced total hip arthroplasty in patients younger than 60 years. Objective:To assess physical outcome of early maximal strength training after total hip arthroplasty. Design:Six- and 12-mo follow-up of 24 (22) total hip arthroplasty patients randomly assigned to 4 wks of maximal strength training and conventional rehabilitation and to conventional rehabilitation only was conducted. After the intervention period, all patients attended conventional rehabilitation. Outcome measures were hip abduction and leg press strength, gait patterns, work efficiency, maximal oxygen consumption, and health-related quality of life. Results:Work efficiency was significantly higher in the strength training and conventional rehabilitation group compared with the conventional rehabilitation–only group after 6 and 12 mos by 29% and 30%, respectively. Leg press for the healthy leg and rate of force development for the operated leg were significantly higher in the strength training and conventional rehabilitation group compared with the conventional rehabilitation–only group 12 mos postoperatively by 36% and 74%, respectively. Conclusions:This study demonstrates higher work efficiency after 6 and 12 mos and improved rate of force development after 12 mos in total hip arthroplasty patients who performed early maximal strength training combined with conventional rehabilitation after total hip arthroplasty surgery compared with total hip arthroplasty patients receiving conventional rehabilitation only. However, the study indicates that a prolonged maximal strength training program and aerobic endurance training are required to fully recover total hip arthroplasty patients.

High local concentrations without systemic adverse effects after impaction of netilmicin-impregnated bone

Background When cancellous bone is impregnated with antibiotics the subsequent release of antibiotics from the bone shows a high early release. Hence, impaction of large amounts of netilmicin-impregnated bone may cause toxic netilmicin values in serum.Patients and methods We studied kidney and otovestibular function after impacting 50 g of netilmicin-impregnated cancellous bone during revision hip or knee arthroplasty in 20 patients. The bone was impacted in the acetabulum (n = 8), proximal femur (n = 9) and distal femur/proximal tibia (n = 3). Serum creatinine concentration was measured and audiometry was performed before and after the operation. Netilmicin concentrations in serum, joint fluid, and in urine were recorded postoperatively at regular intervals. We analyzed pharmacokinetics in two study groups receiving bone impregnated with netilmicin (50 mL), at either 50 mg netilmicin/mL (group I) or 100 mg netilmicin/mL (group II).Results Neither netilmicin-induced renal toxicity, nor otovestibular toxicity was registered. Peak serum netilmicin values in group I and group II were 0.9 (0.5–1.3) mg/L and 1.8 (0.6–4.0) mg/L, respectively (p = 0.04). Peak netilmicin concentrations in wound drainage fluid in group I and group II were 237 (9–647) mg/L and 561 (196–1132) mg/L, respectively (p = 0.01). In both groups, netilmicin was recovered in urine samples for approximately 4 weeks.Interpretation 50 grams of cancellous bone impregnated with 100 mg/mL netilmicin solution was impacted in the hip or knee joint with no adverse effects. Extremely high local concentrations of netilmicin in joint fluid were recorded postoperatively. The use of antibioitic-impregnated cancellous could be an option when performing revision of hip and knee prostheses.

Muscular strength after total hip arthroplasty: A prospective comparison of 3 surgical approaches

Background and purpose — Minimizing the decrease in muscular strength after total hip arthroplasty (THA) might allow patients to recover faster. We evaluated muscular strength in patients who were operated on using 3 surgical approaches. Patients and methods — In a prospective cohort study, 60 patients scheduled for primary THA were allocated to the direct lateral, posterior, or anterior approach. Leg press and abduction strength were evaluated 2 weeks or less preoperatively, 2 and 8 days postoperatively, and at 6-week and 3-month follow-up. Results — Differences in maximal strength change were greatest after 2 and 8 days. The posterior and anterior approaches produced less decrease in muscular strength than the direct lateral approach. 6 weeks postoperatively, the posterior approach produced greater increase in muscular strength than the direct lateral approach, and resulted in a greater increase in abduction strength than the anterior approach. At 3-month follow-up, no statistically significant differences between the groups were found. The operated legs were 18% weaker in leg press and 15% weaker in abduction than the unoperated legs, and the results were similar between groups. Interpretation — The posterior and anterior approaches appeared to have the least negative effect on abduction and leg press muscular strength in the first postoperative week; the posterior approach had the least negative effect, even up to 6 weeks postoperatively. THA patients have reduced muscle strength in the operated leg (compared to the unoperated leg) 3 months after surgery.

Perioperative local infiltration anesthesia with ropivacaine has no effect on postoperative pain after total hip arthroplasty.

Background and purpose — The local infiltration analgesia (LIA) technique has been widely used to reduce opioid requirements and to improve postoperative mobilization following total hip arthroplasty (THA). However, the evidence for the efficacy of LIA in THA is not yet clear. We determined whether single-shot LIA in addition to a multimodal analgesic regimen would reduce acute postoperative pain and opioid requirements after THA. Patients and methods — 116 patients undergoing primary THA under spinal anesthesia were included in this randomized, double-blind, placebo-controlled trial. All patients received oral opioid-sparing multimodal analgesia: etoricoxib, acetaminophen, and glucocorticoid. The patients were randomized to receive either 150 mL ropivacaine (2 mg/mL) and 0.5 mL epinephrine (1 mg/mL) or 150 mL 0.9% saline. Rescue analgesic consisted of morphine and oxycodone as needed. The primary endpoint was pain during mobilization in the recovery unit. Secondary endpoints were pain during mobilization on the day after surgery and total postoperative opioid requirements on the first postoperative day. Results — The levels of pain during mobilization—both in the recovery unit and on the day after surgery—and consumption of opioids on the first postoperative day were similar in the 2 groups. Interpretation — LIA did not provide any extra analgesic effect after THA over and above that from the multimodal analgesic regimen used in this study.

Impact of maximal strength training on work efficiency and muscle fiber type in the elderly: Implications for physical function and fall prevention

ABSTRACT Although aging is typically associated with a decreased efficiency of locomotion, somewhat surprisingly, there is also a reduction in the proportion of less efficient fast‐twitch Type II skeletal muscle fibers and subsequently a greater propensity for falls. Maximal strength training (MST), with an emphasis on velocity in the concentric phase, improves maximal strength, the rate of force development (RFD), and work efficiency, but the impact on muscle morphology in the elderly is unknown. Therefore we evaluated force production, walking work efficiency, and muscle morphology in 11 old (72 ± 3 years) subjects before and after MST of the legs. Additionally, for reference, the MST‐induced morphometric changes were compared with 7 old (74 ± 6 years) subjects who performed conventional strength training (CST), with focus on hypertrophy, as well as 13 young (24 ± 2 years) controls. As expected, MST in the old improved maximal strength (68%), RFD (48%), and work efficiency (12%), restoring each to a level similar to the young. However, of importance, these MST‐induced functional changes were accompanied by a significant increase in the size (66%) and shift toward a larger percentage (56%) of Type II skeletal muscle fibers, mirroring the adaptations in the hypertrophy trained old subjects, with muscle composition now being similar to the young. In conclusion, MST can increase both work efficiency and Type II skeletal muscle fiber size and percentage in the elderly, supporting the potential role of MST as a countermeasure to maintain both physical function and fall prevention in this population. HighlightsHigh intensity maximal strength training (MST) improves work efficiency.In the current study we provide new insight in the underlying muscle morphology.Despite associated with neural adaptations, MST leads to Type II fiber alterations.Similar to moderate intensity hypertrophy‐inducing strength trainingMST is an excellent strategy for improving physical function and preventing falls.

Small and similar amounts of micromotion in an anatomical stem and a customized cementless femoral stem in regular-shaped femurs: A 5-year follow-up randomized RSA study

Background and purpose — High primary stability is important for long-term survival of uncemented femoral stems. Different stem designs are currently in use. The ABG-I is a well-documented anatomical stem with a press-fit design. The Unique stem is designed for a tight customized fit to the cortical bone of the upper femur. This implant was initially developed for patients with abnormal anatomy, but the concept can also be used in patients with normal femoral anatomy. We present 5-year radiostereometric analysis (RSA) results from a randomized study comparing the ABG-I anatomical stem with the Unique femoral stem. Patients and methods — 100 hips with regular upper femur anatomy were randomized to either the ABG-I stem or the Unique femoral stem. RSA measurements were performed postoperatively and after 3, 6, 12, 24, and 60 months. Results — RSA measurements from 80 hips were available for analysis at the 5-year follow-up. Small amounts of movement were observed for both stems, with no statistically significant differences between the 2 types. Interpretation — No improvement in long-term stability was found from using a customized stem design. However, no patients with abnormal geometry of the upper femur were included in this study.

A randomized controlled trial on maximal strength training in 60 patients undergoing total hip arthroplasty: Implementing maximal strength training into clinical practice

Background and purpose — Total hip arthroplasty (THA) patients have reduced muscle strength after rehabilitation. In a previous efficacy trial, 4 weeks’ early supervised maximal strength training (MST) increased muscle strength in unilateral THA patients <65 years. We have now evaluated muscle strength in an MST and in a conventional physiotherapy (CP) group after rehabilitation in regular clinical practice. Patients and methods — 60 primary THA patients were randomized to MST or CP between August 2015 and February 2016. The MST group trained at 85–90% of their maximal capacity in leg press and abduction of the operated leg (4 × 5 repetitions), 3 times a week at a municipal physiotherapy institute up to 3 months postoperatively. The CP group followed a training program designed by their respective physiotherapist, mainly exercises performed with low or no external loads. Patients were tested pre- 3, 6, and 12 months postoperatively. Primary outcomes were abduction and leg press strength at 3 months. Other parameters evaluated were pain, 6-min walk test, Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) Physical Function Short-form score. Results — 27 patients in each group completed the intervention. MST patients were substantially stronger in leg press and abduction than CP patients 3 (43 kg and 3 kg respectively) and 6 months (30 kg and 3 kg respectively) postoperatively (p ≤ 0.002). 1 year postoperatively, no intergroup differences were found. No other statistically significant intergroup differences were found. Interpretation — MST increases muscle strength more than CP in THA patients up to 6 months postoperatively, after 3 months’ rehabilitation in clinical practice. It was well tolerated by the THA patients and seems feasible to conduct within regular clinical practice.

Load transfer in the proximal femur and primary stability of a cemented and uncemented femoral stem: An experimental study on cadaver femurs

There are principally two fixation methods in total hip arthroplasty, cemented and uncemented. Both methods have in general good long-time survival. Studies comparing cemented and uncemented femoral stems indicate that the cemented stems perform somewhat better, at least in the elderly population. The aim of this study was to compare load transfer and the initial micromotion pattern for an uncemented and a cemented stem. A total of 12 human cadavers were tested in a hip simulator during single leg and stair climbing. Strain was measured on the proximal femur before and after implantation of the prostheses, and the values were presented as percentage of physiological strain. The micromovements between the stem and bone were measured and a total point motion was calculated. The results showed small statistically significant differences between the fixation methods, the largest difference being 8.1 percentage points. The uncemented stem had somewhat higher micromotion than the cemented stem, but less than 10 µm. Both stems thus had acceptable primary stability. The main finding of this study is the strain and micromotion pattern of a cemented and an uncemented stem of similar geometry is overall equal. There were small statistical significant differences between the two fixation methods regarding strain and micromotion levels. The differences are considered too small to be clinically relevant.