Total Knee Arthroplasty Rehabilitation Research Articles

Preoperative education in hip and knee arthroplasty patients in Bloemfontein.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are frequently performed surgeries worldwide. Preoperative education enhances patient physiotherapy management and satisfaction and should be tailored to patients' educational needs. Limited research is available regarding the preoperative educational needs for these patients. To determine the extent of preoperative education received and the preoperative educational needs of patients undergoing THA and TKA. A structured interview utilising a self-developed questionnaire was used and included questions exploring preoperative education, educational needs, method of education and health care professional providing education. A total of 14 THA and 36 TKA patients, 2-4 days post-operatively at private hospitals in Bloemfontein, were conveniently sampled. All participants had arthroplasties because of osteoarthritis. All participants with THA and 35 (98%) participants with TKA received preoperative education from orthopaedic surgeons, and 8 (57%) participants with THA and 9 (25%) participants with TKA received preoperative education from physiotherapists. Education was mostly given as pamphlets months before the surgery. Participants received the least amount of information regarding exercises, especially preoperative exercise, pain relief and activities of daily living. This study highlights the need for improvement in patient engagement and education, together with enhanced health care practitioner communication and collaboration. Patient centeredness and individualised THA and TKA preoperative education programmes are recognised as a necessary attribute of quality health care and can lead to improved THA and TKA outcomes. The importance of exercise as part of preoperative interprofessional education in the management of THA and TKA should be emphasised as exercise is the cornerstone for rehabilitation of THA and TKA. This study aimed to emphasise the importance of tailored preoperative education for THA and TKA patients to improve patient outcomes.

Multiple Low Doses of Intravenous Corticosteroids to Improve Early Rehabilitation in Total Knee Arthroplasty: A Randomized Clinical Trial.

Low doses of corticosteroids have been proved to be effective in decreasing the inflammatory cytokines and relieving the pain. However, the optimal dosage of corticosteroids in total knee arthroplasty (TKA) is undetermined. A total of 103 patients were randomly divided into three groups. Group A containing 32 patients received normal saline. Group B including 36 patients used two doses of 100 mg hydrocortisone, given 2 hours before and 8 hours after surgery. Group C involving 35 patients received four doses of 100 mg hydrocortisone, 8 hours apart.The level of interleukin 6 (IL-6) and C-reactive protein (CRP) were lower in group C than those in group A when detected at 12, 24, and 48 hours after operation and even lower than that in group B at 24 and 48 hours (p < 0.05, all). The visual analog scale (VAS) pain scores were significantly reduced by using two doses of hydrocortisone at the first 12 hours compared with group A (p > 0.05), but it did not show statistic difference 24 hours later (p > 0.05). For comparison, patients with multiple doses achieved continuously better outcomes on pain management than the blank control group within postoperative 36 hours at rest and at 24 hours with activity. In addition, patients using multiple doses of hydrocortisone achieved fewer occurrences of nausea and vomiting, fever, and sleeplessness, better knee function recovery, better patient satisfaction, and shorter length of hospital stays (p < 0.05, all).Multiple dose of hydrocortisone was benefit to the pain management and early rehabilitation in TKA and may be recommended to the clinical practice.

A Feasibility Study for Improved Physical Activity After Total Knee Arthroplasty

Physical activity outcomes are poor following total knee arthroplasty (TKA). The purpose was to evaluate feasibility of a physical activity feedback intervention for patients after TKA. Participants completing conventional TKA rehabilitation were randomized to a physical activity feedback (PAF; n = 22) or control (CTL; n = 23) group. The PAF intervention included real-time activity feedback, weekly action planning, and monthly group support meetings (12weeks). The CTL group received attention control education. Feasibility was assessed using retention, adherence, dose goal attainment, and responsiveness with pre- and postintervention testing. The PAF group had 100% retention, 92% adherence (frequency of feedback use), and 65% dose goal attainment (frequency of meeting goals). The PAF group average daily step count increased from 5,754 (2,714) (pre) to 6,917 (3,445) steps/day (post). This study describes a feasible intervention to use as an adjunct to conventional rehabilitation for people with TKA.

Effect of Age on Cost-Effectiveness of Unicompartmental Knee Arthroplasty Compared with Total Knee Arthroplasty in the U.S.

Trade-offs between upfront benefits and later risk of revision of unicompartmental knee arthroplasty compared with those of total knee arthroplasty are poorly understood. The purpose of our study was to compare the cost-effectiveness of unicompartmental knee arthroplasty with that of total knee arthroplasty across the age spectrum of patients undergoing knee replacement. Using a Markov decision analytic model, we compared unicompartmental knee arthroplasty with total knee arthroplasty with regard to lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) from a societal perspective for patients undergoing surgery at forty-five, fifty-five, sixty-five, seventy-five, or eighty-five years of age. Transition probabilities were estimated from the literature; survival, from the Swedish Knee Arthroplasty Register; and costs, from the literature and the Healthcare Cost and Utilization Project (HCUP) database. Costs and QALYs were discounted at 3.0% annually. We conducted sensitivity analyses to test the robustness of model estimates and threshold analyses. For patients sixty-five years of age and older, unicompartmental knee arthroplasty dominated total knee arthroplasty, with lower lifetime costs and higher QALYs. Unicompartmental knee arthroplasty was no longer cost-effective at a $100,000/QALY threshold when total knee arthroplasty rehabilitation costs were reduced by two-thirds or more for these older patients. Lifetime societal savings from utilizing unicompartmental knee arthroplasty in all older patients (sixty-five or older) in 2015 and 2020 were $56 to $336 million and $84 to $544 million, respectively. In the forty-five and fifty-five-year-old age cohorts, total knee arthroplasty had an ICER of $30,300/QALY and $63,000/QALY, respectively. Unicompartmental knee arthroplasty became cost-effective when its twenty-year revision rate dropped from 27.8% to 25.7% for the forty-five-year age group and from 27.9% to 26.7% for the fifty-five-year age group. Unicompartmental knee arthroplasty is an economically attractive alternative in patients sixty-five years of age or older, and modest improvements in implant survivorship could make it a cost-effective alternative in younger patients.

Expert Consensus on Best Practices for Post–Acute Rehabilitation After Total Hip and Knee Arthroplasty: A Canada and United States Delphi Study

To synthesize professional and patient expertise with available evidence to recommend best practices for post-acute rehabilitation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). Two expert panels of clinicians, researchers, and patients from Canada and the US participated in a 3-round, online Delphi survey. Consensus was reached on 22 THA and 24 TKA best practice key statements. Recommendations common to both procedures included the need for supervised rehabilitation interventions provided by trained health professionals early after discharge from the acute care setting to optimize patient outcomes. Personal and environmental contextual factors were identified as influencing the process and outcomes of THA and TKA rehabilitation. Routine outcome assessment was recommended and several standardized outcome tools identified. Short-term followup care in the first 2 years postsurgery was recommended for both procedures. Specifics on timing, rehabilitation providers, need for long-term followup, and interventions differed for THA and TKA. Some recommendations received different levels of support based on the type of panelist (patient, physical therapist, surgeon), professional role (clinician, researcher), and/or country. A rigorous consensus method led to key recommendations for post-acute rehabilitation after primary THA and TKA for OA, which together with available evidence and acknowledgment of contextual factors will inform the development of clinical practice guidelines. This is an important step toward reducing practice variation, closing the evidence-practice gap, and improving the quality of rehabilitation services after THA and TKA.

Intérêt d’un programme préopératoire simplifié de rééducation à domicile sur la durée de séjour des patients opérés d’une prothèse totale de genou

In patients with severe knee osteoarthritis (OA), total knee arthroplasty (TKA) is performed for both symptom relief and to achieve better function in daily life. Implementation of efficient TKA rehabilitation programs with shorter length of stay (LOS) and reduced medical expenditures is an important issue in clinical practice. However, the effectiveness of preoperative rehabilitation programs is still under debate. Most preoperative rehabilitation programs last many weeks and may be more expensive than TKA. The purpose of this study was to investigate the effects of a simplified, easy-to-learn, and less time-consuming preoperative rehabilitation education program on TKA patients. In this randomzied controlled study, we allocated all the patients into study and control group according to chart number. The study group, which comprised 126 patients, participated in a 40-min preoperative home rehabilitation education program 4 weeks prior to TKA. One hundred and seventeen patients in the control group did not participate in this preoperative program. The study group required a shorter hospital LOS (mean, 7.12 days; P = 0.027) and had less hospitalization-related medical expenditures (mean, 123726 New Taiwan dollars [NTD], equivalent to 4266.4 United States dollars [USD] or 3022.1 [Euros]), ( P = 0.001) than the control group. However, the study group showed no significant improvement in function when compared to the control group. Our study demonstrates that a simplified preoperative rehabilitation program can reduce LOS and increase cost savings. This program was recommended as a routine protocol for OA patients before admission for TKA. Level II. Prospective randomized study.

Effects of a preoperative simplified home rehabilitation education program on length of stay of total knee arthroplasty patients

In patients with severe knee osteoarthritis (OA), total knee arthroplasty (TKA) is performed for both symptom relief and to achieve better function in daily life. Implementation of efficient TKA rehabilitation programs with shorter length of stay (LOS) and reduced medical expenditures is an important issue in clinical practice. However, the effectiveness of preoperative rehabilitation programs is still under debate. Most preoperative rehabilitation programs last many weeks and may be more expensive than TKA. The purpose of this study was to investigate the effects of a simplified, easy-to-learn, and less time-consuming preoperative rehabilitation education program on TKA patients. In this randomized controlled study, we allocated all the patients into study and control group according to chart number. The study group, which comprised 126 patients, participated in a 40-min preoperative home rehabilitation education program 4 weeks prior to TKA. One hundred seventeen patients in the control group did not participate in this preoperative program. The study group required a shorter hospital LOS (mean: 7.12 days; P=0.027) and had less hospitalization-related medical expenditures (mean: 123726 New Taiwan dollars [NTD], equivalent to 4266.4 United States dollars [USD] or 3022.1 [Euros]), (P=0.001) than the control group. However, the study group showed no significant improvement in function when compared to the control group. Our study demonstrates that a simplified preoperative rehabilitation program can reduce LOS and increase cost savings. This program was recommended as a routine protocol for OA patients before admission for TKA.

Simultaneous bilateral total knee and ankle arthroplasty as a single surgical procedure

BackgroundSimultaneous osteoarthritis (OA) of the ankle joint complicates primary total knee arthroplasty (TKA). In such cases, rehabilitation of TKA is limited by debilitating ankle pain, but varus or valgus ankle arthritis may even compromise placement of knee prosthetic components.Case presentationWe present a patient with simultaneous bilateral valgus and patellofemoral OA of the knees and bilateral varus OA of the ankle joints that equally contributed to overall disability. This 63 years old, motivated and otherwise healthy patient was treated by simultaneous bilateral total knee and ankle arthroplasty (quadruple total joint arthroplasty, TJA) during the same anesthesia. Two years outcome showed excellent alignment and function of all four replaced joints. Postoperative time for rehabilitation, back to work (6th week) and hospital stay (12 days) of this special patient was markedly reduced compared to the usual course of separate TJA.ConclusionsSimultaneous quadruple TJA in equally disabling OA of bilateral deformed knees and ankles resulted in a better functional outcome and faster recovery compared to the average reported results after TKA and TAA in literature. However, careful preoperative planning, extensive patient education, and two complete surgical teams were considered essential for successful performance. To the best of our knowledge this is the first case report in literature about quadruple major total joint arthroplasty implanted during the same anesthesia in the same patient.

Total Knee Arthroplasty: Muscle Impairments, Functional Limitations, and Recommended Rehabilitation Approaches

The number of total knee arthroplasty (TKA) surgeries performed each year is predicted to steadily increase. Following TKA surgery, self-reported pain and function improve, though individuals are often plagued with quadriceps muscle impairments and functional limitations. Postoperative rehabilitation approaches either are not incorporated or incompletely address the muscular and functional deficits that persist following surgery. While the reason for quadriceps weakness is not well understood in this patient population, it has been suggested that a combination of muscle atrophy and neuromuscular activation deficits contribute to residual strength impairments. Failure to adequately address the chronic muscle impairments has the potential to limit the long-term functional gains that may be possible following TKA. Postoperative rehabilitation addressing quadriceps strength should mitigate these impairments and ultimately result in improved functional outcomes. The purpose of this paper is to describe these quadriceps muscle impairments and discuss how these impairments can contribute to the related functional limitations following TKA. We will also describe the current concepts in TKA rehabilitation and provide recommendations and clinical guidelines based on the current available evidence. Therapy, level 5.

Early Neuromuscular Electrical Stimulation to Optimize Quadriceps Muscle function Following Total Knee Arthroplasty: A Case Report

Case report. Following total knee arthroplasty (TKA), restoration of normal quadriceps muscle function is rare. One month after surgery, quadriceps torque (force) is only 40% of preoperative values and quadriceps activation is only 82% of preoperative levels, despite initiating postoperative rehabilitation the day after surgery. Early application of neuromuscular electrical stimulation (NMES) offers a possible approach to minimize loss of quadriceps torque more effectively than traditional rehabilitation exercises alone. A 65-year-old female underwent a right, cemented TKA. Isometric quadriceps and hamstrings muscle torque were measured preoperatively and at 3, 6, and 12 weeks after TKA. Quadriceps muscle activation was measured using a doublet interpolation technique at the same time points. The patient participated in a traditional TKA rehabilitation program augmented by NMES, which was initiated 48 hours after surgery and continued twice a day for the first 3 weeks, and once daily for 3 additional weeks. Preoperatively, the involved quadriceps produced 75% of the torque of the uninvolved side and demonstrated only 72.9% activation. At 3, 6, and 12 weeks after TKA, quadriceps torque was greater than the preoperative values of the involved side by 16%, 29%, and 56%, respectively. Similarly, activation improved to 93.4%, 94.6%, and 93.5% at 3, 6, and 12 weeks after TKA. Mitigating quadriceps muscle weakness immediately after TKA using early NMES may improve functional outcomes, because quadriceps weakness has been associated with numerous functional limitations and an increased risk for falls. Despite presenting preoperatively with substantial quadriceps torque and activation deficits, the patient in this case demonstrated improvements in quadriceps function at all the times measured, all of which were superior to those reported in the literature. The patient also made substantial improvements in functional outcomes, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), 6-minute walk test, timed up and go (TUG) test, stair-climbing test, and the SF-36 Physical Component Score. Appropriately controlled clinical trials will be necessary to determine whether such favorable outcomes following TKA are specifically attributable to the addition of NMES to the rehabilitation program.

Postoperative Total Knee Arthroplasty Rehabilitation: A New Method Using Music Video

Postoperative Total Knee Arthroplasty Rehabilitation: A New Method Using Music Video

Does Shortened Length of Hospital Stay Affect Total Knee Arthroplasty Rehabilitation Outcomes?

Rehabilitation outcomes were compared after primary total knee arthroplasty between patients who participated in a hospital joint arthroplasty program implemented to decrease length of stay and patients who did not. Once inclusion criteria were met, purposive sampling was used to select subjects for retrospective medical records review. Range of motion and Knee Society scores at preoperative and 3-, 6-, and 12-month postoperative intervals were then compared. Preoperatively, there were no significant differences between groups. Program implementation reduced length of hospital stay by a mean of 1.3 days, which resulted in a decreased range of motion at discharge. No significant differences were found between groups postoperatively at all intervals. Primary total knee arthroplasty rehabilitation outcomes were not compromised by reduced length of hospital stay.

Poster 72: Patient satisfaction after total knee arthroplasty: at least 9 years of follow-up

Objective: To identify factors associated with patient satisfaction after total knee arthroplasty (TKA). Design: Longitudinal design with prospectively collected data. Setting: Rehabilitation unit in level III trauma center. Participants: 290 consecutive patients with osteoarthritis who underwent primary or revision TKA (unilateral) between 1989 and 1993 and were evaluated in December 2002. Interventions: TKA and postoperative inpatient rehabilitation. Main Outcome Measures: We used a modified questionnaire of the British Orthopaedic Association. A scale to evaluate the patient satisfaction was used at 9- to 10-year follow-up with the following categories: excellent, good, fair, and poor. A multiple logistic regression analysis was performed to identify the variables that were independently associated to fair or poor personal satisfaction. Results: Personal satisfaction was excellent or good in 75% of the patients. In the multivariable analysis, pain (OR=7.34; 95% CI, 3.43–16.5) and aids for gait (OR=2.75; 95% CI, 1.23–4.56) were factors associated with fair or poor personal satisfaction at 9 to 10 years postsurgery. Conclusion: In osteoarthritic patients and after 9 to 10 years of follow-up, only pain and gait aids were associated with the personal satisfaction.

Total knee arthroplasty rehabilitation protocol: Whatmakes the difference?

The goals of any rehabilitation protocol should be tocontrol pain, improve ambulation, maximize range of motion,develop muscle strength, and provide emotional support. Over 85%of total knee arthroplasty (TKA) patients will recover kneefunction regardless of which rehabilitation protocol is adopted.However, the remaining 15% of patients will have difficultyobtaining proper knee function secondary to significant pain,limited preoperative motion, or the development ofarthrofibrosis. This subset will require a special,individualized rehabilitation program that may involve prolongedoral analgesia, continued physical therapy, additional diagnosticstudies, and occasionally manipulation. Controlling pain is themainstay of any treatment plan. The program described herein hasbeen used at the Ranawat Orthopaedic Center over the past 10years in more than 2,000 TKAs. © 2003 Elsevier Inc. Allrights reserved.

Management and care of patients undergoing total knee arthroplasty: Variations across different health care settings

To examine variation in the process of care for total knee arthroplasty (TKA) and to highlight the need for rigorous research into the ideal management of TKA. We hypothesize that variation in the process of care for TKA across and within health care systems is associated with identifiable financial and historical factors. We compared access to TKA and typical postoperative rehabilitation management in 12 orthopedic centers in the United States (4 centers), United Kingdom (6 centers), and Australia (2 centers). We collected data from two sources: 1) Empirical data on length of stay and discharge management were collected as part of a prospective study of the outcomes of primary TKA for patients with a diagnosis of osteoarthritis; 2) Structured qualitative interviews were conducted at each of the participating centers to collect data on academic status and reimbursement structure, as well as waiting times for orthopedic consultation and TKA surgery once it had been scheduled. We demonstrated differences in length of acute hospital stay, use of extended care facilities, home physical therapy, and outpatient physical therapy within our cohort of hospitals. The publicly funded hospitals had a significantly longer acute hospital length of stay (mean 11.8 days, SD 7.1) than the private hospitals (mean 6.6 days, SD 4.1; P < 0.0001). Variation in waiting times was associated with the method of surgeon reimbursement and whether the hospital is publicly funded or private. Patients attending private hospitals waited 1-8 weeks for the first consultation and 2-12 weeks for a surgical date after scheduling. In contrast, patients attending publicly funded hospitals waited 4-12 months for a first consultation and 12-18 months for a surgical date after scheduling. Our observations are consistent with the hypothesis that financial reimbursement schemes influence the management of TKA. Further research needs to be done to quantify effects of varying processes of care on the outcome of TKA surgery across different health care settings. This data would elucidate the optimal management of TKA using objective evidence rather than relying on financial incentives or the preservation of historical practices.

Kinematic and kinetic changes during an incremental exercise test on a bicycle ergometer

Stationary cycling is typically recommended following total knee arthroplasty (TKA) operations. However, knee joint biomechanics during cycling remains mostly unknown for TKA patients. Biomechanical differences between the replaced and non-replaced limb may inform applications of cycling in TKA rehabilitation. The purpose of this study was to examine the knee joint biomechanics of TKA patients during stationary cycling. Fifteen TKA participants cycled at 80 revolutions per minute and workrates of 80 W and 100 W while kinematics (240 Hz) and pedal reaction forces using a pair of instrumented pedals (1200 Hz) were collected. A 2x2 (limb × workrate) repeated measures ANOVA was run with an alpha of 0.05. Peak knee extension moment (KEM, p = 0.034) and vertical pedal reaction force (p = 0.038) were significantly reduced in the replaced limbs compared to non-replaced limbs by 21.3% and 5.3%, respectively. Peak KEM did not change for TKA patients with the increased workrate (p = 0.750). However, both peak hip extension moment (p = 0.009) and ankle plantarflexion moment (p = 0.017) increased due to increased workrate. Patients following TKA showed similar decreases in peak KEM and vertical pedal reaction force in their replaced compared to non-replaced limbs, as previously seen in gait. Patients of TKA may rely on their hip and ankle extensors to increases in workrate. Increasing intensity by 20 W did not exacerbate any inter-limb differences for peak KEM and vertical PRF.