Ultimate Range Of Motion Research Articles

Immediate versus delayed passive range of motion following total shoulder arthroplasty

The goal of this study was to compare immediate with delayed range of motion (ROM) following total shoulder arthroplasty (TSA). The hypothesis was that ROM gains would occur earlier with immediate motion but that there would be no difference in ultimate ROM or functional outcome. Sixty patients were randomized to immediate motion (IM) or delayed motion (DM) following TSA. A lesser tuberosity osteotomy was performed in all cases. ROM and functional outcome were compared at 4 weeks, 8 weeks, 3 months, 6 months, and 1 year postoperatively. Compared with preoperative values, in the IM group, forward flexion improved from 106° to 141° at 1 year postoperatively, external rotation improved from 21° to 65°, and internal rotation improved by 2 spinal levels (P < .05). In the DM group, forward flexion improved from 104° to 144°, external rotation improved from 20° to 53°, and internal rotation improved by 4 spinal levels (P < .05). The 2 groups regained motion differently, but there were no significant differences in final ROM or functional outcome scores between the 2 groups. The IM group had higher functional outcome scores initially, but by 3 months postoperatively, there was no difference. The rate of osteotomy healing was 81% in the IM group compared with 96% in the DM group (P = .101). Immediate ROM provides a more rapid return of function compared with a delayed ROM protocol following TSA. However, there are no differences in ultimate ROM or functional outcome between the 2 groups. Moreover, immediate ROM may lower the healing rate of a lesser tuberosity osteotomy.

Preoperative Knee Stiffness and Total Knee Arthroplasty Outcomes

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non–stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P < .0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.

Outcome of Nonoperative vs Operative Treatment of Humeral Shaft Fractures: A Retrospective Study of 213 Patients

Standard treatment for most humeral shaft fractures is nonoperative functional bracing; however, certain clinical scenarios necessitate operative intervention. There have been few studies in the literature comparing nonoperative and operative fixation of humeral shaft fractures. Two-hundred thirteen adult patients with a humeral shaft fracture who satisfied inclusion criteria were treated at 2 level 1 trauma centers with either a functional brace (nonoperative treatment group) or compression plating (operative treatment group). Main outcome measures were evaluated retrospectively and included time to union, nonunion, malunion, infection, incidence of radial nerve palsy, and elbow range of motion (ROM). The occurrence of nonunion (20.6% vs 8.7%; P=.0128) and malunion (12.7% vs 1.3%; P=.0011) was statistically significant and more common in the nonoperative group. There was no significant difference in infection rate between nonoperative and operative treatment (3.2% vs 4.7%; P=1.0000). Radial nerve palsy presented after fracture treatment in 9.5% of patients in the nonoperative group and in 2.7% of patients managed operatively (P=.0678). No difference in time to union or ultimate ROM was found between the 2 groups. Closed treatment of humerus fractures had a significantly higher rate of nonunion and malunion while operative intervention demonstrated no significant differences in time to union, infection, or iatrogenic radial nerve palsy. Nonoperative management has historically been the treatment of choice for many humeral shaft fractures, however, in certain clinical scenarios these fractures may be well served by compression plating.

Outcome of Nonoperative vs Operative Treatment of Humeral Shaft Fractures: A Retrospective Study of 213 Patients

Standard treatment for most humeral shaft fractures is nonoperative functional bracing; however, certain clinical scenarios necessitate operative intervention. There have been few studies in the literature comparing nonoperative and operative fixation of humeral shaft fractures. Two-hundred thirteen adult patients with a humeral shaft fracture who satisfied inclusion criteria were treated at 2 level 1 trauma centers with either a functional brace (nonoperative treatment group) or compression plating (operative treatment group). Main outcome measures were evaluated retrospectively and included time to union, nonunion, malunion, infection, incidence of radial nerve palsy, and elbow range of motion (ROM). The occurrence of nonunion (20.6% vs 8.7%; P=.0128) and malunion (12.7% vs 1.3%; P=.0011) was statistically significant and more common in the nonoperative group. There was no significant difference in infection rate between nonoperative and operative treatment (3.2% vs 4.7%; P=1.0000). Radial nerve palsy presented after fracture treatment in 9.5% of patients in the nonoperative group and in 2.7% of patients managed operatively (P=.0678). No difference in time to union or ultimate ROM was found between the 2 groups. Closed treatment of humerus fractures had a significantly higher rate of nonunion and malunion while operative intervention demonstrated no significant differences in time to union, infection, or iatrogenic radial nerve palsy. Nonoperative management has historically been the treatment of choice for many humeral shaft fractures, however, in certain clinical scenarios these fractures may be well served by compression plating.

Revision surgery after trapeziometacarpal arthroplasty

The majority of patients with trapeziometacarpal joint (TMJ) arthritis can be successfully treated with some form of arthroplasty. Residual pain therefore is rather uncommon, but particularly difficult to treat. The aims of this study were to determine the number of patients in need of additional surgery; to identify the most common causes for persistent pain and to establish a treatment algorithm. Twelve patients (11 females, 1 male) who had undergone secondary surgery after TMJ arthroplasty were retrospectively analyzed at a mean time of 32 months after the primary procedure. Parameters included the indication for secondary surgery, the type of procedure, the ultimate range of motion, residual pain levels, upper extremity function assessed by the DASH score and the distance from the first metacarpal bone to the scaphoid. The overall results were assessed according to the Conolly score. The revision rate after primary arthroplasty at our institution was 2.9%. Most common problems for secondary surgery included mechanical pain due to crepitation of the base of the first metacarpal bone, neuropathy of the superficial branch of the radial nerve and concomitant scaphotrapezial arthritis. A total of 19 procedures were performed resulting in two good, five fair and five poor results. A treatment algorithm is presented.

The role of continuous passive motion after total knee arthroplasty.

The usefulness of continuous passive motion after total knee arthroplasty remains controversial. The reported benefits include decreased rates of knee manipulation, deep vein thrombosis, and postoperative use of analgesics, and a greater range of motion. Other studies have reported increased wound complications, bleeding, and pain. Lack of consensus on the use of continuous passive motion exists because reported studies include many confounding variables. Several studies have shown that continuous passive motion in the hospital decreased the rate of knee manipulation from as high as 21% to as low as 0%. Although many studies show that range of motion may improve more rapidly with continuous passive motion, the ultimate range of motion at followup is unchanged. At the author's institution, continuous passive motion is used three times per day (1 hour sessions), beginning on the first postoperative day, within a 4 to 5 day inpatient hospital pathway. Of 132 knees that had a primary posterior-stabilized total knee arthroplasty, seven knees (5%) had a manipulation for failure to obtain greater than 70 degrees flexion. No patients had major wound complications that required reoperation. There is no specific charge to the patient for the continuous passive motion because it is included in the hospital per diem charge. The literature and the author's data support the use of continuous passive motion to decrease the rate of manipulation (and its costs) for poor range of motion after total knee arthroplasty. If patients follow fixed inpatient hospital pathways, the length (and possibly cost) of hospital stay is not changed by use of continuous passive motion. The data on the effect of continuous passive motion on overall analgesic use and prevalence of deep vein thrombosis are not clear.

Complete quadriceps tendon ruptures.

Forty-four patients with 53 quadriceps tendon ruptures were studied retrospectively with an average follow up of 67.2 months (range: 24 to 155). The type of repair was not associated with differences in functional outcome, patient satisfaction, range of motion, or isokinetic testing. Patients with a delay in surgical treatment in comparison to those immediately repaired had significantly worse functional results (P < .05), lower satisfaction scores (P < .05), and lower isokinetic data for both the injured and uninjured extremities, however, their range of motion and comparative extensor power results were nearly identical. On reviewing all patients, the ultimate range of motion was within an average of 2 degrees of the uninjured side in nearly all patients. Based on the results of this study, all surgical methods can be expected to give comparable results as long as treatment is begun within 1 week of the injury. Regaining range of motion comparable to the uninjured side was not a problem in this series despite a delay in treatment.

Treatment of Infected Total Knee Arthroplasty Using an Articulating Spacer

Twenty-six patients with late infected total knee arthroplasties were treated by debridement and removal of components and all cement, preserving collateral ligaments. At time of debridement, an articulating spacer was fashioned to allow partial weightbearing and knee range of motion (ROM) during rehabilitation. This spacer was implanted using antibiotic-impregnated bone cement. For this purpose, 4.8 g of powdered tobramycin was mixed with each 40-g batch of Simplex cement. Cement was applied early to the components, but applied late to the femur, tibia, and patella to allow molding to the defects and bone without adherence to bone. Patients received tailored intravenous antibiotic therapy for 6 weeks in addition to this antibiotic-impregnated cement for treatment of a variety of gram positive and gram negative organisms. All patients had cemented revision total knee arthroplasty using antibiotic-impregnated cement with standard cementing techniques used. All patients but 1 had reimplantation; this patient died of unrelated causes before revision. Range of motion before revision was 10 degrees to 95 degrees. Followup averaged 30 months (range, 13-70 months). The average Modified Hospital for Special Surgery Knee Score after revision was 87 points (range, 53-100 points), with 92% good to excellent results. Range of motion after reimplantation was 5 degrees to 106 degrees. There have been no recurrences of infection. Use of an articulating spacer to treat infected total knee arthroplasty improves ultimate ROM and soft tissue health and significantly decreases the risk of reinfection.

Treatment options for anterior instability: Open versus arthroscopic

Although open Bankart and capsulorrhaphy repair techniques offer a very reliable method for elimination ofanterior shoulder instability, they have the disadvantages of associated surgical morbidity and potential for loss of external rotation. Arthroscopic Bankart repair has been a developing surgical alternative that offers less surgical morbidity and possibly better ultimate range of motion. However, this latter approach has a higher failure rate. In the future, recognition of the optimal factors for successful treatment with arthroscopic techniques may allow the surgeon to select patients for this method, while directing others to an open approach.

Medical capsular recession for severe varus deformities

Medial capsular recession is an effective method of correcting preoperative fixed varus knee deformities at the time of total knee arthroplasty. If the flexion and extension spaces are properly balanced and filled, knee stability is achievable. Sixty-eight knees that had medial capsular recession were followed for at least 2 years after surgery, 19 of them for more than 10 years, with a mean follow-up period of 4.8 years. Of these knees, 73% had less than 5° of postoperative varus/valgus instability with no deterioration during the followup period. Attenuation or rupture of the medial flap occurred in only two knees. There was no statistical difference in ultimate range of motion, alignment, or presence of bone-cement radiolucencies between knees with medial recession and those without medial recession.