Fall incidence and risk factors in patients after total knee arthroplasty

Incidence and Determinants of Falls Following Hip and Knee Joint Arthroplasty: A Systematic Review and Meta-Analysis

Hip and knee joint arthroplasty is a common procedure. The true incidence and predictors of postoperative falls remain uncertain. The aim of this systematic review and meta-analysis is to (1) determine the overall incidence of falls post hip and knee joint arthroplasty, (2) identify risk factors associated with these falls, and (3) evaluate the effectiveness of fall prevention strategies and interventions in reducing fall incidence. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was registered in PROSPERO. This research was conducted using PubMed, Google Scholar, Web of Science, ScienceDirect, and Wiley Online Library. Two independent reviewers screened studies by title, abstract, and full text. The quality of the included articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A total of 1,282 publications were identified, leading to the review of 988 patients aged between 60 and 88 years, reviewed for this systematic review from seven full-text articles. Fall incidence post total knee arthroplasty (TKA) varied, with five reporting increased rates (36%, 32.9%, 38.2%, 22.1%, and 32%) and two indicating a decrease (50% and 26.4% reduction). All studies emphasized the role of postoperative limitations and psychological factors on fall risk. Additionally, patients living alone had higher odds of falling, highlighting the need for targeted postoperative care. While fall incidence post hip and knee arthroplasty varies, improvements in quality of life and functional outcomes following surgery are reported. Future research should focus on larger sample sizes, control groups, objective assessments, extended follow-up periods, and various joint replacements.

Fall Prevention after Hip and Knee Arthroplasty

Despite the success of total knee arthroplasty and total hip arthroplasty, patients face an increased risk of postoperative falls, often due to surgery-induced changes in muscle strength. Falls can lead to serious consequences, including fractures and reduced quality of life. The majority of falls related to total joint arthroplasty occurs outside the hospital. Effective fall prevention strategies, such as patient education, exercise interventions, environmental modifications, and medication management, are crucial for reducing fall risks and improving patient outcomes. Continued research and innovation in fall prevention are essential for improving patient safety and well-being following joint arthroplasty.

Who breaks their hip? A decade of traumatic hip fracture data

Aims & objectives

Hip fractures lead to significant morbidity, mortality, and healthcare costs, particularly in elderly populations. Understanding the mechanisms underlying these fractures is crucial for developing targeted prevention strategies and counseling patients.

Methods

The National Electronic Injury Surveillance System (NEISS) was utilized to identify a cohort of 25,068 hip fractures from 2013 to 2022. The inclusion criteria mandated classification as a lower trunk fracture and explicit mention of hip fracture in the narrative. Patient age, race, sex, incident location, the time of year, and associated consumer products were compared using 95% confidence intervals and Chi-Squared tests of independence.

Results

A total of 25,068 hip fracture patients were included in this study. Females were more likely to fracture their hip (P < .001) representing 68.4% (95% CI 67.8%-69.0%) of all fractures. Patients were most likely to injure themselves at home (P < .001), accounting for 62.0 % (95% CI 61.4%-62.6%) of fractures. Falls to the floor represented 36.0 % (95% CI 35.4%-36.6%) of fractures, while fractures related to beds, stairs, and chairs emerged as other prevalent mechanisms at 11.2% (95% CI 10.8%-11.6%), 7.9% (95% CI 7.5%-8.2%), and 5.4% (95% CI 5.1%-5.7%), respectively. In the 50-60 age group, stairs present a prominent risk, representing 12.4% (95% CI 10.6%-14.5%) of fractures. Younger individuals suffered fractures most commonly due to high energy activities, such as falls from ladders, bicycles, and stairs (P < .001).

Conclusion

While falls remain the chief cause of hip fractures, many of these injuries stem from overlooked mechanisms. The heightened risk associated with falls from beds and chairs in the elderly, stair-related injuries in middle-aged individuals, and high-force modalities in younger people, highlights the necessity for tailored preventive measures. Providers should counsel their patients on risk reduction measures within the home, while Medicare and other insurers must work to expand coverage for these same measures.

The short- and long-term effects of a fall prevention program on the frequency of falls following total knee replacement: A pragmatic single-blinded randomized controlled trial protocol

BACKGROUND

Falling following total knee replacement (TKR) is a significant issue, and can result in serious fatal and non-fatal injuries. The proposed study aims to investigate the short and long-term effects of integrating a falls prevention program into conventional physiotherapy versus just conventional physiotherapy on the number of falls, and any subsequent effects on balance, and functional ability among TKR patients.

METHODS AND DESIGN

This is a parallel group prospective (52 weeks) randomized single-blinded pragmatic controlled trial conducted at Alrazi Orthopedic Hospital, in Kuwait. Sample size will be 90 pariticpants (45 participants in each group). Particpants will be randomized to intervention or control group. Outcome measures will be collected at baseline, 12 weeks and 52 weeks by investigators who are blinded to treatment allocation. Primary outcome will be fall rate assessed at 52 weeks following the TKR surgery. Secondary outcomes will include knee range of motion, severity of pain, 10-m walk test, Timed Up and Go test, Berg Balance Scale, 30-s sit to stand, patient adherence to home program and patient's satisfaction. Two-way multivariate ANOVA (group × time) will be performed to assess the group (experimental and control group) differences over time (baseline, 12, and 52 weeks).

DISCUSSION

Investigating the physiotherapy programs that could minimize or prevent the risk of falling among TKR patients seems important. The proposed study will be the first step toward determining the exercise program that could be effective in reducing the number of falls among TKR patients.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT05642260.

Postoperative Complications and Readmission Rates in Robotic-Assisted Versus Manual Total Knee Arthroplasty: Large, Propensity Score-Matched Patient Cohorts

INTRODUCTION

There is a paucity of research comparing postoperative complication rates between manual total knee arthroplasty (M-TKA) and robotic-assisted total knee arthroplasty (RA-TKA). This study aims to compare 90-day postoperative complication, readmission, and emergency department rates between RA-TKA and M-TKA.

METHODS

A retrospective review of a multihospital database identified patients who underwent TKA between January 2016 and May 2023. Surgeons who used the robotic-assisted surgery technique in <10% or >90% of their cases annually were excluded. This resulted in 15,999 cases (8,853 RA-TKAs; 7,146 M-TKAs) from 282 surgeons. RA-TKA and M-TKA cohorts were one-to-one matched based on patient sex, age, body mass index, hospital setting, surgeon experience, primary payer, and anesthesia type. Each cohort consisted of 7,146 patients (N = 14,292). 90-day revisits, specifically readmissions, readmissions with >23 hours of observation, and ED visit rates were compared between cohorts. Complications were classified according to the Clinical Classification Software schema and compared between cohorts. Mann-Whitney U, chi-squared, and Fisher exact tests, along with Bonferroni correction, were used to statistically compare cohorts.

RESULTS

All-cause 90-day readmission rates were 2.4% for RA-TKA and 2.6% for M-TKA ( P = 0.36). RA-TKA had fewer revisits (RA-TKA: 7.8%; M-TKA: 8.8%, P = 0.027) and rates of readmission with >23 hours of observation (RA-TKA: 1.4%; M-TKA: 2.0%, P = 0.003). RA-TKA had fewer hospital revisits due to joint stiffness (RA-TKA: 17 revisits; M-TKA: 42 revisits, P = 0.002) and chronic pain (RA-TKA: 1 revisit; M-TKA: 8 revisits, P = 0.039). Fewer readmissions were observed for acute injuries (lower extremity muscle/tendon strains) in the RA-TKA cohort (RA-TKA: 1; M-TKA: 9, P = 0.021). RA-TKA had fewer ED visits due to hematomas (RA-TKA: 0 visits; M-TKA: 7 visits, P = 0.016).

CONCLUSION

In this retrospective matched cohort analysis, RA-TKA was associated with markedly fewer revisits and readmissions with >23 hours of observation compared with M-TKA. No differences in all-cause 90-day readmission were observed between cohorts.

LEVEL OF EVIDENCE

Level III.

STUDY DESIGN

Retrospective review.

Long-term gait analysis in patients after total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Gait abnormalities have been described in patients after total knee arthroplasty (TKA), leading to the development of inter-joint coordination abnormalities and increased risk of falling. Such impairments have been reported to persist in the long-term, although the majority of studies assessed gait pattern especially in the first months after TKA.

RESEARCH QUESTION

What are the long-term gait impairments in patients after TKA compared to healthy age-matched subjects?

METHODS

A systematic search was conducted on MEDLINE/PubMed, EMBASE, CENTRAL and Scopus databases. Observational studies or randomized controlled trials investigating gait spatial-temporal, kinematic and kinetics parameters in a time-window longer than 6 months in patients with TKA compared to healthy age-matched subjects were included. Methodological quality was assessed using the modified Downs and Black (D&B) checklist and participants' characteristics, surgical procedures details and outcome measures were extracted. Pooled or un-pooled findings were categorized into "6 months - 1 year" and "more than 1 year" timepoint categories.

RESULTS

Twenty-eight studies (976 patients) were included. Overall quality was fair with a mean modified D&B score of 63.5 %. Reduced speed, stride length, cadence and longer stance phase were found in patients when compared to healthy individuals at "6 months - 1 year" follow-up. Spatial-temporal parameters deficits were also found at more than 1 year after TKA, where lower single-limb support and longer double-limb support durations were detected. These impairments occurred in concomitance with decreased knee range of motion along the sagittal and frontal planes and altered kinetic parameters. Hip kinematic and kinetic long-term impairments were also detected after TKA.

SIGNIFICANCE

These findings highlighted long-term gait pattern alterations in patients with TKA compared to age-matched healthy subjects. Future studies should identify interventions able to reduce long-term gait pattern alterations and improve function in patients after TKA.

The Effect of Combined Balance Exercise on Knee Range of Motion, Balance, Gait, and Functional Outcomes in Acute Phase Following Total Knee Arthroplasty: A Single-Blind Randomized Controlled Trial

Background and Objectives: Total knee arthroplasty (TKA) improves balance performance in patients with osteoarthritis; however, balance deficit and fall incidence after TKA have been reported. This study aimed to determine the effects of combined balance exercises on knee range of motion (ROM), balance, gait, and functional outcomes during the acute phase after TKA. Materials and Methods: A total of 42 participants were randomly assigned to either the combined balance group (n = 21) or the general physical therapy (control) group (n = 21). The combined balance exercise group performed exercise programs for 30 min per session, five times a week for 4 weeks (20 sessions), and the control group completed general physical therapy, which included active simple exercise. Measurements were performed before and after the 4 weeks of training to assess changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee joint ROM, static balance, timed up-and-go (TUG), and 10 m walk test (10 MWT). Results: The combined balance exercise group demonstrated significant improvements post intervention (p < 0.05) for all outcomes. The time × group interaction effect for the WOMAC scores showed statistically significant interaction effects for pain, stiffness, and physical function; the static and dynamic balance values showed statistically significant interaction effects for CEA, PL, AV, and TUG; and gait ability showed a significant interaction effect for the 10 m walk test (p < 0.05). Conclusions: This study confirmed that combined balance training with general physical therapy has a positive effect on ROM, static and dynamic balance, gait, and functional outcomes in the acute phase post TKA and that combined balance exercise can be proposed as a rapid rehabilitation intervention with general physical therapy following TKA.

Postural stability computerized evaluation in total knee arthroplasty

PURPOSE

To evaluate the balance in patients with total knee arthroplasty (TKA) and knee osteoarthrosis (KOA), measured by postural stability computerized evaluation (PSCE), and to evaluate the effect of post-TKA patients' characteristics in their performance on PSCE.

MATERIALS AND METHODS

An observational cross-sectional study was conducted in two sets of patients: (A) patients with KOA and primary TKA surgery scheduled and (B) patients who underwent primary TKA >9 months. Sociodemographic, radiographic, clinical and PSCE parameters (using the Biodex Balance System) were assessed.

RESULTS

Post-TKA patients placed more load on the replaced knee than the contralateral osteoarthritic knee (p = 0.027). They had less imbalance on the balance tests performed with the eyes open, on stable (p = 0.032), and unstable platforms (p = 0.022). These patients also showed better postural stability in monopodalic stance, both standing on the TKA (p = 0.010) and contralateral knee (p = 0.017). Age, weight, pain on the operated knee, extension deficit on the operated knee, and Berg Balance Scale scores on post-TKA patients were significantly associated with their performance on PSCE tests.

CONCLUSIONS

PSCE can be useful to quantify the balance of post-TKA and KOA patients.

Characterizing patient factors, perioperative interventions, and outcomes associated with inpatients falls after total knee arthroplasty

INTRODUCTION

Mechanical falls represent a potential adverse event after total knee arthroplasty (TKA) and may introduce further injury and delay postoperative recovery. This study aimed to identify patient characteristics associated with inpatient falls, to determine the impact of inpatient falls on surgical outcomes following TKA, and to describe the relationship between tourniquet and/or adductor canal block (ACB) use and fall rates.

METHODS

Patients undergoing primary, elective TKA at a single institution between 2018 and 2022 were retrospectively analyzed. Patients were stratified into groups based on whether they sustained a postoperative inpatient fall or not. Perioperative characteristics, lengths of stay (LOS), rates of 90-day readmissions, and revisions were compared, and fall characteristics were described. Subanalysis was conducted comparing fall incidence based on tourniquet and/or ACB use.

RESULTS

In total 6472 patients were included with 39 (0.6%) sustaining falls. Falls most commonly occurred on postoperative days one (43.6%) and two (30.8%), and were most commonly due to loss of balance (41.9%) or buckling (35.5%). Six (15.4%) fall patients sustained minor injuries, and one (2.6%) sustained major injury (malleolar fracture requiring non-operative orthopaedic management). The LOS (3.0 ± 1.5 vs 2.3 ± 1.5 days, p = 0.002) and all-cause revision rates at latest follow-up (10.3% vs. 2.0%, p = 0.008) were significantly higher in the fall group. Falls were comparable across subgroups based on tourniquet and/or ACB use (p = 0.429).

CONCLUSION

Patients who fell had a longer LOS and higher revision rate postoperatively. Rates of inpatient falls were comparable regardless of tourniquet and/or ACB use. Concern for inpatient falls should not influence surgeons when considering the use of tourniquets and/or ACBs, though well-designed, large-volume, prospective randomized studies are warranted to better understand this relationship.

Rehabilitation Techniques Before and After Total Knee Arthroplasty for a Better Quality of Life

The most important gold standard treatment following advanced knee osteoarthritis is total knee arthroplasty. Following surgery of total knee replacement, the majority of patients report decreased pain and successful long-term results, but recovery is unpredictable, and most patients continue to exhibit muscle weakness in their lower limbs and functional limitations in comparison to similarly aged control individuals. The goal of this review article was to systematically review different articles containing controlled and randomized studies to find out the effectiveness of outpatient care postoperatively on short- and long-term functional recovery. The purpose of this review article is to investigate the possible advantages of pre- and postoperative rehabilitation as well as the value of exercise regimen recommendations following total knee replacement. The following interventions after total knee arthroplasty are discussed in this review article: preoperative education and exercises, continuous passive movement, strengthening interventions, aquatic therapy, balanced training, tourniquet exposure, use of alignment and implants, role of apps in phones and different wearable devices, influence of postoperative protocols, knee bracing, neuromuscular electrical stimulation, and clinical environment. Strengthening and intense functional exercises for patients above 45 years of age, in land or water programs like aquatic activities, with the increasing intensity of the exercises in accordance with the patient's progress, should be included in the best outpatient physical therapy protocols. Because these exercises are so precisely personalized, the best long-term effects after surgery may come from outpatient physiotherapy performed in a clinical setting under the supervision of a registered physiotherapist or medical professional. This review article also includes the change in the quality and well-being of a patient's life who has undergone total knee arthroplasty and practiced the rehabilitation techniques.

Robotic-assisted total knee arthroplasty results in decreased incidence of anterior femoral notching compared to posterior referenced instrumented total knee arthroplasty

OBJECTIVE

Periprosthetic fracture (PPF) is an uncommon but devastating complication after total knee arthroplasty (TKA). Anterior femoral notching (AFN) is one of a perioperative risk factor for PPF. The main purpose of this study was to compare between the rates of anterior femoral notching (AFN) and supracondylar periprosthetic femoral fracture (sPPF) of manual TKA and robotic arm-assisted TKA (RATKA). Meanwhile, blood loss, transfusion rates, inflammatory responses, complications, early clinical and radiological outcomes were also assessed.

METHODS

This retrospective study included 330 patients (133 RATKA and 197 manual TKA). Differences in risks of inflammatory, blood loss, complications (periprosthetic fracture and periprosthetic joint infection), pre-operative and post-operative distal lateral femoral angle (LDFA), distal femoral width (DFW), prosthesis-distal femoral width (PDFW) ratio, AFN, femoral component flexion angle (FCFA), peri-operative and post-operative functional outcomes between the RATKA and manual TKA groups were compared.

RESULTS

The operation time and postoperative CRP level in the RATKA group was significantly longer and higher than that in the manual TKA group (p < .001). However, there was no significant difference in postoperative WBC level (p = .217), hemoglobin loss (p = .362), postoperative drainage (p = .836), and periprosthetic fracture (p = 1.000). There was no significant difference in LDFA (p > .05), DFW(p = .834), PDFW ratio (p = .089) and FCFA (p = .315) between the two groups, but the rate of AFN in the RATKA group was significantly lower than that in the manual TKA group (p < .05). There was no significant difference in ROM between the two groups on POD3, POD 90 and 1 year (p < .05), but the FJS-12 score in the RATKA group was higher than that in the manual TKA group on 1 year (p = .001).

CONCLUSION

Robotic-assisted total knee arthroplasty can decrease the incidence of anterior femoral notching compared to posterior referenced instrumented total knee arthroplasty.

Fear of movement and other associated factors in older patients with total knee arthroplasty

BACKGROUND

Kinesiophobia is an important risk factor for functional activities of patients in the early stage following total knee arthroplasty (TKA).

AIMS

This study aimed to investigate the relationship between fear of movement and associated factors in older patients in the late stage after TKA.

METHODS

The study included 45 older patients (mean age:70.11 ± 0.90 years) with knee osteoarthritis who underwent TKA. Kinesiophobia was assessed with the Tampa Scale of Kinesiophobia (TSK). Pain and strength in the quadriceps femoris (QF) muscle were assessed by the Visual Analog Scale and hand-held dynamometer, respectively. Functional level was determined using the 30-s sit-to-stand test (STS) and 10-m walking test.

RESULTS

There were correlations between TSK and QF muscle strength (r =  -0.538, p < 0.001), activity pain level (r = 0.489, p = 0.001), and 30-s STS (r =  -0.306, p = 0.041). There were no correlations between TSK and age (r = 0.207, p = 0.172) and 10-m walking test (r = 0.112, p = 0.465).

CONCLUSIONS

Increased pain and decreased QF muscle strength and functional level on STS were related with fear of movement in TKA patients. It was concluded that kinesiophobia of older patients with TKA must be considered during the assessment and rehabilitation program in the late stage after TKA.

Association of knee and hip osteoarthritis with the risk of falls and fractures: a systematic review and meta-analysis

OBJECTIVE

Studies evaluating the association of knee and hip osteoarthritis (OA) with falls and fractures have inconsistent findings. We aimed to investigate associations of symptomatic and radiographic knee and hip OA with risk of falls, recurrent falls, and fractures.

METHODS

We conducted an electronic search of databases from inception to February 2023. Two authors independently screened studies, extracted data, and assessed the risk of bias using the Newcastle-Ottawa Scale tool in eligible studies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

Of 17 studies included (n = 862849), 2 had a high risk of bias. Among studies that evaluated falls or fractures as outcomes, 7/8 (87.5%) and 5/11 (45.5%) were self-reported, respectively. Both symptomatic knee and hip OA were associated with increased risk of recurrent falls (knee: OR = 1.55, 95% CI 1.10 to 2.18; hip: OR = 1.50, 95% CI 1.28 to 1.75) but not falls or fractures. Radiographic knee OA increased risk of falls (OR = 1.28, 95% CI 1.03 to 1.59) and did not significantly increase risk of recurrent falls (OR = 1.39, 95% CI 0.97 to 1.97) or fractures (OR = 1.22, 95% CI 0.99 to 1.52). Radiographic hip OA decreased the risk of recurrent falls (OR = 0.70, 95% CI 0.51 to 0.96) but had no statistically significant association with fractures (OR = 1.16, 95% CI 0.79 to 1.71).

CONCLUSION

Symptomatic knee and hip OA were both associated with an increased risk of recurrent falls, and radiographic knee OA was associated with an increased risk of falls. No statistically significant associations of radiographic and symptomatic knee or hip OA with fractures were found.

Comparison of physical function, proprioception, muscle strength, postural balance, and walking in older women with and without total knee arthroplasty

The benefit of total knee arthroplasty (TKA) is that it alleviates pain caused by osteoarthritis; however, other postoperative effects on physical function are unclear. This study aimed to investigate the differences in physical function, proprioception, muscle strength, postural balance, and walking in older women with and without TKA. A total of 36 participants were included in this study; the TKA group comprised older women who underwent TKA (n = 18) and the non TKA group comprised older women who did not undergo TKA (n = 18). All the participants were evaluated for physical function, proprioception, muscle strength, postural balance, and walking. The outcome measures were compared between the 2 groups using an independent t test. Correlations were assessed using Pearson correlation coefficients. Participants in the TKA group had significantly reduced physical function, postural balance, and walking ability compared with those in the non TKA group (P < .05). In the TKA group, physical function was statistically correlated with proprioception, postural balance, and walking (P < .05); in particular, it had a strong correlation with proprioception (R > .60). In the non TKA group, postural balance was significantly associated with muscle strength and walking (P < .05). In particular, it was strongly correlated with walking (R > .90). This study demonstrated that older women undergoing TKA need to actively perform interventions to improve physical function, postural balance, and walking compared with older women with osteoarthritis.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period.

PURPOSE

The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA.

METHODS

Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk.

RESULTS

In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF.

CONCLUSIONS

Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Comparison of the Incidence of Postoperative Acute Kidney Injury Following the Administration of Remimazolam or Sevoflurane in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

We evaluated the incidence of postoperative acute kidney injury (AKI) and complications when remimazolam (RMMZ) or sevoflurane (SEVO) were used in elderly patients undergoing total knee arthroplasty.

METHODS

Seventy-eight participants aged ≥65 were randomly allocated to either the RMMZ or SEVO group. The primary outcome was the incidence of AKI on postoperative day (POD) 2. The secondary outcomes included intraoperative heart rate (HR), blood pressure (BP), total drug administered, emergence time, postoperative complications on POD 2, and hospital length of stay (HLOS).

RESULTS

The incidence of AKI was comparable between the RMMZ and SEVO groups. The doses of intraoperative remifentanil, vasodilators, and additional sedatives were significantly higher in the RMMZ group than in the SEVO group. Overall intraoperative HR and BP tended to remain higher in the RMMZ group. The emergence time in the operating room was significantly faster in the RMMZ group; however, the time required for an Aldrete score ≥ 9 was comparable between the RMMZ and SEVO groups. Postoperative complications and HLOS were comparable between the RMMZ and SEVO groups.

CONCLUSION

RMMZ may be recommended for patients who are expected to decrease in intraoperative vital signs. However, stable hemodynamics with RMMZ were not sufficient to influence the prevention of AKI.

The Impact of Living Arrangements on the Prevalence of Falls after Total Joint Arthroplasty: A Comparison between Institutionalized and General Geriatric Population

Due to population aging, there is an increasing need for orthopedic surgery, especially total knee arthroplasty (TKA) and total hip arthroplasty (THA). In geriatric patients, postoperative falls are common events which can compromise the success of these expensive procedures. The aim of our study was to assess the influence of living arrangements on the prevalence of postoperative falls following joint replacement. We included 441 patients after TKA or THA, living in nursing homes, alone or with family. The prevalence of falls in the first 2 years (15.2%) was significantly influenced by living arrangements: patients with TKA or THA living alone had three times higher odds of falling compared to those living with family, and institutionalized patients with THA had four times higher odds of falling compared to those living with family. Of 67 patients who fell, 6 (8.9%) needed reintervention. For TKA patients, the fall rates were not significantly different between institutions and family, indicating the interest of nursing homes in offering proper care. However, for the THA group, the results were poorer, emphasizing the need for improvement in postoperative rehabilitation. Further multi-centric studies are required for generalizing the impact of living arrangements on fall prevalence after joint replacement.

Mid-vastus total knee arthroplasty for medial osteoarthritis recovers gait balance control better than lateral parapatellar approach three months post-surgery

Total knee arthroplasty (TKA) approaches affect recovery outcomes, with different levels of residual loss of muscle strength and functional deficits. The current study compared the gait balance control in older individuals 3 months after TKA via the lateral parapatellar approach (LPPA) and mid-vastus approach (MVA) in terms of the inclination angle (IA) of the center of pressure (COP) to the body's center of mass (COM) vector, and the rate of change of IA (RCIA). In a gait laboratory, 12 patients with severe medial knee osteoarthritis who had undergone bilateral TKA via LPPA and 12 via MVA were evaluated and compared against 12 healthy controls for their balance control during gait 3 months after surgery. The participants' kinematic data and ground reaction forces were measured synchronously using an 8-camera motion capture system and three forceplates, respectively, from which the COM, COP, IA and RCIA were calculated using a 13-body-segment model. The LPPA group showed significantly greater sagittal IA during DLS (p < 0.01) but less sagittal and frontal RCIA throughout the gait cycle (p < 0.04) compared to controls. The MVA showed better recovery in the balance control with most IA and RCIA variables similar to those of the healthy controls throughout the gait cycle. The patients with LPPA walked with a compromised balance control throughout the gait cycle while the MVA group showed close-to-normal balance control with a slight decrease in sagittal RCIA during SLS. The current between-approach findings were likely related to the differences in the muscles involved during surgery, suggesting that MVA may be a better choice than LPPA when taking short-term gait balance control into consideration.

Fall classification, incidence and circumstances in patients undergoing total knee replacement

To propose a fall-classification framework for patients undergoing total knee replacement (TKR). In addition, we reinforced the available evidence on fall incidence and circumstances and compared the characteristics of fallers versus. nonfallers. Retrospective and prospective data were collected from 253 subjects with severe knee osteoarthritis who were waiting for primary TKR. Falls were classified considering the location of the destabilizing force, source of destabilization and fall precipitating factor. Fall incidence and circumstances were described; the characteristics of fallers and nonfallers in terms of functional and balance performance were compared with F-tests (95% CI). The fall incidence before surgery was 40.3% (95% CI 34.2% to 46.6%). This figure decreased to 13.1% (95% CI 9.2% to 18.0%) and to 23.4% (95% CI 17.8% to 29.6%) at 6 and 12 months after surgery, respectively. Most falls were caused by destabilizations in the base of support (n = 102, 72%) and were due to extrinsic factors (n = 78, 76%) and trip patterns. Significant differences between fallers and nonfallers were found in knee extensor strength and monopodal stability in the surgical limb (p < 0.05). Falls are prevalent in patients with severe knee osteoarthritis. Symptoms and functional performance improve after surgery, and fall incidence is reduced. Most fall events originate from disruptions in the base of support and are precipitated by extrinsic factors, generally trips during walking activities.

Evaluation of the balance function before and after total knee arthroplasty using Berg balance scale

INTRODUCTION

The purpose of this study was to evaluate balance function before and after total knee arthroplasty (TKA) using Berg balance scale (BBS). The study also aimed to identify factors associated with balance impairment.

MATERIALS AND METHODS

Ninety-three knees in 90 patients were prospectively evaluated using their BBS scores, passive knee extension/flexion angles, Visual analogue scale for pain scores, hip-knee-ankle angles, and knee extensor/flexor muscle strengths before and after TKA. A total BBS score of less than 45 indicates an enhanced risk of multiple falls. Multivariate logistic regression models were performed to elucidate factors associated with post-operative BBS score.

RESULTS

A significant difference in mean pre- and post-operative BBS scores were noted (49.3 ± 6.4 vs. 52.2 ± 4.7) (p < 0.05). The percentage of pre- and post-operative BBS scores less than 45 were 20% and 10% (p < 0.05). Rheumatoid Arthritis (RA), lower pre-operative BBS score, and larger post-operative knee flexion contracture were significantly associated with lower post-operative BBS score (p < 0.01). The post-operative knee flexion contracture greater than 10° was significantly associated with substantially high odds of post-operative BBS scores less than 45 (Odds ratio 7.6; 95% confidential interval 1.69-34.17).

CONCLUSIONS

While TKA significantly improved BBS scores, 10% of the patients remained at a risk for multiple falls. RA, lower pre-operative BBS score, and post-operative knee flexion contracture greater than 10° retained balance impairment even after TKA.

Recovery of balance control in bilateral medial knee osteoarthritis after total knee arthroplasty during level walking

Older adults are at higher risk of falling following total knee arthroplasty (TKA). However, it remains unclear how long a full recovery of the balance control during gait post-TKA will take. The current study aimed to bridge this knowledge gap via long-term follow-up gait analyses. Twelve older adults with severe bilateral medial knee osteoarthritis (OA) before, 3 and 12 months after TKA, and twelve healthy controls were evaluated for their balance control during level walking, in terms of the inclination angle (IA) of the center of pressure to center of mass vector, and the rate of change of IA (RCIA). The patients before TKA showed significantly increased sagittal IA but decreased RCIA throughout the gait cycle (p < 0.04) compared to controls, suggesting a compromised balance control. Three months post-TKA, deviations in IA remained, although those in RCIA were improved to normal. One-year post-TKA, no significant differences were found in any of the IA- and RCIA-related variables between patient and Control groups. The results show that TKA surgery was effective in reducing the deviations in the center of mass-center of pressure control in patients with severe bilateral knee OA, and full recovery of balance control can be expected 1 year after surgery.

Survivorship, complications, and outcomes following distal femoral arthroplasty for non-neoplastic indications

Aims

Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

Methods

We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.

Results

Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048).

Conclusion

DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates.

Cite this article: Bone Jt Open 2022;3(3):173–181.

Physical Activity Mediates the Relationship between Gait Function and Fall Incidence after Total Knee Arthroplasty

The present study aims to examine (1) the preoperative factors that can predict postoperative falls, (2) whether postoperative physical activity (PA) mediates the relationship between fall incidence and gait function, and (3) whether postoperative PA levels are associated with fall risk in total knee arthroplasty (TKA) patients. Ninety-six patients (mean age: 72.0 ± 6.1 years) who were observed postoperatively for 6 months were selected. Timed up and go (TUG) was assessed as an indicator of gait function. Fall incidence and PA were investigated for 6 months post-TKA. The body mass index, history of preoperative falls, knee pain, knee extensor strength, range of motion in knee flexion, and modified gait efficacy scale were evaluated. Additionally, postoperative PA levels were categorized into three groups-low: <3,000, moderate: 3,000 to 4,000, and high: ≥4,000 steps/day. The relative fall incidence rate was calculated according to the total number of falls normalized for every 1,000 steps/day for 6 months postoperatively. Twenty-five (26.0%) of the 96 patients had at least one fall. The TUG, knee pain, and knee extensor strength were identified preoperatively as significant variables affecting postoperative falls. The mediated effects model revealed that postoperative fall incidence was predicted by preoperative TUG and postoperative PA. Postoperative PA was significantly associated with preoperative TUG. Moreover, both the preoperative TUG and postoperative PA were selected as significant variables for predicting fall incidence. Thus, postoperative PA mediates the relationship between gait function and fall incidence after TKA. Furthermore, the relative fall incidence rate associated with a low PA level was significantly higher than that associated with moderate and high PA levels. In conclusion, preoperative assessments of TUG performance, muscle strength, and knee pain were effective in predicting fall risk. Additionally, an increase in PA could contribute to reducing fall risk in TKA patients. Therefore, our results suggest that preoperative screening for fall predictors and managing postoperative PA could reduce the fall incidence in TKA patients.

Dynamic stability during stair negotiation after total knee arthroplasty

BACKGROUND

The assessment of dynamic stability is crucial for the prevention of falls in the elderly and people with functional impairments. Evidence that total knee arthroplasty improves balance in patients with severe osteoarthritis is scarce and no information exists about how the surgery affects dynamic stability during stair negotiation.

METHODS

This study aims to investigate if patients before and one year after surgery are less stable compared to asymptomatic controls. Seventeen control and twenty-seven patient participants with end-stage knee osteoarthritis that were scheduled to undergo unilateral total knee arthroplasty were recruited in this study. Participants' assessment was carried out by means of marker-based optical full-body motion capture with force platforms. The extrapolated Centre of mass and the margin of stability metrics were used to examine dynamic stability during stair ascent and descent.

FINDINGS

Patient participants, during both pre-operative and post-operative assessments, were equally balanced to the asymptomatic controls during stair gait (p > .188). Additionally, the patients' overall stability did not improve significantly one year after arthroplasty surgery (p > .252).

INTERPRETATION

Even if pain from arthritis and fear of falling is decreased following surgery, our results indicate that stability in stair walking in not affected by osteoarthritis and total knee arthroplasty.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02422251.

Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA.

METHODS

A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I²-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies.

RESULTS

Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I² 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I² 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I² 42.99%).

CONCLUSION

Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.

The Effect of Progressive Dynamic Balance Training on Physical Function, The Ability to Balance and Quality of Life Among Elderly Women Who Underwent a Total Knee Arthroplasty: A Double-Blind Randomized Control Trial

Total knee arthroplasty (TKA) is used to treat end-stage osteoarthritis. However, this surgical procedure affects the mechanical receptor function and impairs the ability to balance. Dynamic balance training has been reported to improve stability and self-confidence and safely yield increased physical activity. This study aimed to investigate the effect of dynamic balance training on physical function, the ability to balance and quality of life among patients who underwent TKA. Thirty-eight participants were assigned to either the progressive dynamic balance training (PDBT) with physical therapy group (n = 19) or the control group (n = 19). The experimental group undertook a dynamic balance program with physical therapy for 30 minutes per day, five times per week for six weeks, while the control group undertook physical therapy only. A continuous passive motion exercise was performed for 20 minutes after training by both groups. The outcomes were evaluated using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, pain pressure threshold (PPT), range of motion (ROM), Knee Outcome Survey-Activities of Daily Living (KOS-ADLS), Multifunction Force Measuring Plate, timed up and go (TUG) test and Short-Form Health Survey 36 (SF-36). Physical function (WOMAC Osteoarthritis Index, ROM and KOS-ADLS score) and the ability to balance (TUG test score, confidence ellipse area, path length and average velocity) significantly improved (p < 0.05) in the experimental group compared with the control group. In contrast, the physical component summary score for the SF-36 regarding quality of life significantly improved (p < 0.05); however, the mental component summary score for the SF-36 and PPT did not significantly differ between the groups. Therefore, we suggest that PDBT with physical therapy has positive effects on physical function, the ability to balance and quality of life among patients who underwent TKA.

Acceptability and feasibility of a community-based strength, balance, and Tai Chi rehabilitation program in improving physical function and balance of patients after total knee arthroplasty: study protocol for a pilot randomized controlled trial

Background

The rate of falls in patients after total knee arthroplasty (TKA) is high and related to lower limb muscle weakness and poor balance control. However, since routine post-TKA rehabilitation is uncommon, it is paramount to explore alternative strategies to enhance balance and physical functioning in post-TKA patients. As Tai Chi is a proven strategy for improving balance in older people, the proposed study aims to determine the feasibility and acceptability of a 12-week community-based post-TKA multimodal Tai Chi program and to collect preliminary data with respect to the efficacy of such a program in improving balance and physical functioning in post-TKA patients as compared to usual postoperative care.

Methods

A single-blinded 2-arm pilot randomized controlled trial will recruit 52 community-dwelling post-TKA patients (aged > 60 years) in Hong Kong. In addition, 26 untreated asymptomatic controls will be recruited for comparison purposes. The TKA patients will be randomized into either a 12-week multimodal Tai Chi rehabilitation group or a postoperative usual care group (26 each). Participants will perform the outcome assessments at baseline, 6, 12, 24, and 52 weeks after TKA, while asymptomatic controls will have the same assessments at baseline, 12, and 52 weeks after baseline. The rate of recruitment, retention, and attrition, as well as adherence to the intervention, will be measured and used to determine the feasibility of the study and whether a full-scale effectiveness trial is warranted. Further, qualitative interviews will be conducted to explore the acceptability and possible barriers to the implementation of the intervention. Primary and secondary outcomes including both patient-reported surveys and performance-based tests will be compared within and between groups.

Discussion

The study will determine the feasibility and acceptability/potential efficacy of community-based rehabilitation for post-TKA patients and assess whether the intervention has the potential to be assessed in a future fully powered effectiveness trial. The findings will also be used to refine the study design and guide the conduction of a future definitive randomized controlled trial.

Trial registration

ClinicalTrials.gov NCT03615638. Registered on 30 May 2018. https://clinicaltrials.gov/ct2/show/NCT03565380

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05055-5.

A systematic review and meta-analysis of fall incidence and risk factors in elderly patients after total joint arthroplasty

BACKGROUND

Falls in the elderly have become a serious social problem worldwide. Approximately a third of persons fall at least once in the year after total joint arthroplasty (TJA), but preventing and treating falls is still challenging in clinical practice. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of falls after TJA. The present study aimed to quantitatively and comprehensively conclude the risk factors of falls after TJA in elderly patients.

METHODS

The electronic databases to be searched include CNKI, Embase, Medline, and Cochrane central database (all up to November 2018). All studies on the risk factors of falls after TJA in elderly patients without language restriction were reviewed. Process of evaluation of identified studies and extraction of data were independently conducted by 2 reviewers, qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis completed. All analyses were performed by the software Stata 11.0.

RESULTS

A total of 14 studies were included, which altogether included 1284456 patients with TJA, of them 12879 cases of falls occurred after surgery, suggesting the accumulated incidence of 13.1% and the prevalence of in-hospital falls was 1.0%. This study has provided evidence for the preventing of falls in the elderly patients who were underwent TJA. Outcome measures include advanced age, female, Overweight (BMI≥25 kg/m), falls history, use of walking aid, diabetes, cardiac disease, hypertension, COPD and depressive symptoms. The ABC Scale was significantly negatively correlated with falls after lower extremity joint replacement.

CONCLUSIONS

Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent falls after TJA.

Preoperative low muscle mass is a predictor of falls within 12 months of surgery in patients with lumbar spinal stenosis

BACKGROUND

Patients with lumbar spinal stenosis (LSS) may be at high risk of falls due to various factors. No effective fall risk assessments or fall prevention measures have been performed for patients with LSS because only a few studies have evaluated falls in these patients. This study aimed to evaluate the incidence and preoperative predictors of falls within 12 months of surgery in patients with LSS.

METHODS

In this prospective study of 82 consecutive preoperative patients with LSS, preoperative demographic data, previous fall history, leg pain, low back pain, Japanese Orthopaedic Association (JOA) score, Hospital Anxiety and Depression Scale (HADS) scores, lower extremity muscle strength, walking speed, grip strength, and muscle mass were assessed at baseline. Falls were assessed at 3, 6, 9, and 12 months after surgery. Participants were categorized as fallers and non-fallers and baseline variables were compared. Binomial logistic regression was used to identify predictors of falls within 12 months of surgery.

RESULTS

Seventy-four patients (90.2%) completed the 12-month follow-up after surgery, of whom 24 patients (32.4%) experienced falls. A higher proportion of fallers were female and had a history of falls compared to non-fallers. Fallers had a significantly lower JOA score and a higher HADS-depression score compared to non-fallers. Fallers had significantly lower tibialis anterior muscle strength, gait speed, grip strength, and skeletal muscle mass index. Fallers had a higher prevalence of low muscle mass compared with non-fallers. The presence of low muscle mass was significantly predictive of falls within 12 months of surgery (odds ratio, 4.46; 95% confidence interval, 1.02-19.63).

CONCLUSIONS

Patients with LSS have a high incidence of falls after surgery and preoperative low muscle mass may be a predictor of postoperative falls.

Total Joint Arthroplasty Is Associated With a Decreased Risk of Traumatic Falls: An Analysis of 499,094 Cases

INTRODUCTION

The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA.

METHODS

The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs).

RESULTS

Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1).

CONCLUSION

TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis.

LEVEL OF EVIDENCE

Level III Retrospective Case-control study.

[A Structural Equation Model of Health-Related Quality of Life among Older Women Following Bilateral Total Knee Replacement]

PURPOSE

This study aimed to develop and test a structural equation model of health-related quality of life among older women following bilateral total knee replacement based on a literature review and Wilson and Cleary's model of health-related quality of life.

METHODS

One hundred ninety three women who were diagnosed with osteoarthritis, were older than 65 years, and were between 13 weeks and 12 months of having a bilateral total knee replacement were recruited from an outpatient clinic. Data were collected from July 2017 to April 2018 using a structured questionnaire and medical records. Data were analyzed using SPSS/WIN 22.0, AMOS 22.0, and Smart PLS 3.2.4.

RESULTS

The fitness of the hypothetical model was good, with coefficients of determination (R²) ranging between .28 and .75 and predictive relevance (Q²) between .26 and .73. The standardized root mean square residual of the model fit indices for the hypothetical model was .04; which explained 64.2% of physical and 62.5% of mental health-related quality of life. Self-efficacy, symptom status, functional status, and general health perceptions had a significant direct effect on physical health-related quality of life, while social support, symptom status, and general health perceptions had a significant direct effect on participants' mental-health-related quality of life.

CONCLUSION

To improve the physical and mental quality of life of older women who receive bilateral knee replacement, nursing-based intervention strategies that reduce symptoms, improve functional status, and increase health perceptions, self-efficacy, and social support are needed. The most important factor is the symptom status.

Effectiveness of early high-intensity balance training for early home life independence after total knee arthroplasty: a pseudo-randomized controlled trial

OBJECTIVE

In Japan, the number of elderly individuals living alone is increasing, leading to an increase in hospital medical expenses attributed to total knee arthroplasty (TKA). Improvement in balance and functional performance is a priority in the early postoperative stages after TKA. However, there are no reports on the effectiveness of balance training (BT) for inpatients in the early postoperative period. Thus, we aimed to evaluate the effectiveness of early high-intensity BT for early home-life independence after TKA.

METHOD

This pseudo-randomized controlled trial included 49 inpatients who underwent TKA and had osteoarthritis. Inpatients were categorized into the BT or typical training (TT) group. The BT program began on post-TKA day 4, with 12-14 sessions between day 7 and 10 (i.e., 1-2 sessions per day). The effect of the intervention was assessed using balance ability as the main outcome. Sub-outcomes included evaluation of motion function. The differences in each variable before and after intervention were compared, including covariance analysis adjusted for age and sex.

RESULTS

The mean (standard deviation) balance ability indexes in the left and right directions were BT, pre 4.5 (0.8) and post 4.4 (0.8); TT, pre 4.8 (0.9) and post 4.4 (0.8), and those in the forward and backward directions were BT, pre 4.7 (1.7) and post 5.1 (2.1); TT, pre 6.3 (2.6) and post 5.9 (2.0). No significant differences were found between the preoperative and postintervention scores in the two groups for any measured outcome.

CONCLUSION

BT did not appear to improve balance ability or functional performance.

Incidence and Risk Factors for Falls in Women With End-Stage Hip Osteoarthritis

BACKGROUND AND PURPOSE

Fall-induced injuries and resulting deaths are a serious health problem among older adults. The most common risk factors for falls in older adults are muscle weakness, gait deficiencies, and balance deficits. Patients with end-stage hip osteoarthritis (OA) also have many hip dysfunctions, and these all have the potential to increase the risk of falls. However, the incidence and risk factors for falls in patients with end-stage hip OA remain unclear. The aim of this study was to determine the incidence of falls in women with end-stage hip OA and to identify risk factors for falls in this patient population.

METHODS

This study was a cross-sectional analysis. One hundred fifty-three women with end-stage hip OA (mean age = 64.0 years) and 112 age-matched healthy women (mean age = 64.1 years) were analyzed using available data. All participants were examined for the number and circumstances of falls in the past year. The circumstances of falls included the location, time, direction, cause, and injury. We examined the outcome of hip function, ambulatory ability, physical activity, and limping severity in women with end-stage hip OA. Multivariate logistic regression analysis was used to identify factors influencing falls in women with hip OA.

RESULTS

The incidence of at least 1 fall in the past year was significantly higher in women with end-stage hip OA (30.1%) than in healthy women (12.5%) (P < .001). Falls in women with end-stage hip OA were most often caused by tripping and falling forward during the daytime. The majority of falls (65.2%) resulted in injuries and 13.0% resulted in fractures. The occurrence of a fall significantly correlated with limping (odds ratio = 3.26, 95% confidence interval = 1.49-7.14, P = .003) and knee extensor muscle strength (odds ratio = 0.22, 95% confidence interval = 0.05-0.85, P = .029).

CONCLUSIONS

Women with end-stage hip OA have an increased risk of falls and fall-induced injuries. The prevention of falls in this vulnerable population should be a priority among health care practitioners. In particular, women who are limping and have reduced lower knee extensor strength should take care to avoid falls.

High Levels of Kinesiophobia at Discharge from the Hospital May Negatively Affect the Short-Term Functional Outcome of Patients Who Have Undergone Knee Replacement Surgery

Background: Kinesiophobia is a psycho-cognitive factor that hampers recovery after orthopedic surgery. No evidence exists on the influence of kinesiophobia on the short-term recovery of function in patients with knee replacement (KR). Therefore, the aim of the present study is to investigate the impact of kinesiophobia on short-term patient-reported outcomes (PROMs) and performance-based measures (PBMs). Methods: Forty-three KR patients filled in the Tampa scale for kinesiophobia (TSK) at time of discharge. Patients with TSK ≥ 37 were allocated to the kinesiophobia group (n = 24), others to the no-kinesiophobia group (n = 19). Patients were asked to complete PROMs and to execute PBMs at discharge and at 6-weeks follow-up. An independent samples t-test was used to compare group differences for PROMs and PBMs at both measurement sessions. Multiple linear regression analysis models were used to model PBM outcomes from age, pain and TSK scores. Results: Significant differences were observed between groups for PROMs and PBMs. Kinesiophobia significantly contributed to the reduced functional outcomes. Conclusion: At discharge from the hospital, 55.8% of KR patients demonstrated high levels of kinesiophobia (TSK ≥ 37). This may negatively influence short-term recovery of these patients, by putting them at higher risk for falling and reduced functionality.

Falls and fear of falling in older adults with total joint arthroplasty: a scoping review

BACKGROUND

Patients waiting or recovering from total joint arthroplasty (TJA) are at risk for falls which can lead to restriction of activity and negatively impact recovery. The objective of this scoping review is to critically appraise and synthesize the evidence in the reported number of falls, fear of falling, and risk factors associated with falls in older patients waiting for or recovering from TJA.

METHODS

Seven electronic databases were searched with no date limits and using language restriction (English). The inclusion criteria were 1) cohorts that included older adults 60+ years of age, 2) reported prevalence of falls, fear of falling, and/or risk factors for falls in patients who were waiting or recovering from TJA and 3) cross-sectional studies, cohort studies, and case control study designs. The quality assessment of selected articles was assessed using the SIGN Guidelines Checklist.

RESULTS

Of the 866 citations identified, 12 studies met the inclusion criteria and were reviewed. Prevalence of falls in pre-operative TJA patients and post-operative TJA patients ranged from 23 to 63%, and 13 to 42%, respectively. Of those five studies that examined fear of falling, pre-operative TJA patients reported greater fear of falling than post-operative patients. Modifiable risk factors for falls included fear of falling, joint range of motion, and depression.

CONCLUSIONS

An increased risk of falls in patients with TJA was reported both for patients waiting for and recovering from surgery. A number of modifiable risk factors were identified including fear of falling that could be targeted in fall prevention programs for TJA.

Risk factors for falls in patients with total hip arthroplasty and total knee arthroplasty: a systematic review and meta-analysis

OBJECTIVE

Falls are common after total hip arthroplasty (THA) and total knee arthroplasty (TKA). While previous studies have investigated various risk factors for falls in patients following THA and TKA, no systematic reviews have summarized these risk factors. Therefore, the current systematic review aimed to summarize evidence regarding risk factors for falls in patients after THA and/or TKA.

METHODS

MEDLINE, EMBASE, CINAHL, SPORTDiscus, and Physiotherapy Evidence Database (from inception to June 30, 2018) were searched. The methodological quality and quality of evidence of the included studies were assessed by two independent reviewers. Relevant data regarding participants' characteristics, study design, follow-up time points, and identified risk factors were extracted. Meta-analyses and narrative syntheses were performed.

RESULTS

Twelve studies with a total of 1,292,689 participants were included. Twenty-nine identified risk factors for post-THA/TKA falls were classified into either inpatient or post-discharge risk factors. Key risk factors for both post-THA and/or post-TKA inpatient falls that showed moderate level of evidence included: postoperative complications or comorbidities and revision THA/TKA. Likewise, risk factors for post-discharge falls after THA and/or TKA that demonstrated moderate level of evidence included: medications, psychiatric diseases, living alone, prior history of TKA, falls history and female gender. The quality of the included studies varied and sample sizes were not justified.

CONCLUSIONS

This review summarized both non-modifiable and modifiable risk factors for post-THA/TKA falls. Our findings highlight the importance of developing strategies to lower the falls risk among patients following THA/TKA.

The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.

OBJECTIVES

This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.

METHODS

Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion.

PARTICIPANTS

Elderly individuals (65 + years) who underwent total knee arthroplasty.

INTERVENTIONS

Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

SYNTHESIS METHODS

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I². A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.

RESULTS

Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I² = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I² = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I² = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I² = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I² = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I² = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I² = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r² = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r² = 0.02; standardised β = 0.13; P = 0.48).

LIMITATIONS

A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.

CONCLUSION

Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

Falls After Total Knee Arthroplasty: Frequency, Circumstances, and Associated Factors-A Prospective Cohort Study

BACKGROUND

Individuals with total knee arthroplasty (TKA) often experience pain and reduced balance control, which may predispose them to greater fall risk.

OBJECTIVE

The objective of this study was to determine the frequency and circumstance of falls and fall-related risk factors within a 6-month follow-up period in individuals after TKA.

DESIGN

This study was a prospective cohort study.

METHODS

Knee proprioception, the Balance Systems Evaluation Test, knee pain, knee extension and flexion muscle strength, knee range of motion, and balance confidence were evaluated in 134 individuals (39 men, 95 women; mean age = 66.3 years [SD = 6.6 years]) 4 weeks after TKA. Monthly follow-up sessions, via face-to-face or telephone interviews, were implemented to obtain data on fall incidence over 6 months.

RESULTS

Twenty-three individuals after TKA (17.2%) sustained at least 1 fall during the 6-month follow-up period. The median time of the first fall episode was 15 weeks after TKA. Of the 31 fall episodes, most occurred during walking (67.7%). Slipping (35.5%) and tripping (35.5%) were identified as the most frequent causes of falling. Most falls occurred at home (45.2%) or another indoor environment (29.0%). Multivariate binary logistic regression revealed that younger age (odds ratio: 0.91), reduced proprioception of the knee that had undergone surgery ("operated knee") (odds ratio: 1.62), reduced sensory orientation (odds ratio: 0.92), and greater operated knee pain (odds ratio: 1.68) were significantly associated with more falls during the follow-up period.

LIMITATIONS

The results of this study may be generalizable up to 6 months after TKA.

CONCLUSIONS

Intervention efforts should target deficits in knee proprioception and sensory orientation and operated knee pain to prevent future falls in individuals with TKA.

Quadriceps weakness preferentially predicts detrimental gait compensations among common impairments after total knee arthroplasty

Patients with total knee arthroplasty (TKA) have large deficits in physical performance in comparison to their healthy age-matched peers. Limb asymmetry stemming from less relative load borne by the surgical limb during daily mobility is associated with diminished performance and worsens with greater mobility demands. How common targets of postoperative care, such as muscle weakness, lower limb extension power, residual knee pain, and poor balance confidence can influence asymmetrical limb loading remains unclear. Forty-six patients with unilateral TKA underwent testing of impairments and motion analysis during 10° decline walking at 3 and 6 months postoperatively. At 3 months, only quadriceps femoris strength asymmetry was found to be significantly related to both total support moment (M_T ) (β = 0.431; p < 0.001) and knee extensor moment (M_K ) (β = 0.493; p < 0.001) asymmetry. Again at 6 months, only quadriceps strength asymmetry was related to M_T (β = 0.432; p < 0.001) and M_K (β = 0.534; p < 0.001) asymmetry. Quadriceps strength significantly improved over time in both limbs, however, deficits between limbs remained. Persistent quadriceps weakness is a key factor associated with walking compensation patterns that are limiting the capacity for greater physical performance of patients with TKA. The pronounced asymmetry in limb and knee loading at 3 months remains unchanged until at least 6 months after surgery, and its association with quadriceps strength asymmetry does not substantially change over time. While other factors may also prompt gait compensations, emphasis on improved quadriceps strength should be a focus of efforts to resolve gait compensations and enhance physical performance outcomes. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2355-2363, 2018.

Risk of falls in patients with knee osteoarthritis undergoing total knee arthroplasty: A systematic review and best evidence synthesis

OBJECTIVES

Falls occur frequently in patients with impaired ambulation and may dramatically affect the elderly population. Aim was to document the incidence of falls in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA), and to identify factors and treatments that may influence the risk of falls.

METHODS

A systematic literature search was conducted on three medical electronic databases, PubMed, PeDRO, and Cochrane Collaboration. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used. Risk of bias analysis and best evidence synthesis were performed. The main aspects related to falls were analyzed: prevalence, risk factors, correlation with clinical outcome, effect of treatments.

RESULTS

The systematic review identified 11 papers on 1237 patients. Pre-operative fall prevalence ranged from 23% to 63%, while post-operative values ranged from 12% to 38%. Moderate evidence was found on no influence of clinical scales, no BMI differences between "faller" and "non-faller", and on influence of limited pre-operative range of motion. Conflicting evidence was found for sex, history of previous falls, age, kyphosis, muscle weakness, fear of falling, depression, balance, gait impairment. No evidence was found for the effectiveness of surgical or rehabilitative strategies on falls reduction.

CONCLUSIONS

OA patients undergoing TKA are at high risk of falls, which is reduced but still present after surgery. Although some risk factors were identified, there are no studies demonstrating the possibility of reducing the incidence of this deleterious event, which warrants further research efforts to better manage this fragile population of elderly patients.

Review of perioperative falls

Falls are a known public health problem, and there is increasing recognition of the importance of perioperative falls for risk prediction and quality assessment. Our objective was to review existing literature regarding the occurrence, injuries, and risk factors of preoperative and postoperative falls. A systematized search of PubMed entries between 1947 and November 2015 produced 24 articles that met inclusion criteria. Most studied orthopaedic surgery patients older than 65 yr. Four were rated 'good' quality. Interrater reliability for the quality assessment was moderate (κ = 0.77). In the 3-12 months before surgery, the proportion of preoperative patients who fell ranged from 24 to 48%. Injuries were common (70%). The rate of postoperative falls ranged from 0.8 to 16.3 per 1000 person-days, with a gradual decline in the months after surgery. Injuries from postoperative falls occurred in 10-70% of fallers, and 5-20% experienced a severe injury. Risk factors were not well studied. Prospective studies reported a higher percentage of falls and fall-related injuries than retrospective studies, suggesting that there may be underdetection of falls and injuries with retrospective studies. Perioperative falls were more common than falls reported in the general community, even up to 12 months after surgery. Surgery-related falls may therefore occur beyond the hospitalization period. Future studies should use a prospective design, validated definitions, and broader populations to study perioperative falls. In particular, investigations of risk factors and follow-up after hospitalization are needed.

REGISTRY NUMBER

PROSPERO registration number CRD42015029971.

Fall incidence and associated risk factors among people with a lower limb amputation during various stages of recovery - a systematic review

Purpose: The objective of this study was to estimate fall incidence and describe associated risk factors among people with a lower limb amputation (LLA) during various stages of recovery: the surgical ward, in-patient rehabilitation and return to community life. Materials and methods: A systematic search of relevant English language articles was performed using PubMed and EMBASE. Out of 310 initial "hits," six retrospective cohort studies, one prospective cohort study and eleven cross-sectional studies from which fall incidence and risk factors could be extracted, were selected for critical review. Fall incidence and associated risk factors were extracted and analyzed in the context of various clinical stages of recovery after amputation. The studies were evaluated for quality using the "Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies." Results: Results showed that during all stages of recovery, people with a LLA are at increased risk of falling compared with able-bodied individuals, as well as other clinical populations. Each stage of recovery is associated with different fall risk factors. The current review is limited mainly by the paucity of studies on the topic. Conclusions: Specialised care focusing on the most relevant risk factors for each stage of recovery may enhance fall prevention during post-fall recovery. Implications for rehabilitation •  People with a lower limb amputation are at a high risk of falling in all stages of their clinical course.      •  Health professionals should be aware that people with a lower limb amputation in the first 4 years ofamputation or with four or more health-related problems are at an increased risk.      •  Health professionals should also be aware that increased gait variability, excess confidence in balance andwalking abilities and less cautious stair walking, impose an elevated risk of falling and should focus theirefforts in reducing these factors.

Preoperative Risk Factors for Postoperative Falls in Persons Undergoing Hip or Knee Arthroplasty: A Longitudinal Study of Data From the Osteoarthritis Initiative

OBJECTIVE

To identify preoperative risk factors associated with posthospitalization falls over an approximate 2-year postoperative period in patients undergoing both hip and knee arthroplasty.

DESIGN

A longitudinal cohort design.

SETTING

Communities surrounding 4 urban university-based medical centers.

PARTICIPANTS

Adults (N = 596) with hip or knee arthroplasty over a 9-year period and followed yearly.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome measure was a self-reported history of falls over the 2-year postoperative period. A fall was recorded when the participant reported landing on the floor or ground. Preoperative predictors of falls derived from previous evidence included preoperative fall history, depressive symptom severity, narcotic use, age, activity level, and comorbidity. Multinomial regression analysis was performed to determine factors that predicted either a single fall or multiple falls during a 2-year postoperative period.

RESULTS

Preoperative predictors of multiple postoperative falls were a preoperative history of falls, depressive symptoms, and hip vs knee arthroplasty. Patients with hip arthroplasty were more than twice as likely (odds ratio, 2.26; 95% confidence interval, 1.21-4.20) as patients with knee arthroplasty to have multiple self-reported falls in the first 2 postoperative years. No predictors were found for persons who reported falling only once postoperatively. Findings were generally supported in a sensitivity analysis.

CONCLUSIONS

Clinicians involved in the pre- and postoperative care of persons undergoing hip or knee arthroplasty can use these findings to inform fall risk screening and intervention delivery to reduce fall risk in patients who are at risk for multiple falls after hip or knee arthroplasty.

Recovery of balance function among individuals with total knee arthroplasty: Comparison of responsiveness among four balance tests

BACKGROUND AND AIM

Balance deficits are common after total knee arthroplasty (TKA); however the responsiveness of commonly used balance measurement tools has not been well defined. The objective of this prospective study was to compare the internal and external responsiveness of four measurement tools in assessing recovery of balance function following TKA.

METHODS

A total of 134 individuals with TKA (95 women; age: 66.3±6.6years) completed the Balance Evaluation Systems Test (BESTest), Mini-BESTest, Brief-BESTest, and Berg Balance Scale (BBS) at 2, 4, 8, 12, and 24 weeks post-TKA. The Functional Gait Assessment (FGA) served as the anchor measure, and was also measured across these time points. Internal responsiveness was indicated by the standardized response mean (SRM), while external responsiveness was reflected by the degree of association of the changes of balance scores with those of FGA.

RESULTS

The SRM ranged from 0.60-1.14 for the BESTest, 0.40-0.94 for the Mini-BESTest, 0.27-0.91 for the Brief-BESTest, and 0.19-0.70 for the BBS, over time. The change in BESTest and Mini-BESTest scores predicted the change in the FGA scores across all time periods, except for the Mini-BESTest between weeks 12-24, accounting for 13-27%, and 12-24% of the variance, respectively. The Brief-BESTest scores only predicted FGA scores between the weeks 2-4 (R²=20%). The changes in BBS scores were not associated with the FGA.

CONCLUSION

The BESTest is the most responsive in measuring recovery of balance among individuals with TKA. The Mini-BESTest is a reasonable option during time constraints.

Pre-operative predictors of post-operative falls in people undergoing total hip and knee replacement surgery: a prospective study

INTRODUCTION

Pain and disability often persist following hip (THR) and knee replacement (TKR) surgery predisposing patients to increased risk of falling. This study identified pre-operative predictors for post-operative falls in TKR and THR patients, and the incidence and circumstances of falls in the 12 months post-surgery.

MATERIALS AND METHODS

A survey was undertaken of patients before THR and TKR, and was repeated 12 months post-operation. The survey included (1) medical history and medications usage, (2) pain and function, (3) health-related and physical activity and (4) fear of falls and history of falls questionnaires. Patients were classified as 'fallers' (≥1 fall) or 'non-fallers' based on prospectively documented falls in the 12 months post-surgery. Binary logistic regression was conducted to identify independent pre-operative predictors of incident falls status.

RESULTS

Eighty-two of the 243 participants (33.7%) reported ≥1 fall in the 12 months post-operatively [60 (34.1%) patients following TKR and 22 (32.8%) following THR]. The logistic regression model was statistically significant, χ ² = 24.731, p < 0.001, the model explaining 22% of the variance in falls, and correctly classifying 73.7% of cases as fallers or non-fallers. Reduced SF-36v2 general health sub-scale, increased planned physical activity and previous falls in the preceding year were predictors of falls. Those reporting ≥1 fall pre-operatively were three times more likely to fall post-operatively.

CONCLUSION

People awaiting hip or knee joint replacement surgery might present with complex conditions that predispose them to greater risk of falling post-operation. Review of general health and history of falling is recommended pre-operatively to identify patients at risk.