Preoperative grip strength measurement and duration of hospital stay in patients undergoing total hip and knee arthroplasty

The effect of spinal versus general anaesthesia on perioperative muscle weakness in patients having bilateral total hip arthroplasty: a single center randomized clinical trial

BACKGROUND

Perioperative neuro-endocrine stress response may contribute to acquired muscle weakness. Regional anaesthesia has been reported to improve the outcome of patients having total hip arthroplasty. In this study, it was hypothesized that spinal anaesthesia (SA) decreases the perioperative neuro-endocrine stress response and perioperatively acquired muscle weakness (PAMW), as compared to general anaesthesia (GA).

METHODS

Fifty subjects undergoing bilateral total hip arthroplasty (THA) were randomly allocated to receive a standardized SA (n = 25) or GA (n = 25). Handgrip strength was assessed preoperatively, on the first postoperative day (primary endpoint) and on day 7 and 28. Respiratory muscle strength was measured by maximal inspiratory pressure (MIP). Stress response was assessed by measuring levels of Adrenocorticotropic hormone (ACTH), cortisol and interleukin-6 (IL-6).

RESULTS

Handgrip strength postoperatively (day 1) decreased by 5.4 ± 15.9% in the SA group, versus 15.2 ± 11.7% in the GA group (p = 0.02). The handgrip strength returned to baseline at day 7 and did not differ between groups at day 28. MIP increased postoperatively in patients randomized to SA by 11.7 ± 48.3%, whereas it decreased in GA by 12.2 ± 19.9% (p = 0.04). On day 7, MIP increased in both groups, but more in the SA (49.0 ± 47.8%) than in the GA group (14.2 ± 32.1%) (p = 0.006). Postoperatively, the levels of ACTH, cortisol and IL-6 increased in the GA, but not in the SA group (p < 0.004).

CONCLUSION

In patients having bilateral THA, SA preserved the postoperative respiratory and peripheral muscle strength and attenuated the neuro-endocrine and inflammatory responses.

TRIAL REGISTRATION

clinicaltrials.gov NCT03600454.

Malnutrition is associated with postoperative complications in elderly patients undergoing total hip arthroplasty

INTRODUCTION

Malnutrition in elderly patients with hip fracture has been described as a factor associated with poor outcomes. This evidence for elderly patients undergoing elective total hip arthroplasty (THA) for osteoarthritis is not well-established.

METHODS

We retrospectively studied a cohort of patients with an age ≥65 years admitted to the hospital for THA between January 2018 and December 2020. Demographic characteristics were collected. Albumin and total lymphocyte count were included in the pre-operative analysis and 24h postoperatively. Nutritional screening was carried out 24h postoperatively. GLIM criteria were applied for the diagnosis of malnutrition.

RESULTS

25 patients out of the total cohort of 65 (38.4%) were malnourished. Five out of six patients (83.3%) with postoperative complications presented malnutrition compared with 20 of 59 patients (33.8%) without postoperative complications (P=0.028). Mean length of stay (LOS) was 3.49±0.88 days. Five out of six (83.3%) patients with postoperative complications presented LOS >3 days compared with one out of six patients (16.6%) with LOS ≤3 days (P=0.009). 26 patients (40%) were referred to a community health centre, no differences in diagnosis of malnutrition were detected compared with patients who were discharged home. Patients with a diagnosis of malnutrition were significantly older, had a lower body mass index (BMI), a lower preoperative and postoperative albumin and worse anthropometric parameters.

CONCLUSIONS

Malnutrition is associated with postoperative complications and longer LOS in elderly patients with elective THA. Risk factors for malnutrition are older age and low BMI.

Does Hand Grip Strength (HGS) Predict Functional Independence Differently in Patients Post Hip Replacement Due to Osteoarthritis versus Patients Status Post Hip Replacement Due to a Fracture?

Purpose

The aim of the study was to determine whether hand grip strength (HGS) predicts functional independence in older patients who have undergone hip replacement due to osteoarthritis versus older patients who have undergone hip replacement surgery due to fracture.

Patients and Methods

The study included 239 patients aged 65 and over in the first weeks after total hip replacement during rehabilitation treatment. Multivariate linear regression was used to determine HGS as a predictor of activities of daily living (ADL) and instrumental activities of daily living (IADL) in both groups: patients post hip replacement due to osteoarthritis and patients post hip replacement due to a fracture.

Results

Analysis showed that pre-rehab HGS in the osteoarthritis group predicts improved activities of daily living after rehabilitation (ADL, OR = 1.098; CI 95% 1.052-1.147 and IADL, OR = 1.182; CI 95% 1.103-1.267) and 6 months after (ADL, OR = 1.191; CI 95% 1.066-1.329 and IADL, OR = 1.096; CI 95% 1.012-1.186). In the fracture group, HGS predicts the ADL (OR = 1.081; CI 95% 1.015-1.152) after rehabilitation, and IADL after rehabilitation (OR = 1.122; CI 95% 1.046-1.205) and 6 months after (OR = 1.090; 95% CI 1.021-1.64).

Conclusion

HGS in patients after hip replacement surgery predicts functional independence in basic and complex activities of daily living. This can allow the identification of osteoarthritis patients with low hand grip - who can be considered as patients with a higher risk of an unsatisfying outcome of surgery. These patients should undergo pre-rehabilitation and should be monitored, and/or supported in terms of rehabilitation after discharge.

Mitochondrial function, grip strength, and activity are related to recovery of mobility after a total knee arthroplasty

Low muscle quality and a sedentary lifestyle are indicators for a slow recovery after a total knee arthroplasty (TKA). Mitochondrial function is an important part of muscle quality and a key driver of sarcopenia. However, it is not known whether it relates to recovery. In this pilot study, we monitored activity after TKA using a wrist mounted activity tracker and assessed the relation of mitochondrial function on the rate of recovery after TKA. Additionally, we compared the increase in activity as a way to measure recovery to traditional outcome measures. Patients were studied 2 weeks before TKA and up to 6 months after. Activity was monitored continuously. Baseline mitochondrial function (citrate synthase and complex [CP] 1-5 abundance of the electron transport chain) was determined on muscle tissue taken during TKA. Traditional outcome measures (Knee Injury and Osteoarthritis Outcome Score [KOOS], timed up-and-go [TUG] completion time, grip, and quadriceps strength) were performed 2 weeks before, 6 weeks after, and 6 months after TKA. Using a multivariate regression model with various clinical baseline parameters, the following were significantly related to recovery: CP5 abundance, grip strength, and activity (regression weights 0.13, 0.02, and 2.89, respectively). During recovery, activity correlated to the KOOS-activities of daily living (ADL) score (r = 0.55, p = 0.009) and TUG completion time (r = -0.61, p = 0.001). Mitochondrial function seems to be related to recovery, but so are activity and grip strength, all indicators of sarcopenia. Using activity trackers before and after TKA might give the surgeon valuable information on the expected recovery and the opportunity to intervene if recovery is low.

Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study

Background and Aims

Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients.

Material and Methods

This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression.

Results

The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013).

Conclusion

HGS can be used as a preoperative test in predicting hospital LOS after major surgery.

Grip Strength as a Predictor of the Functional Outcome of Hip-Fracture Patients

BACKGROUND

Patients with hip fracture are limited as to physical activity. It is difficult to evaluate the physical function of the legs at admission; however, it is easy to measure grip strength, which has been reported to be correlated with systemic muscular strength and physical function. The objective of this study was to investigate the utility of grip strength in predicting functional outcome after hip fracture.

METHODS

Fifty-seven patients who underwent surgery for hip fracture were evaluated for height, weight, Body Mass Index (BMI), grip strength, bone density (femoral neck), hemoglobin, Hemoglobin A1c (HbA1c), Hasegawa's Dementia Scale-Revised (HDS-R), and albumin at admission and Functional Independence Measure (FIM) at discharge. Spearman's rank correlation coefficient was used to evaluate the relation between grip strength and the above variables. Furthermore, factors of walking acquisition were analyzed by logistic regression analysis and decision-tree analysis.

RESULTS

Correlation analysis showed that grip strength was positively correlated with bone density at admission and FIM at discharge and negatively correlated with age. In the logistic regression analysis, the independent factor associated with walking acquisition was grip strength (OR 1.26; 95%CI 1.018-1.566; p=0.0339). In the decisiontree analysis, grip strength was the initial divergence variable for walking acquisition (the percentage with walking acquisition was 80.0% of the patients with grip strength ≧13.2 kg VS. 18.7% of the patients with grip strength < 13.2 kg).

CONCLUSIONS

Grip strength at admission was definitive in predicting the functional outcome of patients with hip fracture who underwent surgery.

Reproducibility and agreement between three positions for handgrip assessment

The protocol established for taking hand grip dynamometry measurements determines that the patient must be in a sitting position. This protocol cannot be applied due to the patient’s conditions in some cases, such as abdominal surgery, musculoskeletal spine or hip injuries. The purpose was to determine the reproducibility and level of agreement between the Handgrip dynamometry in supine position with the elbow flexed or extended, and the one measured in the sitting position, the design was a descriptive cross-sectional study. The population were young apparently healthy between 18 and 30 years of age (N = 201). Handgrip measurement was performed on both upper limbs in a sitting position with a flexed elbow, a supine position with a flexed elbow, and supine position with the elbow extended. Reproducibility was nearly perfect in all positions (ICC 0.95–0.97). Regarding the level of agreement for the comparison between sitting and supine positions with a flexed elbow, an average difference of − 0.406. For supine position with an extended elbow and supine position with a flexed elbow, the average difference was − 1.479. Considering the results, clinicians or researchers can choose any of the positions evaluated herein and obtain reliable results as long as the standardization process is followed.

Low Grip Strength Associated with Clinical Outcomes after Total Hip Arthroplasty - A Prospective Case-Control Study

OBJECTIVE

To assess whether low grip strength (GS) is associated with clinical outcomes after total hip arthroplasty (THA).

METHODS

A prospective case-control study was designed to assess 231 cases of primary THA between January 1, 2015 to May 1, 2018, at an urban tertiary care hospital. Patients were placed into two cohorts based on preoperative GS levels. Low GS in the present study was defined as GS lower than 26 kg for men and 16 kg for women in the dominant hand. Baseline data were prospectively collected and included patient demographics (age, sex, body mass index [BMI]), the surgeon's diagnoses, medical history, length of stay, and American Society of Anaesthesiologists' (ASA) score. Clinical outcomes included surgery- and prosthesis-related variables. The Harris hip score (HHS) and the Short Form Health Survey (SF-12) were completed at the baseline visit and at 1 and 2 years postoperatively in the outpatient department to assess the hip's function and quality of life. Differences in baseline data, length of study (LOS), 90-day postoperative complications, and hospital readmissions were compared. Besides, the correlations between GS and Harris hip score (HHS) and Short Form score (SF-12) were tested.

RESULTS

A total of 202 participants have completed records for analysis finally. The patients were followed up for an average of 24.8 months postoperatively (24-26 months). Eighty-two patients (40.6%) had low GS before THA. Patients with low GS were more likely to be female, older, fracture of femoral head or neck as the primary cause, albumin <3.5 g/dL, and have a lower BMI, higher ASA score, increased rates of the pressure sore, blood transfusion, and LOS compared to normal GS (all P < 0.05). Also, patients in the low GS cohort showed a statistically significant increased unplanned hospital readmissions and decreased discharge home compared to normal GS (both P < 0.05). There was an increasing rate of complications between the two cohorts, for cardiac complications, pressure sore after THA, respiratory complications, urinary tract infection, stroke, and DVT (all P < 0.05). A partial correlation test by controlling medical comorbidities and demographic factors was used to determine the correlation between GS and HHS. There was a significant correlation between them (r = -0.673; P = 0.002). A similar condition was detected in the correlation between GS and SF-12 (r = 0.645; P = 0.001).

CONCLUSIONS

Clinicians should be encouraged to include GS assessment in their evaluation of patients who planned to undergo THA in order to optimize the treatment of high-risk individuals.

Handgrip strength predicts 1-year functional recovery and mortality in hip fracture patients

OBJECTIVES

Muscle strength is a possible predictor of adverse events. It could have prognostic value in patients with hip fracture (HF). The aim of this study was to determine if handgrip strength is associated with functional impairment, readmissions, and mortality at one year in elderly patients with HF.

DESIGN

A prospective observational study was carried out. It included a cohort of patients aged 65 years or older with a diagnosis of fragility HF, consecutively from January 2013 to February 2014 and seen in follow-up at one year. Statistical analysis was performed using SPSS v21 software.

MAIN OUTCOME MEASURES

Five hundred and nine patients with a mean age of 85.4 ± 0.3 years were included, of whom 403 (79.2 %) were women. Clinical and functional outcomes, laboratory parameters and anthropometric measurements were collected.

RESULTS

Of the total sample, 339 (66.6 %) had reduced handgrip strength, and these patients were older, more frequently institutionalized, had poorer functional and cognitive status, higher comorbidity, higher surgical risk, lower body mass index and a greater intra-hospital mortality (all p < 0.01). At one year, patients with lower handgrip strength had a major change in their ability to walk (32.7 % vs. 10.9 %, p < 0.001) and a higher mortality rate (30.4 % vs. 8.8 %, p < 0.001). However, in patients over 91 years of age, there was no association between lower handgrip strength and change in ability to walk. There were no differences in the number of readmissions.

CONCLUSION

Low handgrip strength in elderly patients with HF predicts greater functional disability and higher long-term mortality.

Association of handgrip strength with patient-reported outcome measures after total hip and knee arthroplasty

About 33% patients with osteoarthritis undergoing total hip/knee arthroplasty are not satisfied with the outcome, warranting the need to improve patient selection. Handgrip strength (HGS) has been suggested as a proxy for overall muscle strength and may be associated with post-arthroplasty function. This study aims to assess the association of pre-operative HGS with change in hip/knee function and quality of life in patients with arthroplasty. 226 hip (THA) and 246 knee (TKA) arthroplasty patients were included in this prospective cohort study. Pre-operative HGS was assessed by means of a dynamometer and the HOOS/KOOS and SF-36 questionnaires were collected before arthroplasty and 1 year thereafter. The association of HGS with score change on each sub-domain of the included questionnaires was assessed by linear regression models, adjusting for sex, body mass index and baseline score. Mean pre-operative HGS was 26 kg for patients undergoing THA and 24 kg for those undergoing TKA. HGS was positively associated with an increased improvement score on “function in sport and recreation”-domain in hip (β = 0.68, P = 0.005) and knee (β = 0.52, P = 0.049) and “symptoms”-domain in hip (β = 0.56, P = 0.001). For patients with THA, HGS was associated with the “quality of life” domain (β = 0.33, P = 0.033). In patients with TKA, HGS was associated with the physical component score (β = 0.31, P = 0.001). All statistically significant effects were positive, indicating that with greater pre-operative HGS, an increased gain in 1-year post-surgery score was observed. HGS can be used as a tool to inform patients with OA who are future candidates for a prosthesis about the possible improvements of certain aspects of life after arthroplasty.

Grip Strength: An Indispensable Biomarker For Older Adults

Grip strength has been proposed as a biomarker. Supporting this proposition, evidence is provided herein that shows grip strength is largely consistent as an explanator of concurrent overall strength, upper limb function, bone mineral density, fractures, falls, malnutrition, cognitive impairment, depression, sleep problems, diabetes, multimorbidity, and quality of life. Evidence is also provided for a predictive link between grip strength and all-cause and disease-specific mortality, future function, bone mineral density, fractures, cognition and depression, and problems associated with hospitalization. Consequently, the routine use of grip strength can be recommended as a stand-alone measurement or as a component of a small battery of measurements for identifying older adults at risk of poor health status.

The impact of sarcopenic obesity on knee and hip osteoarthritis: a scoping review

BACKGROUND

The progressive, debilitating nature of knee and hip osteoarthritis can result in severe, persistent pain and disability, potentially leading to a need for total joint arthroplasty (TJA) in end-stage osteoarthritis. TJA in adults with obesity is associated with increased surgical risk and prolonged recovery, yet classifying obesity only using body mass index (BMI) precludes distinction of obesity phenotypes and their impact on surgical risk and recovery. The sarcopenic obesity phenotype, characterized by high adiposity and low skeletal muscle mass, is associated with higher infection rates, poorer function, and slower recovery after surgery in other clinical populations, but not thoroughly investigated in osteoarthritis. The rising prevalence and impact of this phenotype demands further attention in osteoarthritis treatment models of care, particularly as osteoarthritis-related pain, disability, and current treatment practices may inadvertently be influencing its development.

METHODS

A scoping review was used to examine the extent of evidence of sarcopenic obesity in adults with hip or knee osteoarthritis. Medline, CINAHL, Web of Science and EMBASE were systematically searched from inception to December 2017 with keywords and subject headings related to obesity, sarcopenia and osteoarthritis.

RESULTS

Eleven studies met inclusion criteria, with indications that muscle weakness, low skeletal muscle mass or sarcopenia are present alongside obesity in this population, potentially impacting therapeutic outcomes, and TJA surgical risk and recovery.

CONCLUSIONS

Consideration of sarcopenic obesity should be included in osteoarthritis patient assessments.

Combination of measures of handgrip strength and red cell distribution width can predict in-hospital complications better than the ASA grade after hip fracture surgery in the elderly

BACKGROUND

Early detection of a high-risk patient following hip fracture surgery is of paramount clinical importance. American Society of Anesthesiologists (ASA) grading is an easy and efficient index in predicting a worse outcome. The red cell distribution width (RDW) and handgrip strength, are gaining interest as a prediction tool as well. Accordingly, the objective of this study was to investigate the potential association between ASA, RDW and grip strength and detect the effects of combining RDW and grip strength for predicting early complication after hip fracture surgery in the elderly.

METHODS

Eighty-three consecutive patients operated with hip fracture surgeries were identified retrospectively. Age, gender, diagnosis, RDW, handgrip strength and ASA grade were recorded. Admission to the intensive care unit (ICU), length of ICU stay, transfer to other departments, in-hospital death, and readmission were investigated as early complications. Logistic regression analysis was applied to evaluate the estimates in predicting complications, and receiver operating characteristics curves were constructed to compare the estimates and decide which method is more accurate.

RESULTS

After the surgery, 52% of the patients were admitted to the ICU. From the analyses, RDW and grip strength had no significant relation with each other. However, the ICU stay was correlated with RDW and grip strength but not for the ASA grade. A higher ASA grade and grip strength could independently predict ICU admission. The combination of RDW with grip strength outweighed the ASA grade in predictive ability.

CONCLUSIONS

The current study indicated that combining RDW and grip strength measures can be efficient and clinically relevant in predicting early postoperative complications after fragility hip fracture in the elderly. Due to the objectivity and availability of those two approaches, patient care, and functional outcomes are expected to be improved by adopting these measures in the clinical setting.

The Influence of Muscle Weakness on the Association Between Obesity and Inpatient Recovery From Total Hip Arthroplasty

BACKGROUND

There is ongoing discussion about whether preoperative obesity is negatively associated with inpatient outcomes of total hip arthroplasty (THA). The aim was to investigate the interaction between obesity and muscle strength and the association with postoperative inpatient recovery after THA.

METHODS

Preoperative obesity (body mass index [BMI] >30 kg/m²) and muscle weakness (hand grip strength <20 kg for woman and <30 kg for men) were measured about 6 weeks before THA. Patients with a BMI <18.5 kg/m² were excluded. Outcomes were delayed inpatient recovery of activities (>2 days to reach independence of walking) and prolonged length of hospital stay (LOS, >4 days and/or discharge to extended rehabilitation). Univariate and multivariable regression analyses with the independent variables muscle weakness and obesity, and the interaction between obesity and muscle weakness, were performed and corrected for possible confounders.

RESULTS

Two hundred and ninety-seven patients were included, 54 (18%) of whom were obese and 21 (7%) who also had muscle weakness. Obesity was not significantly associated with prolonged LOS (odds ratio [OR] 1.36, 95% confidence interval [CI] 0.75-2.47) or prolonged recovery of activities (OR 1.77, 95% CI 0.98-3.22), but the combination of obesity and weakness was significantly associated with prolonged LOS (OR 3.59, 95% CI 1.09-11.89) and prolonged recovery of activities (OR 6.21, 95% CI 1.64-23.65).

CONCLUSION

Obesity is associated with inpatient recovery after THA only in patients with muscle weakness. The results of this study suggest that we should measure muscle strength in addition to BMI (or body composition) to identify patients at risk of prolonged LOS.

Grip strength among community-dwelling older people predicts hospital admission during the following decade

BACKGROUND

Lower grip strength on admission to hospital is known to be associated with longer stay, but the link between customary grip and risk of future admission is less clear.

OBJECTIVE

To compare grip strength with subsequent risk of hospital admission among community-dwelling older people in a U.K. setting.

DESIGN

Cohort study with linked administrative data.

SETTING

Hertfordshire, U.K.

SUBJECTS

A total of 2,997 community-dwelling men and women aged 59-73 years at baseline.

METHODS

The Hertfordshire Cohort Study (HCS) participants completed a baseline assessment between 1998 and 2004, during which grip strength was measured. Hospital Episode Statistics and mortality data to March 2010 were linked with the HCS database. Statistical models were used to investigate the association of grip strength with subsequent elective, emergency and long-stay hospitalisation and readmission.

RESULTS

There was a statistically significant negative association between grip strength and all classes of admission in women [unadjusted hazard ratio per standard deviation (SD) decrease in grip strength for: any admission/death 1.10 (95% CI: 1.06, 1.14), elective admission/death 1.09 (95% CI: 1.05, 1.13), emergency admission/death 1.21 (95% CI: 1.13, 1.31), long-stay admission/death 1.22 (95% CI: 1.13, 1.32) and unadjusted relative risk per SD decrease in grip strength for 30-day readmission/death 1.30 (95% CI: 1.19, 1.43)]. These associations remained significant after adjustment for potential confounding factors (age, height, weight for height, smoking, alcohol, social class). In men, unadjusted rates for emergency admission/death, long-stay admission/death and readmission/death were significantly associated with grip strength; associations that similarly withstood adjustment.

CONCLUSION

This study provides the first evidence that grip strength among community-dwelling men and women in the U.K. is associated with risk of hospital admission over the following decade.