Patient activity after TKA depends on patient-specific parameters

Device-Measured Physical Activity in 3506 Individuals with Knee or Hip Arthroplasty

PURPOSE

Hip and knee arthroplasty aims to reduce joint pain and increase functional mobility in patients with osteoarthritis; however, the degree to which arthroplasty is associated with higher physical activity is unclear. The current study sought to assess the association of hip and knee arthroplasty with objectively measured physical activity.

METHODS

This cross-sectional study analyzed wrist-worn accelerometer data collected in 2013-2016 from UK Biobank participants (aged 43-78 yr). Multivariable linear regression was performed to assess step count, cadence, overall acceleration, and activity behaviors between nonarthritic controls, end-stage arthritic, and postoperative cohorts, controlling for demographic and behavioral confounders. From a cohort of 94,707 participants with valid accelerometer wear time and complete self-reported data, electronic health records were used to identify 3506 participants having undergone primary or revision hip or knee arthroplasty and 68,389 nonarthritic controls.

RESULTS

End-stage hip or knee arthritis was associated with taking 1129 fewer steps per day (95% confidence interval (CI), 811-1447; P < 0.001) and having 5.8 fewer minutes per day (95% CI, 3.0-8.7; P < 0.001) of moderate-to-vigorous activity compared with nonarthritic controls. Unilateral primary hip and knee arthroplasties were associated with 877 (95% CI, 284-1471; P = 0.004) and 893 (95% CI, 232-1554; P = 0.008) more steps than end-stage osteoarthritic participants, respectively. Postoperative unilateral hip arthroplasty participants demonstrated levels of moderate-to-vigorous physical activity and daily step count equivalent to nonarthritic controls. No difference in physical activity was observed between any cohorts in terms of overall acceleration, or time spent in daily light activity, sedentary behavior, or sleep.

CONCLUSIONS

Hip and knee arthroplasties are associated with higher levels of physical activity compared with participants with end-stage arthritis. Unilateral hip arthroplasty patients, in particular, demonstrate equivalence to nonarthritic peers at more than 1 yr after surgery.

How Active Are Our Patients in the First 6 Weeks Following Total Knee Arthroplasty?

BACKGROUND

Patient activity after total knee arthroplasty (TKA) surgery has been estimated through patient- reported outcome measures. The use of data from an implanted sensor that transmits daily gait activity provides a more objective, complete recovery trajectory.

METHODS

In this retrospective analysis of 794 patients who received a TKA with sensors in the tibial extension between October 4, 2021, and January 13, 2023, the average age of the patients was 64 years, and the cohort was 54.9% women. During the 6-week postoperative period, 90.3% of patients transmitted data. Patient activity in terms of qualified step count, cadence, walking speed, stride length, functional tibial range of motion, and functional knee range of motion were compared at 1 week, 3 weeks, and 6 weeks postoperatively.

RESULTS

All gait parameters increased in the first six weeks post-surgery: qualified step count increased 733%, cadence increased 22%, walking speed increased 50%, stride length increased 17%, tibial range of motion (ROM) increased 19%, and functional knee ROM increased 14%. There were statistically significant differences at both postoperative periods (P = 0.029, P < 0.001, and P < 0.001 at 3 and 6 weeks, respectively) in step counts for different body mass index (BMI) categories, with qualified step counts decreasing with increasing BMI. Patients under 65 years tended to have a higher qualified step count than those 65 and older at all time points, but these differences were not statistically significant. Men had significantly higher step counts than women (P < 0.001 at 1, 3, and 6 weeks).

CONCLUSIONS

Initial results with an implanted sensor that collects data during activities of daily living confirm that 90% of patients transmit objective gait metrics daily after TKA surgery. Those results differ by sex and BMI.

Factors associated with physical activity following total knee arthroplasty for knee osteoarthritis: a longitudinal study

BACKGROUND

After total knee arthroplasty (TKA), patients' physical activity (PA) levels at 6 months are lower than those of healthy subjects. Few studies have investigated the factors associated with PA at 6 months after TKA by objectively measuring preoperative and postoperative PA intensity using an accelerometer and knee function using a goniometer and dynamometer. The purpose of this study was to determine the factors associated with PA levels at 6 months after TKA based on objective data.

METHODS

Eighty-two patients (mean [SD] age 74.5 [6.4] years) with moderate-to-severe knee osteoarthritis (OA) who were scheduled for TKA at the Nagoya Orthopaedic and Joint Replacement Clinic from July 2018 to July 2019 were enrolled in this longitudinal study. All patients underwent evaluations of knee function, including range-of-motion and knee-extension muscle strength; knee pain; performance in the timed up-and-go test; and accelerometer-measured PA both preoperatively and 6 months postoperatively. Factors associated with PA at 6 months after TKA were assessed using a hierarchical multiple linear regression analysis adjusted for age, sex, body mass index, and presence of diabetes mellitus.

RESULTS

A higher average daily step count at 6 months after TKA was significantly associated with greater preoperative knee-extension muscle strength on the operated side (β = 0.155, p = 0.028) as well as a higher preoperative average daily step count (β = 0.834, p < 0.001). Furthermore, average daily time spent in moderate-to-vigorous-intensity PA postoperatively was significantly associated only with time spent in moderate-to-vigorous-intensity PA preoperatively (β = 0.723, p < 0.001).

CONCLUSION

These findings indicate that a higher preoperative daily step count and greater preoperative knee-extension muscle strength on the operated side may be associated with a higher daily step count at 6 months after TKA. Factors associated with PA differed by the PA intensity level. Rehabilitation and interventions for psychosocial factors before TKA beginning when mild knee OA first occurs are expected to lead to increased PA in TKA patients.

Interactive Combinations Between Gait Speed and Physical Function at Acute Phase Can Predict the Physical Activity at 2 Years After Total Knee Arthroplasty Using Classification and Regression Tree Analysis

OBJECTIVE

To clarify the interactive combinations of various clinical factors associated with physical activity (PA) at 2 years after total knee arthroplasty (TKA) using classification and regression tree (CART) analysis.

DESIGN

A retrospective cohort study.

SETTING

A single university hospital.

PARTICIPANTS

286 patients who underwent TKA (N=286).

MAIN OUTCOME MEASURES

PA was assessed preoperatively, 3 weeks, and 2 years after TKA. Physical functions, namely, 10 m walking test (10MWT), timed Up and Go test, 1-leg standing time, isometric knee extension and flexion strength, knee joint stability, knee pain, femora-tibial angle, and the passive knee extension and flexion angle, were measured before surgery as a baseline and 3 weeks after TKA as acute phase. CART analysis was conducted to clarify the interactive combinations that accurately predict the PA at 2 years after TKA.

RESULTS

The results of CART analysis indicated that gait speed (≥1.05 m/s) at the acute phase after TKA was the primal predictor for the postoperative PA at 2 years. The highest postoperative PA at 2 years was determined by gait speed (≥1.05 m/s) and PA (>74.5) at the acute phase. The PA at baseline and at acute phase, as well as the body mass index were also selected as predictors of postoperative PA at 2 years.

CONCLUSION

The present study suggested that acquiring gait speed (≥1.05 m/s) and PA (>74.5) in the postoperative acute phase is the predictive of a high PA at 2 years after TKA.

Predictors of Adherence to a Step Count Intervention Following Total Knee Replacement: An Exploratory Cohort Study

OBJECTIVE

To explore the person-level predictors of adherence to a step count intervention following total knee replacement (TKR).

DESIGN

Prospective cohort study, nested within the PATHway trial.

METHODS

Participants who had recently undergone TKR were recruited from 3 rehabilitation hospitals in Sydney, Australia, for the main trial. Only data from participants who were randomized to the TKR intervention group were analyzed. Participants in the intervention group (n = 51) received a wearable tracker to monitor the number of steps taken per day. Step count adherence was objectively measured at 3 months as the number of steps completed divided by the number prescribed and multiplied by 100 to express adherence as a percentage. Participants were classified into 4 groups: withdrawal, low adherence (0%-79%), adherent (80%-100%), and >100% adherent. Ordinal logistic regression was used to identify which factors predicted adherence to the prescribed step count.

RESULTS

Of the 51 participants enrolled, nine (18% of 51) withdrew from the study before 3 months. Half of participants were classified as >100% adherent (n = 24%, 47%). Ten were classified as low adherence (20%), and 8 participants were classified as adherent (16%). In the univariable model, lower age (OR 0.90; 95% CI 0.83-0.97), higher patient activation (OR 1.03; 95% CI 1.00-1.06), and higher technology self-efficacy (OR 1.03; 95% CI 1.00-1.06) were associated with higher adherence. After adjusting for age in the multivariable model, patient activation and technology self-efficacy were not significant.

CONCLUSION

Younger age, higher patient activation, and higher technology self-efficacy were associated with higher adherence to a step count intervention following TKR in the univariable model. Patient activation and technology self-efficacy were not associated with higher adherence following adjustment for age. J Orthop Sports Phys Ther 2022;52(9):620-629. Epub: 9 July 2022. doi:10.2519/jospt.2022.11133.

Prevalence and determinants of physical activity, sedentary behaviour and fatigue five years after total knee replacement

OBJECTIVE

To determine the prevalence and predictors of physical activity, sedentary behaviour and fatigue five years after total knee replacement surgery.

DESIGN

A longitudinal cohort study.

SETTING

Community-dwelling adults who had previously undergone total knee replacement.

METHODS

Five-year follow-up questionnaire data were obtained from participants previously enrolled in a randomised controlled trial examining rehabilitation after total knee replacement. Main study outcomes at one year did not differ between randomisation groups, hence data were pooled for the present longitudinal analysis. Before and one and five years after surgery, participants completed questionnaires (Active Australia Survey, WOMAC, SF12 v2, demographics and fatigue).

RESULTS

272/422 community-dwelling adults (45-74 years) completed the questionnaires at five years. Excessive sedentary behaviour was evident in 91% of the cohort, predicted by excessive sedentary behaviour and lack of energy at one year. Inadequate physical activity at five years was evident for 59% of the cohort, predicted by higher fatigue and comorbidity scores pre-surgery and inadequate physical activity at one year. Just under half (47%) of the cohort experienced clinically-important fatigue at five years, predicted by clinically-important fatigue before and one year after surgery, lack of sleep before surgery and physical activity one year after surgery.

CONCLUSION

Documenting physical activity, sedentary behaviour and fatigue before and one year after knee replacement is important to identify those at risk of longer-term inadequate physical activity, excessive sedentary behaviour and clinically-important fatigue. Interventions to maintain activity and reduce sedentary behaviour are needed to reap the potential health benefits of total knee replacement surgery.

Effect of the knee replacement surgery on activity level based on ActivPAL: a systematic review and meta-analysis study

Background

The knee replacement (KR) surgery aims to restore the activity level and reduce the risk of experiencing disabilities. The outcomes of this surgery are evaluated mainly with subjective tools or low validity objective tools. However, the effect of the surgery on activity level using high validity objective accelerometer is still in question.

Methods

A systematic review and meta-analysis were conducted to evaluate the benefit of KR surgery alone to enhance physical activity recommendations based on high validity accelerometer. Two independent reviewers evaluated five electronic databases (Cochrane-Central-Register-of-Controlled Trials, EMBASE, PubMed, Web of Science, and Scopus) to find relative studies between January 2000 and October 2021. The quality assessments and risk of bias assessments were examined.

Results

Three articles were included with 202 participants (86 males, 116 females), with an average age of 64 years and an average 32 kg/m² body mass index. The results found that the number of steps was significantly improved up to 36.35 and 45.5% after 6-months and 1-year of the surgery, respectively. However, these changes did not meet the recommended activity level guideline and could be related to the patients’ health status and their activity level before the surgery. No significant changes were seen in sedentary time, standing time, and upright time after 6-months and 1-year follow-ups. Heterogeneity among studies was low to moderate (0–63%).

Conclusion

Knee replacement surgery is an effective treatment for improving patients’ quality of life with severe knee injuries. However, various factors impact the success of surgical and achieving maximum benefit of the surgery. One factor, sedentary time, can be reduced by implementing pre-and post-surgery exercise or physical activity recommendations. Further studies are needed to understand the benefit of surgery with or without rehabilitation assessed using high validity monitors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05531-2.

Amount and type of physical activity and sports from one year forward after hip or knee arthroplasty-A systematic review

INTRODUCTION

After rehabilitation following total hip or knee arthroplasty (THA/TKA), patients are advised to participate in physical activity (PA) and sports. However, profound insight into whether people adopt a physically active lifestyle is lacking. Aim is to gain insight into the performed amount and type of PA (including sports) and time spent sedentarily by persons after THA/TKA.

METHODS

A systematic review (PROSPERO: CRD42020178556). Pubmed, Cinahl, EMBASE and PsycInfo were systematically searched for articles reporting on amount of PA, and on the kind of activities performed between January 1995-January 2021. Quality of the articles was assessed with the adapted tool from Borghouts et al.

RESULTS

The search retrieved 5029 articles, leading to inclusion of 125 articles reporting data of 123 groups; 53 articles reported on subjects post-THA, 16 on post-hip-resurfacing arthroplasty, 40 on post-TKA, 15 on post-unicompartimental knee arthroplasty and 12 on a mix of arthroplasty types. With respect to quality assessment, 14 articles (11%) met three or fewer criteria, 29 (24%) met four, 32 (26%) met five, 42 (34%) met six, and 6 (5%) met seven out of the eight criteria. PA levels were comparable for THA and TKA, showing a low to moderately active population. Time spent was mostly of low intensity. Roughly 50% of -subjects met health-enhancing PA guidelines. They spent the largest part of their day sedentarily. Sports participation was relatively high (rates above 70%). Most participation was in low-impact sports at a recreational level. Roughly speaking, participants were engaged in sports 3 hours/week, consisting of about three 1-hour sessions.

CONCLUSION

Activity levels seem to be low; less than half of them seemed to perform the advised amount of PA following health-enhancing guidelines Sports participation levels were high. However, many articles were unclear about the definition of sports participation, which could have led to overestimation.

Objectively Measured Physical Activity, Sedentary Behavior and Functional Performance before and after Lower Limb Joint Arthroplasty: A Systematic Review with Meta-Analysis

Patients after joint arthroplasty tend to be less physically active; however, studies measuring objective physical activity (PA) and sedentary behavior (SB) in these patients provide conflicting results. The aim of this meta-analysis was to assess objectively measured PA, SB and performance at periods up to and greater than 12 months after lower limb arthroplasty. Two electronic databases (PubMed and Medline) were searched to identify prospective and cross-sectional studies from 1 January 2000 to 31 December 2020. Studies including objectively measured SB, PA or specific performance tests in patients with knee or hip arthroplasty, were included in the analyses both pre- and post-operatively. The risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN). After identification and exclusion, 35 studies were included. The data were analyzed using the inverse variance method with the random effects model and expressed as standardized mean difference and corresponding 95% confidence intervals. In total, we assessed 1943 subjects with a mean age of 64.9 (±5.85). Less than 3 months post-operative, studies showed no differences in PA, SB and performance. At 3 months post-operation, there was a significant increase in the 6 min walk test (6MWT) (SMD 0.65; CI: 0.48, 0.82). After 6 months, changes in moderate to vigorous physical activity (MVPA) (SMD 0.33; CI: 0.20, 0.46) and the number of steps (SMD 0.45; CI: 0.34, 0.54) with a large decrease in the timed-up-and-go test (SMD −0.61; CI: −0.94, −0.28) and increase in the 6MWT (SMD 0.62; CI: 0.26–0.98) were observed. Finally, a large increase in MVPA (SMD 0.70; CI: 0.53–0.87) and a moderate increase in step count (SMD 0.52; CI: 0.36, 0.69) were observed after 12 months. The comparison between patients and healthy individuals pre-operatively showed a very large difference in the number of steps (SMD −1.02; CI: −1.42, −0.62), but not at 12 months (SMD −0.75; −1.89, 0.38). Three to six months after knee or hip arthroplasty, functional performance already exceeded pre-operative levels, yet PA levels from this time period remained the same. Although PA and functional performance seemed to fully restore and exceed the pre-operation levels at six to nine months, SB did not. Moreover, PA remained lower compared to healthy individuals even longer than twelve months post-operation. Novel rehabilitation protocols and studies should focus on the effects of long-term behavioral changes (increasing PA and reducing SB) as soon as functional performance is restored.

The Cut-off Value of Physical Activity for Undergoing Total Knee Arthroplasty in Patients with Knee Osteoarthritis

BACKGROUND

We aimed to determine a cut-off value for physical activity (PA), measured using an accelerometer, between patients with knee osteoarthritis (OA) who decided to undergo total knee arthroplasty (TKA) and those who continued conservative treatment.

METHODS

Forty-two participants were assigned to either a TKA group or a non-TKA group (21 per group). They were instructed to wear an accelerometer throughout the day. Average daily steps (steps/day), average daily time of light PA (LPA) (min/day), and average daily time of moderate-to-vigorous PA (MVPA) (min/day) were measured for seven days. Variables between the two groups were compared using univariate analyses, and then a stepwise logistic regression was conducted to determine which variables best correlated with undergoing TKA. The PA cut-offs were analysed using the receiver operating characteristic curve.

RESULTS

Pain severity (p = 0.002), KL grade (p = 0.001), and MVPA (p = 0.012) differed significantly between the groups. The most useful cut-off value was 5.84 (min/day) for MVPA (AUC = 0.773), although only pain severity and KL grade were found to be significant contributors to undergoing TKA.

CONCLUSIONS

Our results revealed there was a significant decrease in PA levels (MVPA cut-off, 5-6 min/day) in the TKA group compared with the non-TKA group.

End-stage knee osteoarthritis with and without sarcopenia and the effect of knee arthroplasty - a prospective cohort study

Background

Sarcopenia often accompanies osteoarthritis (OA), which is managed by total knee arthroplasty (TKA) in the late stage. Recent studies have suggested a higher risk of post-operative complications after TKA in sarcopenic OA subjects, but whether TKA can benefit them similar to non-sarcopenic subjects remains unexplored. This study aimed to examine the dynamic, mutual impact of sarcopenia and TKA in a one-year post-operative period.

Methods

This prospective cohort study was conducted between 2015 to 2018 at our hospital. Patients with end-stage OA of the knee waiting for TKA were recruited into the study. Primary outcome measures were change in muscle strength, mass and function. Secondary outcome measures were quality of life (QOL) measurements for pain, psychological and physical health.

Results

Fifty-eight patients were recruited, of which 79.3% were female and 32.8% already had sarcopenia at baseline. The average age of sarcopenic subjects and non-sarcopenic subjects was comparable (67.89 ± 7.07 vs. 67.92 ± 6.85; p = 0.99), but sarcopenic subjects had a lower body mass index (BMI) (25.64 ± 2.64 vs. 28.57 ± 4.04; p = 0.01). There was a statistically significant improvement in walking speed (10.24 ± 5.35 vs. 7.69 ± 2.68, p < 0.01) and muscle strength in both sarcopenic and non-sarcopenic patients after TKA. This was accompanied by an improvement trend in muscle mass in all subjects. There was no change in handgrip power before and after TKA and subsequent follow-up (19.31 ± 5.92 vs. 18.98 ± 6.37 vs. 19.36 ± 7.66; p = 0.97). QOL measured before, after and at follow-up with WOMAC (total: 42.27 ± 15.98 vs. 20.65 ± 15.24 vs. 16.65 ± 18.13) and SF12v2 (PCS: 33.06 ± 8.55 vs. 38.96 ± 8.01 vs. 40.67 ± 7.93) revealed progressive significant improvement (both comparisons p ≤ 0.01). Further analysis with the IPAQ also found increased engagement of high-intensity activities.

Conclusions

This study showed that sarcopenia among patients with end-stage OA of the knee is not uncommon, but both sarcopenic and non-sarcopenic OA patients achieved significant clinical and functional improvement after TKA. Further studies with a larger sample size and different ethnicities could help ascertain a beneficial role of TKA in sarcopenic OA subjects.

Trial registration

Registry: ClinicalTrials.gov, Registration number: NCT03579329. Date of registration: 6 July 2018. Retrospectively registered.

Embedded sensing package for temporary bone cement spacers in infected total knee arthroplasty

The re-infection rate of total knee arthroplasty (TKA) after two stage revision (15%) remains high as it can be challenging to determine whether the infection has been fully cleared between the first and second stage procedures. Temporary embedded sensor systems could be a potential solution to indicate whether the infection has been cleared. In this study a telemetric sensor system to integrate with a bone cement spacer and measure knee joint temperature was designed and evaluated. The sensor package precision, accuracy, hysteresis, and thermal equilibrium were empirically determined. Cadaveric testing was performed with the sensor package implanted inside the femoral notch alongside a pre-formed femoral and tibial bone cement spacer. The limb was tested though 30,000 cycles at 0.5 Hz under a 500 N load. Accuracy and precision of the sensing package were found to be ±0.24 °C and 0.09 °C respectively with negligible hysteresis. Thermal insulation caused by the implant itself was found to produce a thermal time constant of 263 ± 5 s, resulting in a 17 min rise time. Memory capacity enabled data logging every 20 s for a 6 week period before necessitating data transfer. Bluetooth was suitable for data transmission while the package was implanted. Following cyclic loading of the cadaveric specimen, imaging and debridement revealed no issues related to mechanical integrity of the bone cement spacer or encapsulated sensor package. While additional validation is required before use in patients, the concept of temporary embedded sensing technology to aid management of infection treatments is promising.

Monitoring Patient Recovery After THA or TKA Using Mobile Technology

BACKGROUND

Smartphones offer the possibility of assessing recovery of mobility after total hip or knee arthroplasty (THA or TKA) passively and reliably, as well as facilitating the collection of patient-reported outcome measures (PROMs) with greater frequency.

QUESTIONS/PURPOSES

We investigated the feasibility of using mobile technology to collect daily step data and biweekly PROMs to track recovery after total joint arthroplasty.

METHODS

Pre- and post-operative daily steps were recorded in prospectively enrolled patients (128 THA and 139 TKA) via an app, which uses the phone's accelerometer. During 6-month follow-up, patients also completed PROMs (the pain numeric rating scale, the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS JR] and the Knee Injury and Osteoarthritis Outcome Score Joint Replacement [KOOS JR]), and HOOS or KOOS JR quality of life domain via a mobile-enabled web link.

RESULTS

At least 6 months of follow-up was completed by 65% for THA and 68% for TKA patients. Reasons for non-completion included time commitment, phone battery, app issues, and health complications. Responses from 78% of requested PROMs were returned with 96% of patients returning at least one post-operative PROM. Step data were available from 92% of days from male patients and 86% of days from female patients. The most robust recovery occurred early, within the first 2 months. The groups with higher pre-operative steps were more likely to recover their maximum daily steps at an earlier time point. Correlations between step counts and PROMs scores were modest.

CONCLUSION

Assessing large amounts of post-TKA and post-THA step data using mobile technology is feasible. Completion rates were good, making the technology very useful for collecting frequent PROMs. Being unable to ensure that patients always carried their phones limited our analysis of the step counts.

Preoperative activity levels are an important indicator of postoperative activity in cementless TKAs

Introduction

It is of interest if preoperative activity level has an impact on postoperative activity level following cementless TKA.

Methods

This review contained 127 patients who had a preoperative Lower Extremity Activity Scale (LEAS) score ≥ to 10 (active patients) and 121 patients <10 (inactive patients).

Results

Postoperatively, the results showed a difference in LEAS Activity (Active 10.5 vs. Inactive 8.7, p < 0.001). Active patients had a drop in their activity level by 1.2 on the LEAS score, yet inactive patients increased by 1.6 (p < 0.0001).

Conclusion

Preoperative activity levels are a good indicator for postoperative activity in cementless TKA.

The Dark Side of Arthroplasty: Competing Risk Analysis of Failed Hip and Knee Arthroplasty With Periprosthetic Joint Infection

BACKGROUND

Increasing total hip (THA) and knee (TKA) arthroplasties inevitably lead to accumulating failed arthroplasty (FA) with periprosthetic joint infections (PJI) and definite treatment recommendations are scarce. Our aims were to evaluate patient and infection site specific risk factors, and to identify case-dependent salvage procedure recommendations.

METHODS

Retrospective analysis was conducted of salvage procedures for FA after PJI (amputation, Girdlestone resection arthroplasty [GRA], arthrodesis, or chronic fistulation [CF]) from 2008 to 2018. Univariable and multivariable modeling of revision and mortality rates, using cumulative incidence competing risk analysis, and Cox proportional hazards models were calculated.

RESULTS

In total, 135 patients (THA 62%; TKA 38%) were diagnosed for FA after PJI, having undergone an average of 3 [1-4] revisions at a mean follow-up of 12.8 [7.8-20.9] years. Forty-four percent of THAs and 55% of TKAs had to be revised following FA, 44% deceased during follow-up, and 16% could be reconverted to an infection-free arthroplasty. GRA revealed significantly higher revision rates than CF (P = .015) for THA. Lower age (P = .003), higher number of revisions before FA (P = .007), more than one microorganism at infection site (P = .034), and GRA (P = .037, only THA) prevailed independent risk factors for revision. Patients' age remained an independent mortality risk factor (P = .001).

CONCLUSION

High-risk patients suffering from FA after THA with poor constitution profit from controlled constitution of CF, reducing the risk for revision surgeries and hospitalization. In case of FA after TKA, data did not allow definite treatment recommendations. We believe that education concerning amputation should be considered early after multiple TKA revisions.

Changes in actual daily physical activity and patient-reported outcomes up to 2 years after total knee arthroplasty with arthritis

The current study aimed 1) to describe changes in patient-reported outcomes and physical activity measured with an accelerometer preoperatively, 6 months and 2 years postoperatively in older patients undergoing total knee arthroplasty (TKA) for arthritis, and 2) to examine the predictors of the changes in physical activity (PA). This study included 58 patients (mean age 72.6 years, 84.5% women) who completed the Oxford Knee Score (OKS) and the 8-item Short Form Health Survey. Physical activity measured mean steps per day, duration of light physical activity and moderate-to-vigorous physical activity (MVPA) per week. All PA indicators and patient-reported outcomes improved 6 months postoperatively. After 6 months, knee-related pain and function gradually improved, and MVPA increased. The OKS was a sole predictor of improvement in PA during the 2-year study period, suggesting the importance of disease-specific quality of life.

Primary total knee replacement leads to an increase in physical activity but no changes in overall time of sedentary behaviour: a retrospective cohort study using an accelerometer

INTRODUCTION

There is no consensus between patient-reported subjective scores and objectively measured physical activity (PA) behaviour after total knee arthroplasty (TKA). The aim of this study was to understand the volume and pattern of physical activity and daily energy consumption after total knee arthroplasty for osteoarthritis.

METHOD

Physical activity patterns of 36 patients (31 female, 5 male) with an average age of 67.3 ± 6.7 (50-81) years and end-stage gonarthrosis were investigated using an accelerometer (ActiCal) for seven consecutive days prior to and six months after total knee arthroplasty. Knee Society scores, Oxford knee scores, range of motion, and muscle strength around knee were also recorded.

RESULTS

Sedentary behaviour did not change after total knee arthroplasty (p = 0.975). Increases in light physical activity time (p = 0.005) and moderate-vigorous physical activity time (p = 0.006) were found significant. In the post-operative period, light PA awake time increased 25% and moderate-vigorous PA awake time increased four times compared with the pre-operative value. In addition, a significant increase was observed in the amount of daily energy expenditure after TKA (p = 0.001). The subjective functional scores were increased in the post-operative period compared with baseline values (p < 0.001). While a significant increase in knee flexion angle was found after TKA (p = 0.01), there was no increase in muscle strength around the knee (p = 0.096).

CONCLUSION

Accumulation patterns of activity evaluated by using an accelerometer objectively can give a new insight to realize the behavioral changes after total knee arthroplasty. Daily life style changes can be encouraged by means of objective evaluations.

Improved levels of physical activity in patients over 75 years following total knee arthroplasty

PURPOSE

There is insufficient evidence regarding the precise levels of physical activity (PA) in older patients following total knee arthroplasty (TKA). The aims of this study were (1) to describe the changes in the amount and intensity of PA before and after TKA with an accelerometer in older patients, compared with age- and sex-matched healthy participants and (2) to assess the effect of TKA on PA depending on age.

METHODS

Sixty-six primary TKA patients aged 60 years or over (mean age, 73.3 years) wore an accelerometer (Lifecorder EX) for 10 consecutive days and completed the Oxford Knee Score (OKS) before and at 6 months after TKA. PA was evaluated by mean step count and time spent (min) engaged in PA per day. PA intensity was classified as light (1.5-3 metabolic equivalents (METs)), moderate to vigorous (≥3 METs), and total (≥1.5 METs). Sixty-four healthy participants completed a single assessment of PA.

RESULTS

Each of the PA measures and OKS increased significantly after TKA. Compared with healthy controls, light and total PA improved to 100% at 6 months after TKA in patients 75 years or older. By contrast, moderate-to-vigorous PA was 32% of that of the controls and rose to 78% after TKA. PA intensity in patients aged 60-74 years was 31-74% of the controls but did not reach the same level after TKA.

CONCLUSION

TKA in older patients increases the amount of PA, with light and total PA suitable parameters for assessing PA.

Does Activity-Based Rehabilitation With Goal Attainment Scaling Increase Physical Activity Among Younger Knee Arthroplasty Patients? Results From the Randomized Controlled ACTION Trial

BACKGROUND

Especially in younger knee osteoarthritis patients, the ability to perform physical activity (PA) after knee arthroplasty (KA) is of paramount importance, given many patients' wish to return to work and perform demanding leisure time activities. Goal Attainment Scaling (GAS) rehabilitation after KA may improve PA because it uses individualized activity goals. Therefore, our aim was to objectively quantify PA changes after KA and to compare GAS-based rehabilitation to standard rehabilitation.

METHODS

Data were obtained from the randomized controlled ACTION trial, which compares standard rehabilitation with GAS-based rehabilitation after total and unicompartmental KA in patients <65 years of age. At 2 time points, preoperatively and 6 months postoperatively, 120 KA patients wore a validated 3-dimensional accelerometer for 1 consecutive week. Data were classified as sedentary (lying, sitting), standing, and active (walking, cycling, running). Repeated measures analysis of variance was used to compare PA changes over time.

RESULTS

Complete data were obtained for 97 patients (58% female), with a mean age of 58 years (±4.8). For the total group, we observed a significant increase in PA of 9 minutes (±37) per day (P = .01) and significant decrease in sedentary time of 20 minutes (±79) per day (P = .02). There was no difference in standing time (P = .11). There was no difference between the control group and the intervention group regarding changes in PA, nor between the total KA group and the unicompartmental KA group.

CONCLUSION

We found a small but significant increase in overall PA after KA, but no difference between GAS-based rehabilitation and standard rehabilitation. Likely, enhanced multidisciplinary perioperative strategies are needed to further improve PA after KA.

Improvements in Objectively Measured Activity Behaviors Do Not Correlate With Improvements in Patient-Reported Outcome Measures Following Total Knee Arthroplasty

BACKGROUND

Activity monitors have added a new dimension to our ability to objectively measure physical activity in patients undergoing total knee arthroplasty (TKA). The aim of the study is to assess whether changes in the time spent sitting, standing, and stepping were associated with changes in patient-reported outcome measures (PROMs) before and after TKA.

METHODS

Valid activPAL data (>3 days) and PROMs were obtained from 49 men and women (mean [SD] age, 62.8 [8.6] years; body mass index, 33.8 [7.1] kg/m²) who underwent primary TKA, before and at 6 weeks or 6 months after surgery. Patient-reported symptoms of pain, stiffness, and knee function were obtained using the Knee injury and Osteoarthritis Outcome Score and Oxford Knee Score questionnaires.

RESULTS

Mean (SD) Knee injury and Osteoarthritis Outcome Score (80.1 [16.3] to 41.6 [6.5], P < .001) and Oxford Knee Score (12.0 [9.8] to 17.7 [22.8], P < .001) scores improved 6 months after TKA. Walking time (mean [95% confidence interval]; min/d) increased from before (79 [67-91]) to 6 months after TKA (101 [88-114], P = .006). Standing time (318 [276-360] to 321 [291-352], P = .782) and sitting time (545 [491-599] to 509.0 [459.7-558.3], P = .285) did not change from before to 6 months after TKA. Participants took more steps (2559 [2128-2991] to 3515 [2983-4048] steps/day, P = .001) and accumulated more steps (31 [30-34] to 34 [33-35] steps/min, P < .001) after TKA compared to before. There were no associations between changes in activity behaviors and changes in PROMs (P > .05).

CONCLUSION

Despite improvements in self-reported knee pain and functional ability, these changes do not correlate with improvements in objectively measured light-intensity and sedentary activity behaviors.

A Step in the Right Direction: Body Location Determines Activity Tracking Device Accuracy in Total Knee and Hip Arthroplasty Patients

INTRODUCTION

Step counts measured by activity monitoring devices (AMDs) and smartphones (SPs) can objectively measure a patient's activity levels after total hip and knee arthroplasty (total joint arthroplasty [TJA]). This study investigated the use and optimal body location of AMDs and SPs to measure step counts in the postoperative period.

METHODS

This was a two-armed, prospective, observational study of TJA inpatients (n = 24) and 2-week status after TJA (n = 25) completing a 100-ft walk. Observer-counted steps were compared with those measured by AMDs (wrist and ankle) and SPs (hip and neck). Acceptable error was defined as <30%. Error rates were treated as both dichotomous and continuous variables.

RESULTS

AMD and SP step counts had overall unacceptable error in TJA inpatients. AMDs on the contralateral ankle and SPs on the contralateral hip had error rates less than 30% at 2 weeks postoperatively. Two-week postoperative patients required lower levels of assist (11/25 walker; 4/25 no assist), and significant improvements in stride length (total hip arthroplasty 1.27 versus 1.83 ft/step; total knee arthroplasty 1.42 versus 1.83 ft/step) and cadence (total hip arthroplasty 74.6 versus 166.0 steps/min; total knee arthroplasty 73.5 versus 144.4 steps/min) were seen between inpatient and postoperative patients. Regression analysis found that increases in postoperative day and cadence led to a decrease in device error.

CONCLUSION

In inpatients with TJA, AMDs and SPs have unacceptable variability and limited utility for step counting when using a walker. As gait normalizes and the level of ambulatory assist decreases, AMDs on the contralateral ankle and SPs on the contralateral hip demonstrated low error rates. These devices offer a novel method for measurement of objective outcomes and potential for remote monitoring of patient progress after TJA.

LEVEL OF EVIDENCE

Level II, prospective, three-armed study, prognostic study.

Three-Year Follow-Up Study of Physical Activity, Physical Function, and Health-Related Quality of Life After Total Hip Arthroplasty

BACKGROUND

Little is known about the long-term changes in physical activity (PA) after total hip arthroplasty (THA). The purpose of this study is to describe the changes in the number of steps and intensity of PA as measured by accelerometers, patient-reported physical function, and health-related quality of life of THA patient preoperatively and at 1 and 3 years after THA.

METHODS

This study included 153 patients (mean age, 61.4 years; 86.3% women) who wore an accelerometer for 10 consecutive days and completed the Oxford Hip Score (OHS) and the Short Form 8 at the 5-year follow-up after THA. PA was evaluated based on the mean steps per day and the time spent performing moderate-to-vigorous PA (MVPA) per week.

RESULTS

All 5 indicators had significantly increased at 1 year after THA, although only MVPA and OHS had further increased significantly at the 3-year follow-up. The predictor of improvement in the number of steps from baseline to 1 year post-THA was younger age, while those of improvement in MVPA from baseline to 3-year post-THA were younger age, higher OHS, and better Short Form 8 mental component scores using mixed-model analysis. Participation in the PA measurements was high (69.9%) at the 3-year follow-up. No significant changes were observed for these outcomes in the remaining cohort beyond 3 years after THA.

CONCLUSION

In post-THA patients, MVPA continued to increase for 3 years postoperatively. Therefore, PA must be measured over the medium term to long term following THA.

Current clinical utilisation of wearable motion sensors for the assessment of outcome following knee arthroplasty: a scoping review

OBJECTIVES

Wearable motion sensors are used with increasing frequency in the evaluation of gait, function and physical activity within orthopaedics and sports medicine. The integration of wearable technology into the clinical pathway offers the ability to improve post-operative patient assessment beyond the scope of current, questionnaire-based patient-reported outcome measures. This scoping review assesses the current methodology and clinical application of accelerometers and inertial measurement units for the evaluation of patient activity and functional recovery following knee arthroplasty.

DESIGN

This is a systematically conducted scoping review following Joanna Briggs Institute methodology for scoping reviews and reported consulting the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews. A protocol for this review is registered with the Open Science Framework (https://osf.io/rzg9q).

DATA SOURCES

CINAHL, EMBASE, MEDLINE and Web of Science databases were searched for manuscripts published between 2008 and 2019.

ELIGIBILITY CRITERIA

We included clinical studies reporting the use of any combination of accelerometers, pedometers or inertial measurement units for patient assessment at any time point following knee arthroplasty.

DATA EXTRACTION AND SYNTHESIS

Data extracted from manuscripts included patient demographics, sensor technology, testing protocol and sensor-based outcome variables.

RESULTS

45 studies were identified, including 2076 knee arthroplasty patients, 620 patients with end-stage osteoarthritis and 449 healthy controls. Primary aims of the identified studies included functional assessment, physical activity monitoring and evaluation of knee instability. Methodology varied widely between studies, with inconsistency in reported sensor configuration, testing protocol and output variables.

CONCLUSIONS

The use of wearable sensors in evaluation of knee arthroplasty procedures is becoming increasingly common and offers the potential to improve clinical understanding of recovery and rehabilitation. While current studies lack consistency, significant opportunity exists for the development of standardised measures and protocols for function and physical activity evaluation.

Light intensity physical activity increases and sedentary behavior decreases following total knee arthroplasty in patients with osteoarthritis

PURPOSE

To describe objectively measured changes in the volume and pattern of physical activity and sedentary behavior in patients undergoing total knee arthroplasty for osteoarthritis.

METHODS

Physical activity and sedentary behavior were measured in patients (13 males, 76 females) with a mean age of 64 years (range 55-80) and end-stage osteoarthritis of the knee, using an accelerometer (ActiGraph GT3X+) for seven consecutive days (24 h/day) prior to, 6 weeks and 6 months after total knee arthroplasty. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), University of California Los Angeles (UCLA) Activity index and range of motion (ROM) were also assessed.

RESULTS

Proportion of time spent in sedentary behavior decreased from baseline to 6 months (mean 70.1 vs. 64.0%; p = 0.009) and the interruptions to sedentary behavior improved between baseline and 6 months after total knee arthroplasty (mean 85.0-93.0 breaks/day, p = 0.014). Proportion of time spent in light physical activity increased from baseline to 6 months after total knee arthroplasty (29.0 vs. 34.8%; p = 0.008). There was no change in time spent in moderate to vigorous physical activity after total knee arthroplasty. WOMAC (median 71.0 vs. 4.0, p < 0.001), UCLA (median 2.0 vs. 5.0, p < 0.001) as well as ROM [median (0.0°-90.0°) vs. (0.0°-110°), p < 0.05] scores improved between baseline and 6 months after total knee arthroplasty.

CONCLUSION

Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors. The use of accelerometers in this study gives new insights into activity accumulation patterns in a clinical population and highlights their use in determining a behavioral response to an intervention.

LEVEL OF EVIDENCE

II.

Sedentary Behavior in Patients With Knee Osteoarthritis Before and After Total Knee Arthroplasty: A Systematic Review

Objective:The objective of this systematic review is to integrate the available evidence on changes in sedentary behavior (SB) in patients with knee osteoarthritis after total knee arthroplasty (TKA).Methods:A systematic literature search from January 2002 to October 31, 2017, was performed for studies assessing objectively and/or subjectively measured SB following TKA. The Scottish Intercollegiate Guidelines Network Methodology appraisal tool was used to critically appraise the methodological quality of the included studies.Results:Ten studies reporting on SB with a total of 1,028 participants were included in the review. Three studies reported changes in SB with two showing a reduction in SB and one (with high risk of bias) an increase in SB after TKA. Seven studies showed no change in SB following TKA.Conclusion:Currently, there is insufficient evidence which suggests that SB time improves following TKA. Detailed assessments of SB after TKA are needed.

Impact of a tailored activity counselling intervention during inpatient rehabilitation after knee and hip arthroplasty - an explorative RCT

Background

The aim of the study was to improve physical activity (PA), well-being and clinical outcome after total knee and hip arthroplasty through tailored activity counselling during inpatient rehabilitation.

Methods

65 patients (aged 70.4 ± 7.3 years, BMI 28.5 ± 4.3) starting inpatient rehabilitation after primary knee or hip arthroplasty due to osteoarthritis were recruited and pseudo-randomized into an intervention (IG) and a control group (CG). Twice a week, the IG was encouraged to increase their daily step count by 5%. PA, e. g. number of steps, step frequency, or active minutes, was measured by step activity monitoring. Well-being and clinical outcome were assessed using the SF-36, Oxford Knee/Hip Score and Global rating of Change. Procedures were conducted at the onset of inpatient rehabilitation, and repeated one and 6 months after inpatient rehabilitation.

Results

Data sets were obtained from 49 patients (IG: n = 23, CG: n = 26). Both groups significantly increased their number of daily steps from the 1 month to the 6 months follow up after rehabilitation: CG: 9019 (95%CI: 7812, 10,226), IG: 9280 (7972, 10,588) and CG: 10921 (9571, 12,271), IG: 11326 (9862, 12,791) respectively. Additionally, well-being and clinical outcome improved significantly in both groups. No significant differences in physical activity, clinical outcome and well-being were found between the groups.

Conclusions

PA counselling during inpatient rehabilitation does not improve PA, well-being and clinical outcome in patients with primary knee or hip arthroplasty in addition to the rehabilitation program. PA interventions may be more effective after the completion of the inpatient rehabilitation phase.

Trial registration

DRKS DRKS00012682. Registered retrospectively on 03–07- 2017.

Prevalence and determinants of physical activity and sedentary behaviour before and up to 12 months after total knee replacement: a longitudinal cohort study

OBJECTIVE

This study aims to evaluate the prevalence and determinants of inadequate physical activity and excessive sedentary behaviour before and after total knee replacement.

DESIGN, SETTING AND SUBJECTS

Secondary analysis was performed on data from a cohort of 422 adults (45-74 years), drawn from 12 public or private hospitals, undergoing primary unilateral or bilateral total knee replacement surgery.

MAIN MEASURES

Questionnaires were used to determine the presence of inadequate physical activity and excessive sedentary behaviour before and 6  and 12 months after total knee replacement surgery. Knee pain, activity limitations, comorbidities, muscle strength, psychological well-being, fatigue, sleep and body mass index were measured/assessed as possible determinants of physical activity or sedentary behaviour.

RESULTS

Before surgery, 77% ( n = 326) of the cohort participated in inadequate physical activity according to World Health Organization guidelines, and 60% ( n = 253) engaged in excessive sedentary behaviour. Twelve months after surgery, 53% ( n = 185) of the cohort engaged in inadequate physical activity and 45% ( n = 157) in excessive sedentary behaviour. Inadequate physical activity before surgery ( P = 0.02), obesity ( P = 0.07) and comorbidity score >6 ( P = 0.04) predicted inadequate physical activity 12 months after surgery. Excessive sedentary behaviour and activity limitations before surgery predicted excessive sedentary behaviour 12 months after surgery.

CONCLUSION

Although there were improvements after total knee replacement, 12 months after surgery about half the cohort did not meet World Health Organization recommendations for activity. Pre-surgery assessment of physical activity, activity limitations, sedentary behaviour and body mass index is essential to identify patients at risk for long-term inactivity.

Changes in Physical Activity After Total Hip or Knee Arthroplasty: A Systematic Review and Meta-Analysis of Six- and Twelve-Month Outcomes

OBJECTIVE

Little is known about the extent to which physical activity (PA) levels change following total knee or hip joint replacement relative to pain, physical function, and quality of life. Our objective was to conduct a systematic review and meta-analysis on changes in PA relative to pain, quality of life, and physical function after total knee or hip joint replacement.

METHODS

We searched the PubMed (Medline), Embase, and CINAHL databases for peer-reviewed, English-language cohort studies measuring PA with an accelerometer from presurgery to postsurgery. Random-effects models were used to produce standardized mean differences (SMDs) for PA, quality of life, pain, and physical function outcomes. Heterogeneity was assessed using I² .

RESULTS

Seven studies (336 participants) met the eligibility criteria. No significant increase in PA was found at 6 months (SMD 0.14 [95% confidence interval (95% CI) -0.05, 0.34]; I² = 0%) and a small to moderately significant effect was found for increasing PA at 12 months (SMD 0.43 [95% CI 0.22, 0.64]; I² = 0%). Large improvements were found at 6 months in physical function (SMD 0.97 [95% CI 0.12, 1.82]; I² = 92.3%), pain (SMD -1.47 [95% CI -2.28, -0.65]; I² = 91.6%), and quality of life (SMD 1.02 [95% CI 0.30, 1.74]; I² = 83.2%).

CONCLUSION

Physical activity did not change at 6 months, and a small to moderate improvement was found at 12 months postsurgery, despite large improvements in quality of life, pain, and physical function. Reasons for the lack of increased PA are unknown but may be behavioral in nature, as a sedentary lifestyle is difficult to change. Changing sedentary behavior should be a future focus of research in this subgroup.

High wear resistance of femoral components coated with titanium nitride: a retrieval analysis

PURPOSE

The objective of this study was to evaluate the in vivo wear resistance of cobalt-chromium femoral components coated with titanium nitride (TiN). Our null hypothesis was that the surface damage and the thickness of the TiN coating do not correlate with the time in vivo.

METHODS

Twenty-five TiN-coated bicondylar femoral retrievals with a mean implantation period of 30.7 ± 11.7 months were subjected to an objective surface damage analysis with a semi-quantitative assessment method. A visual examination of scratches, indentations, notches and coating breakthroughs of the surfaces was performed. The roughness and the coating thickness of the TiN coating were evaluated in the main articulation regions.

RESULTS

Narrow scratches and indentations in the range of low flexion angles on the retrieval surfaces were the most common modes of damage. There was no evidence of delamination on the articulation surface but rather at the bottom of isolated severe indentations or notches. An analysis of three retrievals revealed a coating breakthrough in the patellofemoral joint region, resulting from patella maltracking and a dislocation. The arithmetical mean roughness of the TiN surface slightly increased with the implantation period. In contrast, the maximum peak height of the roughness profile was reduced at the condyles of the retrieved components in comparison with new, unused surfaces. No significant association between the coating thickness and implantation period was determined. Moreover, the measured values were retained in the range of the initial coating thickness even after several years of in vivo service.

CONCLUSIONS

As was demonstrated by the results of this study, the surface damage to the TiN coating did not deteriorate with the implantation period. The calculated damage scores and the measured coating thickness in particular both confirmed that the TiN coating provides low wear rates. Our findings support the use of wear-resistant TiN-coated components in total knee arthroplasty with the objective of reducing the risk of aseptic loosening. However, in terms of TiN-coated femoral components, particular attention should be paid to a correct patellar tracking in order to avoid wear propagation at the implant.

Predictors of multidimensional functional outcomes after total knee arthroplasty

Multiple assessments are used clinically after total knee arthroplasty (TKA) including self-report, performance tasks, and physical activity levels. It is unclear if these different functional assessments are interchangeable or if they measure different constructs. The objective of this study was to characterize different functional measures before and after TKA. We characterized function before and after TKA using perceived function (KOOS ADL), physical performance (gait speed), and daily activity (steps/day via accelerometry); compared function in people undergoing TKA to age-matched healthy controls; and examined characteristics of those undergoing TKA for potential predictors of postoperative function. Prior to TKA, all three functional assessments were significantly lower for participants than those of healthy controls and each measure remained lower for participants than for controls postoperatively. All three functional assessments developed differently over time postoperatively. Each functional outcome had a unique set of predictors. Perceived function was predicted primarily by anxiety and depression, physical performance was most strongly predicted by age, and daily activity was chiefly predicted by BMI. Pressure pain threshold was a common predictor across all models. Functional limitations exist preoperatively and persist postoperatively across different measures in people undergoing TKA when compared to those measures in healthy controls. Functional outcomes after TKA are different depending on the functional measure utilized, implying that different constructs underlie each measure. Multiple functional measures should be assessed to provide a more comprehensive assessment of function after TKA. Further work should assess the impact of interventions designed to treat modifiable predictors of postoperative TKA function. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2790-2798, 2017.

Does physical activity change following hip and knee replacement? Matched case-control study evaluating Physical Activity Scale for the Elderly data from the Osteoarthritis Initiative

OBJECTIVES

To determine whether physical activity measured using the Physical Activity Scale for the Elderly (PASE), changes during the initial 24 months post-total hip (THR) or knee replacement (TKR), and how this compares to a matched non-arthroplasty cohort.

DESIGN

Case-controlled study analysis of a prospectively collected dataset.

SETTING

USA community-based.

PARTICIPANTS

116 people post-THR, 105 people post-TKR compared to 663 people who had not undergone THR or TKR, or had hip or knee osteoarthritis. Cohorts were age-, gender- and BMI-matched.

MAIN OUTCOME MEASURES

Physical activity assessed using the 12-item PASE at 12 and 24 months post operatively.

RESULTS

There was no significant difference in total PASE score between pre-operative to 12 months (mean: 136 vs 135 points; p=0.860) or 24 months following THR (mean: 136 vs 132 points; p=0.950). Whilst there was no significant difference in total PASE score from pre-operative to 12 months post-TKR (126 vs 121 points; p=0.930), by 24 months people following TKR reported significantly greater physical activity (126 vs 142 points; p=0.040). There was no statistically significant difference in physical activity between the normative matched and THR (p≥0.140) or TKR (p≥0.060) cohorts at 12 or 24 months post joint replacement.

CONCLUSIONS

Physical activity is not appreciably different to pre-operative levels at 12 or 24 months post-THR, but was greater at 24 months following TKR. Health promotion strategies are needed to encourage greater physical activity participation following joint replacement, and particularly targeting those who undergo THR.

Changes in social isolation and loneliness following total hip and knee arthroplasty: longitudinal analysis of the English Longitudinal Study of Ageing (ELSA) cohort

OBJECTIVE

To determine the prevalence and change in social isolation and loneliness in people before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in England.

DESIGN

The English Longitudinal Study of Ageing (ELSA) dataset, a prospective study of community-dwelling older adults, was used to identify people who had undergone primary THA or TKA because of osteoarthritis. Social isolation was assessed using the ELSA Social Isolation Index. Loneliness was evaluated using the Revised University of California, Los Angeles (UCLA) Loneliness Scale. The prevalence of social isolation and loneliness were calculated and multilevel modelling was performed to assess the potential change of these measures before arthroplasty, within a two-year operative-recovery phase and a following two-year follow-up.

RESULTS

The sample consisted of 393 people following THA and TKA. The prevalence of social isolation and loneliness changed from 16.9% to 18.8% pre-operative to 21.8% and 18.9% at the final post-operative follow-up respectively. This was not a statistically significant change for either measure (P = 0.15; P = 0.74). There was a significant difference in social isolation at the recovery phase compared to the pre-operative phase (P = 0.01), where people following arthroplasty reported an increase in social isolation (16.9-21.4%). There was no significant difference between the assessment phases in respect to UCLA Loneliness Scale score (P ≥ 0.74).

CONCLUSIONS

Given the negative physical and psychological consequences which social isolation and loneliness can have on individuals following THA or TKA, clinicians should be mindful of this health challenge for this population. The reported prevalence of social isolation and loneliness suggests this is an important issue.

Preoperative characteristics of working-age patients undergoing total knee arthroplasty

Objective

Total Knee Arthroplasty (TKA) is performed more in working-age (<65 years) patients. Until now, research in this patient population has been conducted mainly among retired (≥65 years) patients. Aim of this study was therefore to describe demographic, physical, psychological and social characteristics of working TKA patients and to subsequently compare these characteristics with retired TKA patients and the general population.

Methods

A cross-sectional analysis. Preoperative data of 152 working TKA patients was used. These data were compared with existing data of retired TKA patients in hospital registers and with normative values from literature on the general population. Demographic, physical, psychological and social (including work) characteristics were analyzed.

Results

The majority (83.8%) of working TKA patients was overweight (42.6%) or obese (41.2%), a majority (72.4%) was dealing with two or more comorbidities, and most (90%) had few depressive symptoms. Mean physical activity level was 2950 minutes per week. Compared to the retired TKA population, working TKA patients perceived significantly more stiffness and better physical functioning and vitality, were more physically active, and perceived better mental health. Compared to the general population working TKA patients perceived worse physical functioning, worse physical health and better mental health, and worked fewer hours.

Conclusion

This study shows that a majority of working TKA patients are overweight/obese, have multiple comorbidities, but are highly active in light-intensity activities and have few depressive symptoms. Working patients scored overall better on preoperative characteristics than retired patients, and except for physical activity scored overall worse than the general population.

Quantifying the relative change in physical activity after Total Knee Arthroplasty using accelerometer based measurements

Osteoarthritis is amongst the top five most disabling conditions affecting Americans over 65 years of age and imposes an annual economic burden estimated at $ 89.1 billion. Nearly half of the cost of care of Osteoarthritis is attributable to hospitalizations for total knee arthroplasties (TKA) and total hip arthroplasties (THA). The current clinical practice relies predominantly on subjective assessment of physical function and pain via patient reported outcome measures (PROM) that have proven inadequate for providing a validated, reliable and responsive measure of TKA outcomes. Wearable activity monitors, which produce a trace of regularly monitored physical activity derived from accelerometer measurements, provide a novel opportunity to objectively assess physical functional status in Osteoarthritis patients. Using data from the Osteoarthritis Initiative (OAI), we demonstrate the feasibility of quantifying the relative change in physical activity patterns in Osteoarthritis subjects using accelerometer based measurements of daily physical activity.

What Do Patients Expect From Total Knee Arthroplasty? A Delphi Consensus Study on Patient Treatment Goals

BACKGROUND

Although total knee arthroplasty (TKA) is among the most frequent orthopedic procedures for end-stage knee osteoarthritis (OA), systematically developed patient treatment goals for this elective intervention are missing. This constitutes a relevant barrier toward patient-centered healthcare.

METHODS

A Delphi consensus study was conducted. Patients who were candidates for TKA were recruited through 11 outpatient orthopedic surgeons, 4 physiotherapists, and a patient organization in Germany. The initial questionnaire included 20 potential treatment goals derived from a systematic review on outcomes assessed in TKA trials. Patients were asked to rate these potential treatment goals as "main goal," "secondary goal," or "no goal." It was specified that a main goal must be met to consider TKA as successful. Patients could add further goals which were included in the next questionnaire together with a feedback on their own and the group's previous rating. Patients could then confirm or revise their responses to find group consensus, which was defined as ≥70% of participants rating a treatment goal as main goal.

RESULTS

From initial 108 participants, 93 (86%) completed the study. Consensus was achieved that symptom reduction ("pain reduction," "improvement of stability"), functional improvements (improvement of "physical function," "range of motion," "walking distance," "walking stairs," "physical activity"), "improvement of quality of life," and prevention and safety concerns ("prevention from secondary impairments," "long implant survival") are the main treatment goals of patients who are candidates for TKA.

CONCLUSION

Physicians should consider patient treatment goals in routine clinical decision making to meet the requirements of patient-centered healthcare. Researchers should consider those treatment goals in effectiveness studies on TKA.

Understanding barriers and facilitators to healthy eating and physical activity from patients either before and after knee arthroplasty

PURPOSE

We sought to identify patient-reported barriers and facilitators to healthy eating and physical activity among patients before or after knee arthroplasty.

MATERIALS AND METHODS

Twenty patients with knee osteoarthritis aged 40-79 years who had knee arthroplasty surgery scheduled or completed within 3 months were interviewed. Interview topics included perceived barriers and facilitators to healthy eating and activity before or after surgery. Interviews were coded and analyzed using constant comparative analysis.

RESULTS

Interviews were completed with 11 pre-operative (67.1 ± 7.6 years, 45.5% female, BMI 31.2 ± 6.3) and nine post-operative patients (61.7 ± 11.7 years, 44.4% female, BMI 30.2 ± 4.7 kg/m²). The most commonly identified personal barriers to healthy eating identified were desire for high-fat/high-calorie foods, managing overconsumption and mood. Factors related to planning, portion control and motivation to improve health were identified as healthy eating facilitators. Identified personal barriers for activity included pain, physical limitations and lack of motivation, whereas facilitators included having motivation to improve knee symptoms/outcomes, personal commitment to activity and monitoring activity levels.

CONCLUSION

Identifying specific eating and activity barriers and facilitators, such as mood and motivation to improve outcomes, provides critical insight from the patient perspective, which will aid in developing weight management programs during rehabilitation for knee arthroplasty patients. Implications for rehabilitation This study provides insight into the identified barriers and facilitators to healthy eating and physical activity in knee arthroplasty patients, both before and after surgery. Intrapersonal barriers that may hinder engagement in physical activity and rehabilitation include pain, physical limitations and lack of motivation; factors that may help to improve activity and the rehabilitation process include being motivated to improve knee outcomes, having a personal commitment to activity and tracking activity levels. Barriers that may interfere with healthy eating behaviors and knee arthroplasty rehabilitation include the desire for high-fat/high-calorie foods, overeating and mood; whereas planning and portion control may help to facilitate healthy eating. Understanding barriers and facilitators to healthy eating and physical activity can help guide rehabilitation professionals with their discussions on weight management with patients who had or are contemplating knee arthroplasty.

Evaluating physical function and activity in the elderly patient using wearable motion sensors

Wearable sensors, in particular inertial measurement units (IMUs) allow the objective, valid, discriminative and responsive assessment of physical function during functional tests such as gait, stair climbing or sit-to-stand.

Applied to various body segments, precise capture of time-to-task achievement, spatiotemporal gait and kinematic parameters of demanding tests or specific to an affected limb are the most used measures.

In activity monitoring (AM), accelerometry has mainly been used to derive energy expenditure or general health related parameters such as total step counts.

In orthopaedics and the elderly, counting specific events such as stairs or high intensity activities were clinimetrically most powerful; as were qualitative parameters at the ‘micro-level’ of activity such as step frequency or sit-stand duration.

Low cost and ease of use allow routine clinical application but with many options for sensors, algorithms, test and parameter definitions, choice and comparability remain difficult, calling for consensus or standardisation.

Cite this article: Grimm B, Bolink S. Evaluating physical function and activity in the elderly patient using wearable motion sensors. EFORT Open Rev 2016;1:112–120. DOI: 10.1302/2058-5241.1.160022.

Aerobic Physical Fitness and Recreational Sports Participation After Total Knee Arthroplasty

Context:

Total knee arthroplasty (TKA) is routinely performed in younger patients who desire to be active in fitness and recreational sports. The activities patients can participate in without symptoms and the level of aerobic fitness routinely maintained are important to investigate.

Objective:

To determine physical activity (PA) and recreational sports resumed after primary TKA, symptoms or limitations with these activities, and the effect of postoperative rehabilitation on achieving fitness and sports goals.

Data Sources:

A systematic review of the literature from 2005 through 2015 was conducted using the PubMed database.

Study Selection:

Original investigations that were conducted at least 1 year after primary TKA and reported the percentage of patients who returned to recreational activities or routinely participated in aerobic PA recommended by the American Heart Association (AHA) were included in this study.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

Data were extracted as available from 19 eligible studies. Assessment of study quality was rated using the MINORS (Methodological Index for Non-Randomized Studies) instrument.

Results:

There were 5179 knees (mean age, 67.5 years) followed for a mean 4.8 years postoperatively. Marked variability was present between studies regarding the percentage of patients who resumed recreational activities (34%-100%), most of which were low impact. Only 2 studies used accelerometers to measure PA; these reported a low range (0%-16.5%) of patients who met AHA guidelines. Few studies determined whether symptoms or limitations were experienced during PA. None described rehabilitation exercises or factors that would influence patients’ ability to return to recreational or fitness activities.

Conclusion:

Little evidence is available regarding the effect of TKA on return to recreational and (objectively measured) aerobic fitness. The extent of symptoms or limitations during PA and the long-term effects of such problems remain unclear. Valid predictions cannot be made on factors that may affect return to recreational sports or other aerobic PA after TKA.

Walking on a compliant surface does not enhance kinematic gait asymmetries after unilateral total knee arthroplasty

PURPOSE

To investigate gait asymmetries and the effect of walking on compliant surfaces in individuals with unilateral total knee arthroplasty (TKA), hypothesizing that asymmetries would increase as an effect of the compliant surface.

METHODS

Individuals with unilateral TKA ~19 months post-operative (n = 23, median age 59 years) recruited from one orthopaedic clinic and age- and gender-matched healthy individuals without knee complaints (n = 23, median age 56 years) walked at comfortable speed on a hard surface and on a compliant surface. 3D kinematic analyses were made for knee and hip angles in sagittal and frontal planes, stance time, step length, and gait velocity.

RESULTS

Shorter stance time (p < 0.01) and less peak knee flexion (p < 0.001) at weight bearing acceptance was found in the prosthetic side compared with the contralateral side. Larger knee (p < 0.01) and hip (p < 0.001) adduction was found compared with healthy controls. Neither asymmetries between the prosthetic and the contralateral side nor differences compared with healthy controls were enhanced when walking on compliant surfaces compared with hard surfaces.

CONCLUSION

The TKA group adapted their gait to compliant surfaces similarly to healthy controls. Gait asymmetries in the TKA group observed on hard surface were not enhanced, and adduction in hip and knee joints did not increase further as an effect of walking on compliant surfaces. Thus, unfavourable knee joint loading did not increase when walking on a compliant surface. This implies that recommendations for walking on soft surfaces to reduce knee joint loading are not counteracted by increased gait asymmetries and unfavourable joint loading configurations.

LEVEL OF EVIDENCE

III.

Total joint replacement: A multiple risk factor analysis of physical activity level 1-2 years postoperatively

Background and purpose - The effect of total joint arthroplasty (TJA) on physical activity is not fully understood. We investigated the change in physical activity after TJA and patient factors associated with change. Patients and methods - Using a total joint replacement registry, primary total hip arthroplasty (THA) patients (n = 5,678) and knee arthroplasty (TKA) patients (n = 11,084) between January 1, 2010 and December 31, 2012 were identified. Median age at THA was 68 and median age at TKA was 67. Change in self-reported physical activity (minutes per week) from before TJA (within 1 year of surgery) to after TJA (1-2 years) was the outcome of interest. Patient demographics and comorbidities were evaluated as risk factors. Multiple linear regression was used. Results - Median physical activity before surgery was 50 min/week (IQR: 0-140) for THA patients and 58 (IQR: 3-143) for TKA patients. Median physical activity after surgery was 150 min/week (IQR: 60-280) for both THA patients and TKA patients. Following TJA, 50% of patients met CDC/WHO physical activity guideline criteria. Higher body mass index was associated with lower change in physical activity (THA: -7.1 min/week; TKA: -5.9 min/week). Females had lower change than males (THA: -11 min/week; TKA: -9.1 min/week). In TKA patients, renal failure was associated with lower change (-17 min/week), as were neurological disorders (-30 min/week). Interpretation - Self-reported minutes of physical activity increased from before to after TJA, but 50% of TJA patients did not meet recommended physical activity guideline criteria. Higher body mass index, female sex, and specific comorbidities were found to be associated with low change in physical activity. Patient education on the benefits of physical activity should concentrate on these subgroups of patients.

Does Physical Activity Increase After Total Hip or Knee Arthroplasty for Osteoarthritis? A Systematic Review

Study Design Systematic review. Background Despite improvements in self-reported symptoms and perceived functional ability after total hip arthroplasty (THA) and total knee arthroplasty (TKA), it is unclear whether changes in objectively measured physical activity (PA) occur after surgery. Objective To determine if objectively measured PA increases after THA and TKA in adults with osteoarthritis. Methods Five electronic databases were searched from inception to March 3, 2015. All study designs objectively measuring PA before and after THA or TKA were eligible, including randomized controlled trials, cohort studies, and case-control studies. Two reviewers independently screened abstracts and full texts and extracted study demographic, PA, and clinical outcome data. Standardized mean differences (SMDs) and 95% confidence intervals were calculated for accelerometer- and pedometer-derived estimates of PA. Risk of methodological bias was assessed with Critical Appraisal Skills Programme checklists. Results Eight studies with a total of 373 participants (238 TKA, 135 THA) were included. Findings were mixed regarding improvement in objectively measured PA at 6 months after THA (SMDs, -0.20 to 1.80) and TKA (SMDs, -0.36 to 0.63). Larger improvements from 2 studies at 1 year postsurgery were generally observed after THA (SMDs, 0.39 to 0.79) and TKA (SMDs, 0.10 to 0.85). However, at 1 year, PA levels were still considerably lower than those of healthy controls (THA SMDs, -0.25 to -0.77; TKA SMDs, -1.46 to -1.80). Risk-of-bias scores ranged from 3 to 9 out of 11 (27%-82%) for cohort studies, and from 3 to 8 out of 10 (30%-80%) for case-control studies. Conclusion The best available evidence indicates negligible changes in PA at 6 months after THA or TKA, with limited evidence for larger changes at 1 year after surgery. In the 4 studies that reported control-group data, postoperative PA levels were still considerably less than those of healthy controls. Improved perioperative strategies to instill behavioral change are required to narrow the gap between patient-perceived functional improvement and the actual amount of PA undertaken after THA and TKA. Registered with PROSPERO (registration number CRD42014010155). Level of Evidence Therapy, level 2a. J Orthop Sports Phys Ther 2016;46(6):431-442. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6449.

Comprehensive geriatric assessment of effects of hospitalization and long-term rehabilitation of patients following lower extremity arthroplasty

[Purpose] This study was performed to examine the effects of subacute physical therapy (PT) on activities of daily living (ADL), quality of life, and geriatric aspects of patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). [Subjects] The subjects were TKA (n=56) and THA (n=39) patients who received PT on the first day of independent ADL (up to 2 weeks) and just prior to discharge (4 weeks). [Methods] The functional independence measure (FIM), grip strength, knee extension strength (KES), timed up and go (TUG) test, mini-mental state examination (MMSE), geriatric depression scale short form (GDS-15), fall efficacy scale (FES), and medical outcome study 8-item short-form health survey (SF-8) were used as outcome measure, and comorbidity involvement was also investigated. [Results] Improvements in FIM, KES, TUG, GDS-15, FES, and SF-8 scores were seen in both groups (effect size, 0.31-0.87). Poor PT effects were found for THA patients aged ≥65 years, for TKA and THA patients with an MMSE score ≤28, and for THA patients with two or more comorbidities. [Conclusion] Positive effects were seen in patients who received PT at 2-4 weeks after surgery. Thus, additional PT for approximately 2 weeks after the beginning of independent ADL may be beneficial.

How Much Improvement in Patient Activity Can Be Expected After TKA?

Most patients expect an improvement of physical activity after total knee arthroplasty (TKA). The aim of this study was to evaluate improvement in physical activity after TKA. An accelerometer was used to measure activity in 221 patients before and 1 year after TKA. The measurements included the total number of steps and time spent lying, sitting/standing, or walking. Threshold for achievement of health-enhancing physical activity (HEPA) guidelines and step-defined lifestyle were applied to the data. Measured steps per day improved from 5371 to 6587. Only 50 patients (22.6%) met the HEPA guidelines, whereas 31% achieved an active lifestyle. Improvement in daily step number was influenced by age (P<.001), body mass index (P<.001) and preoperative activity (P<.001). After TKA, patients improved in physical activity and one-third achieved an active lifestyle. Patient-specific characteristics and preoperative levels of physical activity had a relevant influence on activity after TKA. [Orthopedics. 2016; 39(3):S18-S23.].

Return to Sports and Physical Activity After Total and Unicondylar Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.

OBJECTIVES

Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.

METHODS

PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) 'arthroplasty', 'sports' and 'recovery of function', the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.

RESULTS

Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89% after TKA and from 75 to >100% after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1-4.6 after UKA and 0.2-1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.

CONCLUSIONS

Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.