Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty

The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

Feasibility and initial efficacy of a multimodal swelling intervention after total knee arthroplasty: A prospective pilot study with historical controls

BACKGROUND

Swelling after total knee arthroplasty (TKA) is often profound and persistent, increasing risks of DVT, infection, and wound dehiscence, and impairing rehabilitation. We investigated the feasibility and initial efficacy of a multimodal swelling control intervention (MSI), comprised of an inelastic adjustable compression garment (CG), manual lymph drainage (MLD) massage, and home exercise program (HEP) after total knee arthroplasty (TKA) compared to a control group.

METHODS

Sixteen individuals (mean age 64.7 ± 7.1y) performed MSI for three weeks after TKA, through day 21 (D21). Outcome measures included patient satisfaction, safety, patient adherence, and swelling measured by Single Frequency Bioimpedance Assessment (SF-BIA). All outcomes were measured preoperatively and at postoperative D4, D7, D14, D21 and, three weeks after discontinuing MSI, on D42. Efficacy of MSI was calculated with Hedge's g effect size estimates using the SF-BIA ratios for MSI versus CONTROL (N = 56; mean age 64.3 ± 9.3y) at key post operative time points.

RESULTS

Patient satisfaction was 93% with no adverse events. Adherence to CG, MLD, and HEP were 85%, 99%, and 97% respectively. Peak swelling reduction with MSI was at D21 (Hedges' g = 1.60 at D21 (95% CI 0.99, 2.21)). Minimal change in swelling was observed three weeks after cessation of MSI on D42.

CONCLUSIONS

The self-administered MSI program is feasible and demonstrated strong initial efficacy to control swelling after TKA. Minimal rebound swelling was observed once MSI was withdrawn at D21. Future studies should examine the efficacy of inelastic adjustable compression in a randomized controlled trial.