Discharge From the Postanesthesia Care Unit With Motor Blockade After Spinal Anesthesia Safely Optimizes Fast Track Recovery in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Post anesthesia care units (PACU) await return of motor function in lower extremities, prior to discharge for patients undergoing spinal anesthesia. The purpose of this study was to assess the impact of a newly utilized recovery protocol that facilitated early discharges of patients undergoing total hip and knee arthroplasties (THA/TKA) to the floor before full motor recovery from spinal anesthesia is achieved.

METHODS

A total of 647 patients undergoing spinal anesthesia for primary THA (n = 190) and TKA (n = 457) were divided into 2 groups: (1) Early PACU discharge group: patients with partial or full motor blockade at discharge. (2) Control PACU discharge group: patients with full motor recovery at discharge. Readiness for discharge was assessed using a modified Aldrete Score system. The primary outcome was incidences of hypotension or rapid responses post-operatively.

RESULTS

There was no significant difference in the incidence of hypotension between the two groups (1.4 versus 1.39%, P = 1.0) and zero rapid responses were noted. Early discharge shortened mean PACU LOS time from 86.50 minutes to 70.27 minutes (P < .01). There was no difference in the incidence of nausea (0.55 versus 0%; P = .51) ordizziness (2.22 versus 0.35%; P = .09).

CONCLUSION

In this retrospective observational study, we found that early PACU discharge did not result in an increase in hemodynamic consequences on the surgical floor. Thus, discharge from PACU can be safely and more expeditiously performed without waiting for return of motor function in patients receiving spinal anesthesia for THA/TKA using a modified Aldrete Score recovery protocol.

Early unrestricted vs. partial weight bearing after uncemented total hip arthroplasty: a systematic review and meta-analysis

Background

The choice of postoperative weight bearing protocol after uncemented total hip arthroplasty (THA) remains controversial. The aim of this study was to assess the efficacy and safety of immediate unrestricted weight bearing (UWB) compared with partial weight bearing (PWB) in patients undergoing uncemented THA.

Methods

Relevant articles were retrieved from electronic databases. Both randomized controlled trials (RCTs) and non-RCTs were included but analyzed separately. All functional and clinical outcomes with at least 2 independent study outcomes were meta-analyzed.

Results

A total of 17 studies were investigated. No adverse effect was found regarding micromotion of the femoral stem with immediate UWB following uncemented THA. There was also no correlation between immediate UWB and failure of ingrowth fixation and higher risks of femoral stem subsidence and surgical revision in RCTs. Harris hip score was better in patients with immediate UWB than those with PWB at 1 year post surgery, but the difference was not statistically significant.

Conclusions

Immediate UWB did not have extra harm compared with PWB in patients undergoing uncemented THA. UWB was not superior to PWB. Considering the improvement of Harris score and the compliance of patients, UWB can be encouraged in THA rehabilitation.

Exploring treatment effect heterogeneity of a PROMs alert intervention in knee and hip arthroplasty patients: A causal forest application

Patient reported outcome measures (PROMs) experience an uptake in use for hip (HA) and knee arthroplasty (KA) patients. As they may be used for patient monitoring interventions, it remains unclear whether their use in HA/KA patients is effective, and which patient groups benefit the most. Nonetheless, knowledge about treatment effect heterogeneity is crucial for decision makers to target interventions towards specific subgroups that benefit to a greater extend. Therefore, we evaluate the treatment effect heterogeneity of a remote PROM monitoring intervention that includes ∼8000 HA/KA patients from a randomized controlled trial conducted in nine German hospitals. The study setting gave us the unique opportunity to apply a causal forest, a recently developed machine learning method, to explore treatment effect heterogeneity of the intervention. We found that among both HA and KA patients, the intervention was especially effective for patients that were female, >65 years of age, had a blood pressure disease, were not working, reported no backpain and were adherent. When transferring the study design into standard care, policy makers should make use of the knowledge obtained in this study and allocate the treatment towards subgroups for which the treatment is especially effective.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Influência da reabilitação física sobre aspectos funcionais em indivíduos submetidos à artroplastia total de quadril: uma revisão sistemática

Resumo Objetivo: Avaliar, por meio de revisão sistemática, a influência do tratamento fisioterapêutico sobre a funcionalidade, amplitude de movimento articular e força muscular em pacientes submetidos à artroplastia total de quadril devido à osteoartrite. Métodos: A busca sistemática de ensaios clínicos randomizados e não randomizados foi conduzida utilizando os bancos de dados eletrônicos PubMed, Web of Science, PEDro, Cochrane, Clinical Trials e SciELO, com base nas estratégias de pesquisa recomendadas pelos itens de relatórios preferenciais para análises sistemáticas e metanálises (PRISMA). Resultados: Em geral, protocolos supervisionados por fisioterapeutas associados à realização de exercícios ativos da musculatura periarticular do quadril e de extensores de joelho têm propiciado importante prognóstico físico e funcional. Exercícios resistidos (dinâmicos e isométricos) de alta intensidade são mais eficazes para a funcionalidade. Para a força muscular e Amplitude de movimento (ADM), exercícios dinâmicos com 3 a 5 séries de 8 a 12 repetições com baixa e alta intensidade promoveram ganhos mais expressivos em relação a outras modalidades terapêuticas. Conclusões: As técnicas e os protocolos utilizados pela fisioterapia para o tratamento da ATQ são variados e possuem importante eficácia clínica comprovada na literatura.

Capsulectomy vs capsulotomy in total hip arthroplasty. Clinical outcomes and proprioception evaluation: Study protocol for a randomized, controlled, double blinded trial

Background

Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted.The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy.

Methods

In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2).

Discussion

Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery.

Trial registration

ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016.

Rehabilitation after resurfacing hip arthroplasty: cost-utility analysis alongside a randomized controlled trial

OBJECTIVE

To assess the costs, effects, and cost-utility of an accelerated physiotherapy programme versus a standard physiotherapy programme following resurfacing hip arthroplasty.

DESIGN

A cost-utility analysis alongside a randomized controlled trial.

SETTING

A UK National Health Service hospital and patients' homes.

SUBJECTS

A total of 80 male resurfacing hip arthroplasty patients randomized post procedure to one of the two programmes.

INTERVENTIONS

The accelerated physiotherapy programme commenced in hospital with patients being fully weight bearing, without hip precautions, and following a range of exercises facilitating gait re-education, balance, and lower limb strength. Standard physiotherapy commenced in hospital, but hip precautions were used and exercises were only partially weight bearing. In both groups, patients continued with their exercises at home for an eight-week period.

MAIN MEASURES

Data on healthcare contacts were collected from patients to 12 months and costed using unit costs from national sources. Information was also collected on patients' costs. Health-related quality of life was measured using the EuroQol EQ-5D questionnaire and used to estimate quality-adjusted life years (QALYs) to 12 months. Mean costs and QALYs for each trial arm were compared.

RESULTS

On average, the accelerated physiotherapy programme was less expensive (mean cost difference -£200; 95% confidence interval: -£656 to £255) and more effective (mean QALY difference 0.13; 95% confidence interval: 0.05 to 0.21) than standard physiotherapy and had a high probability of being cost-effective.

CONCLUSION

From the National Health Service perspective, an accelerated physiotherapy programme for male patients undergoing revision of total hip arthroplasty (RHA) is very likely to be cost-effective when compared to a standard physiotherapy programme.

Activity levels following hip resurfacing arthroplasty: A tool to help manage patient expectations

Background

When compared to total hip arthroplasty (THA), hip resurfacing arthroplasty (HRA) is usually undertaken in younger, more active patients with hip osteoarthritis. Previous research has noted that patients are able to return to pre-operative activity levels, with many even increasing their activity post HRA, but patterns in post-operative recovery have been less well investigated.

Materials and Methodology

A randomised controlled trial dataset was analysed to explore activity levels attained after HRA. Data was collected on 80 male patients. The primary outcome of focus was the University of California, Los Angeles (UCLA) Activity Index, with follow-up at 6 weeks, 16 weeks and 1 year.

Results

Mean UCLA at baseline was 5.4 (SD; 2.1) which, after an initial fall to 4.7 (SD; 1.6, p = 0.008) at 6 weeks, increased at both the 16 week and 1 year follow ups (p < 0.001), with a final mean activity index of 7.2 (SD; 1.7). Mode UCLA at 1 year was 7 or 8, representing patients who are regularly taking part in activities such as cycling and golf.

Conclusion

Following HRA, patients can achieve significant improvements in activity measured using the UCLA Activity Index. Activity levels have been shown to initially decrease following HRA, with improvement throughout the first postoperative year. The results of this study provide clinicians with a simple tool to help patients visualise their post-operative recovery. This may have implications when managing patient expectations of post-operative activity level in both HRA and large head THA populations.

Utility of gabapentin in meeting physical therapy goals following posterior spinal fusion in adolescent patients with idiopathic scoliosis

OF BACKGROUND DATA

Posterior spinal fusion surgery for scoliosis requires extensive postoperative analgesic care. In 2014, we initiated the use of gabapentin as an adjunct for multimodal pain management in spine fusion patients. The effect of gabapentin on postoperative recovery in scoliosis patients was evaluated using the time to meet postoperative physical therapy goals. This measure was chosen because the actions required to achieve the goals are specific and reproducible. Secondary outcomes included morphine equivalents and maximum pain scores.

AIMS

The purpose of this study was to evaluate the effects of gabapentin on time to achieve physical therapy goals following posterior spinal fusion in adolescents with scoliosis.

METHODS

A retrospective chart review was performed and patients treated perioperatively with gabapentin were compared with those who did not receive gabapentin. Outcome measures included the postoperative day that physical therapy goals were met, days to discharge, morphine equivalents, and maximum pain scores. The 4 physical therapy goals included logroll, transition from lying to sitting, ambulate 250 feet, and ascend/descend at least 3 stairs.

RESULTS

There were 50 patients in the gabapentin group and 51 patients in the control group. In the gabapentin group, there was a statistically significant decrease in the time required to meet physical therapy goals. Notably, gabapentin was independently associated with a 5.34 times higher odds of completion of the most challenging physical therapy goal (stairs) within 1 day (P = .04; 95% CI=1.24-37.44). There was not a statistically significant difference in length of hospital stay between the groups (P = .116; 95% CI=0-1).

CONCLUSION

In this retrospective analysis, the use of perioperative gabapentin is associated with a statistically significant decrease in time to completing physical therapy goals after spinal fusion for adolescent idiopathic scoliosis.

Decreasing Postanesthesia Care Unit to Floor Transfer Times to Facilitate Short Stay Total Joint Replacements

PURPOSE

We describe a process for studying and improving baseline postanesthesia care unit (PACU)-to-floor transfer times after total joint replacements.

DESIGN

Quality improvement project using lean methodology.

METHODS

Phase I of the investigational process involved collection of baseline data. Phase II involved developing targeted solutions to improve throughput. Phase III involved measured project sustainability.

FINDINGS

Phase I investigations revealed that patients spent an additional 62 minutes waiting in the PACU after being designated ready for transfer. Five to 16 telephone calls were needed between the PACU and the unit to facilitate each patient transfer. The most common reason for delay was unavailability of the unit nurse who was attending to another patient (58%). Phase II interventions resulted in transfer times decreasing to 13 minutes (79% reduction, P < .001). Phase III recorded sustained transfer times at 30 minutes, a net 52% reduction (P < .001) from baseline.

CONCLUSIONS

Lean methodology resulted in the immediate decrease of PACU-to-floor transfer times by 79%, with a 52% sustained improvement. Our methods can also be used to improve efficiencies of care at other institutions.

Rehabilitation of revision total hip replacement: A multi-centre survey of current practice

BACKGROUND

Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation.

AIMS AND OBJECTIVES

To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery.

METHODS

An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically.

RESULTS

There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably.

CONCLUSIONS

This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.

A comparison of multidisciplinary team residential rehabilitation with conventional outpatient care for the treatment of non-arthritic intra-articular hip pain in UK Military personnel - a protocol for a randomised controlled trial

BACKGROUND

Non-arthritic hip disorders are defined as abnormalities of the articulating surfaces of the acetabulum and femur before the onset of osteoarthritis, including intra-articular structures such as the acetabular labrum and chondral surfaces. Abnormal femoroacetabular morphology is commonly seen in young men who constitute much of the UK military population. Residential multidisciplinary team (MDT) rehabilitation for patients with musculoskeletal injuries has a long tradition in the UK military, however, there are no studies presenting empirical data on the efficacy of a residential MDT approach compared with individualised conventional outpatient treatment. With no available data, the sustainability of this care pathway has been questioned. The purpose of this randomised controlled trial is to compare the effects of a residential multidisciplinary intervention, to usual outpatient care, on the clinical outcomes of young active adults undergoing treatment for non-arthritic intra-articular hip pain.

METHODS/DESIGN

The trial will be conducted at the Defence Medical Rehabilitation Centre, Headley Court, UK. One hundred military male participants with clinical indicators of non-arthritic intra-articular hip pain will be randomly allocated to either: (1) 7-day residential multidisciplinary team intervention, n = 50; (2) 6-week physiotherapist-led outpatient intervention (conventional care), n = 50. Measurements will be taken at baseline, post-treatment (1-week MDT group; 6-weeks physiotherapy group), and 12-weeks. The primary outcome measures are the function in daily living sub-scale of the Copenhagen Hip and Groin Outcome Score (HAGOS), the physical function subscale of the Non-arthritic Hip Score (NAHS), and VAS pain scale. Secondary outcomes include objective measures of physical capacity and general health. An intention-to-treat analysis will be performed using linear and mixed models.

DISCUSSION

This study will be the first to assess the efficacy of intensive MDT rehabilitation, versus conventional outpatient care, for the management of non-arthritic hip pain. The results from this study will add to the evidence-base and inform clinical practice for the management of intra-articular non-arthritic hip pain and femoroacetabular impingement in young active adults.

TRIAL REGISTRATION

ISRCTN Reference: ISRCTN 59255714 dated 11-Nov-2015.

Impact of Total Hip Resurfacing Arthroplasty on Health-Related Quality of Life Measures: A Systematic Review and Meta-Analysis

The aim of this study was to investigate the effect of total hip resurfacing arthroplasty (RA) on general health-related quality of life (HRQOL) and disease/hip-specific measures. Original studies published after 2000, enrolling at least ten skeletally mature patients with a minimum follow-up of 6 months were considered. The standardized mean difference (SMD) was obtained with a random effects model. The cumulative patient population encompassed 1898 patients (2123 RA). Mean follow-up duration was 4 years. The physical component score (P<0.001) and mental component score (P=0.05) of SF-12, and the EuroQol-5D (P<0.0001) improved significantly. WOMAC global score and the subscales (P<0.00001) were also improved. Harris Hip Score (P<0.00001), Oxford Hip Score (P<0.001) and UCLA (P<0.00001) were markedly improved and patient satisfaction was favorable.

A feasibility randomised controlled trial of pre-operative occupational therapy to optimise recovery for patients undergoing primary total hip replacement for osteoarthritis (PROOF-THR)

Objective:

To assess the feasibility of a pre-operative occupational therapy intervention for patients undergoing primary total hip replacement.

Design:

Single blinded feasibility randomised controlled trial, with data collection prior to the intervention, and at 4, 12, and 26 weeks following surgery.

Setting:

Recruitment from two NHS orthopaedic outpatient centres in the West Midlands, UK.

Subjects:

Patients awaiting primary total hip replacement due to osteoarthritis were recruited. Following pre-operative assessment, patients were individually randomised to intervention or control by a computer-generated block randomisation algorithm stratified by age and centre.

Interventions:

The intervention group received a pre-surgery home visit by an occupational therapist who discussed expectations, assessed home safety, and provided appropriate adaptive equipment. The control group received treatment as usual.

Outcomes:

The study assessed the feasibility of recruitment procedures, delivery of the intervention, appropriateness of outcome measures and data collection methods. Health related quality of life and resource use were recorded at 4, 12 and 26 weeks.

Results:

Forty-four participants were recruited, 21 were randomised to the occupational therapy intervention and 23 to usual care. Analysis of 26 week data included 18 participants in the intervention group and 21 in the control. The intervention was delivered successfully with no withdrawals or crossovers; 5/44 were lost to follow-up with further missing data for participation and resource use.

Conclusions:

The feasibility study provided the information required to conduct a definitive trial. Burden of assessment would need to be addressed. A total of 219 patients would be required in an efficacy trial.

Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review

BACKGROUND

Existing review required updating.

OBJECTIVE

To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis.

DESIGN

Systematic review from January 2007 to November 2013.

DATA SOURCES

AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied.

ELIGIBILITY CRITERIA

Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed.

OUTCOMES

Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion.

STUDY APPRAISAL

Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered.

RESULTS

11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.

LIMITATIONS

The overall quality and quantity of trials, and their diversity, prevented meta-analyses.

CONCLUSIONS

Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.

Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations. A single-blinded randomised controlled trial

OBJECTIVE

To examine if 2 weekly sessions of supervised progressive resistance training (PRT) in combination with 5 weekly sessions of unsupervised home-based exercise is more effective than 7 weekly sessions of unsupervised home-based exercise in improving leg-extension power of the operated leg 10 weeks after total hip replacement (THR) in patients with lower pre-operative function.

METHOD

A total of 73 patients scheduled for THR were randomised (1:1) to intervention group (IG, home based exercise 5 days/week and PRT 2 days/week) or control group (CG, home based exercise 7 days/week). The primary endpoint was change in leg extension power at 10 week follow up. Secondary outcomes were isometric hip muscle strength, sit-to-stand test, stair climb test, 20 m walking speed and patient-reported outcome (HOOS).

RESULTS

Sixty-two completed the trial (85%). Leg extension power increased from baseline to the 10 week follow up in both groups; mean [95% CI] IG: 0.29 [0.13; 0.45] and CG: 0.26 [0.10; 0.42] W/kg, with no between-group difference (primary outcome) (P = 0.79). Maximal walking speed (P = 0.008) and stair climb performance (P = 0.04) improved more in the IG compared to CG, no other between-group differences existed.

CONCLUSIONS

In this trial, supervised PRT twice a week in addition to 5 weekly sessions of unsupervised exercise for 10 weeks was not superior to 7 weekly sessions of unsupervised home-based exercise for 10 weeks in improving the primary outcome, leg-extension power of the operated leg, at the primary endpoint 10 weeks after surgery in THR patients with lower pre-operative function.

TRIAL REGISTRATION

NCT01214954.

Task-oriented exercises and early full weight-bearing contribute to improving disability after total hip replacement: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an in-hospital programme based on task-oriented exercises associated with early full weight-bearing in patients with multiple comorbidities undergoing total hip replacement.

DESIGN

Randomized controlled trial.

SETTING

Specialised rehabilitation centre.

SUBJECTS

A total of 100 patients (mean age of 69 (8) years; 40 males, 60 females).

INTERVENTIONS

The experimental group underwent task-oriented exercises and was encouraged to abandon any walking aids by the end of their in-hospital stay. The control group underwent open chain kinetic exercises, and was recommended to use partial weight-bearing and walking aids until three months after surgery. Both groups individually followed programmes of 90-minute sessions five times a week for three weeks.

OUTCOME MEASURES

Western Ontario and McMaster Universities Osteoarthritis Index, Pain Numerical Rating Scale, Functional Independence Measure, and Short-Form Health Survey. The participants were evaluated before, after training, and after a further 12 months.

RESULTS

There were no significant between-group differences at baseline. After training, a between-group difference of 12 points was found for the Western Ontario and McMaster Universities Osteoarthritis Index - functional subscale, indicating a clinically tangible treatment effect on disability. The Functional Independence Measure increased by 31 and 15 points in the experimental and control group, respectively. A linear mixed model revealed significant effects of time, group, and time by group interaction on disability, pain, activities of daily living, and most of the physical quality of life domains.

CONCLUSION

Task-oriented exercises associated with early full weight-bearing improve disability, pain, activities of daily living, and quality of life after total hip replacement.

A study of the inter-rater reliability of a test battery for use in patients after total hip replacement

Objective:

To assess the within-day inter-rater reliability of a test battery of functional performance, muscle strength and leg extension power on total hip replacement patients.

Design:

A test–retest design was used.

Setting:

Orthopaedic department at a Regional Hospital in Denmark.

Subjects:

Two convenience samples of 20 total hip replacement patients were included.

Intervention:

The tests were performed three months after total hip replacement. Two raters performed test and re-test, with two hours rest in-between.

Main measures:

The test battery included: sit-to-stand performance, 20-metre maximum walking speed, stair climb performance, isometric muscle strength (hip abduction/flexion), and leg extension power. Absolute reliability was assessed with Bland Altman plots, standard error of measurement (SEM), and minimal detectable change. Relative reliability was assessed with intra-class correlation coefficient.

Results:

Systematic differences between testers were seen in tests of walking speed (0.32 seconds p = 0.03) and stair climb performance (0.18 seconds p = 0.003). In per cent of the grand mean, the standard error of measurement was 3%–10%, indicating the measurement error on a group level, and the minimal detectable change was 10%–27%, indicating the measurement error on an individual level. The intra-class correlation coefficients were above 0.80 in all tests (range 0.83–0.95).

Conclusions:

The tests showed acceptable relative and absolute inter-rater reliability on a group level, but not on an individual level (except from test of walking speed and stair climb performance). Systematic differences between testers were considered clinically irrelevant (0.3 and 0.2 seconds).