Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study

Different squatting positions after total knee arthroplasty: A retrospective study

BACKGROUND

Total knee arthroplasty (TKA) has been shown to improve quality of life and reduce pain. High-flexion activities such as squatting, kneeling, and floor transfers are mainly listed as demanding tasks. Among them, squatting is an important position.

AIM

To provide a new squat position classification and evaluate the different squatting positions of a series of patients after primary TKA.

METHODS

From May 2018 to October 2019, we retrospectively reviewed 154 video recordings of the squatting-related motions of patients after TKA. Among the included patients, 119 were women and 35 were men. Their mean age at the index surgery was 61.4 years (range, 30 to 77).

RESULTS

The median follow-up was 12 mo (range, 6 to 156 mo). We classified those squatting-related motions into three major variations according to squatting depth: Half squat, parallel squat, and deep squat. The angles of hip flexion, knee flexion, and ankle dorsiflexion were measured in the screenshots captured from the videos at the moment of squatting nadir. A total of 26 patients were classified as half squats, 75 as parallel squats, and 53 as deep squats. The angles of hip flexion, knee flexion, and ankle dorsiflexion all differed significantly among the three squatting positions (P < 0.001). In the parallel squat group, the mean knee flexion angle (°) was 116.5 (SD, 8.1; range, 97 to 137). In the deep squat group, the mean knee flexion angle (°) was 132.5 (SD, 9.3; range, 116 to 158).

CONCLUSION

Among the three squatting positions, deep squat showed the highest hip, knee, and ankle flexion angles, followed by the parallel squat. With the improvement of squatting ability, the patient's postoperative satisfaction rate was also significantly enhanced. However, the different squatting abilities of the patients cannot be effectively distinguished from the scoring results (P > 0.05). Our squatting position classification offers a pragmatic approach to evaluating patients’ squatting ability after TKA.

The Canadian Occupational Performance Measure (COPM) as Routine Practice in Community-Based Rehabilitation: A Retrospective Chart Review

Objective

To investigate whether patients experienced improved functional outcomes as a result of their admission to rehabilitation and to identify whether the service provided effective, patient-centered and goal-directed rehabilitation.

Design

Retrospective chart review of admission and discharge data from patients accessing the service between 2011 and 2019.

Setting

Community-based interdisciplinary rehabilitation service.

Participants

Consecutive patients (N=612) admitted to the service.

Interventions

Routine care delivered with a median duration of 181 days and an interquartile range of 120-261 days.

Main Outcome Measures

The Canadian Occupational Performance Measure (COPM) administered on admission and discharge and an improvement ≥2 in the COPM subscales of performance and satisfaction.

Results

Of 612 participants, 96% had the COPM administered at admission (baseline) and 68% again at discharge. Performance and satisfaction were measured in 584 patients at admission, 406 at discharge, and 404 at both time points. For performance, 243 patients (60%) experienced an improvement (≥2), with an average of 2.2 points. For satisfaction, 268 patients (66%) experienced an improvement (≥2), with an average of 2.8 points. Factors influencing outcomes, differed. For each 10 year increase in patient age, the average improvement in satisfaction was 0.26 points lower (95% confidence interval, 0.07-0.45) after adjusting for sex, duration, completion, and health condition.

Conclusions

Irrespective of patient-related factors and regardless of age, sex, health condition, or discharge plan, the majority of patients reported a positive functional outcome in COPM Performance and satisfaction as a result of time spent in the community-based rehabilitation service. This service provided equitable care and patient-centered, goal-focused, and outcome-based therapy that enabled patients to improve their functional capacity.

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee Replacement: A Randomized Clinical Trial

IMPORTANCE

Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

OBJECTIVES

To compare the effectiveness of later-stage exercise programs after TKR and to explore heterogeneity of treatment effects.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm single-blind randomized clinical trial (January 7, 2015, to November 9, 2017) using an intent-to-treat approach with follow-ups at 3 months and 6 months. The setting was Allegheny County, Pennsylvania (an outpatient physical therapy clinic and 4 community centers). Participants had primary TKR performed more than 2 months previously, were 60 years or older, experienced moderate functional limitations, and were medically cleared to exercise.

INTERVENTIONS

Clinic-based physical therapy exercise (physical therapy arm), community-based group exercise (community arm), and usual care (control arm). The control arm continued their usual care, whereas the exercise arms participated in supervised exercise programs lasting 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was arm differences in the Western Ontario and McMaster Universities Osteoarthritis Index-Physical Function (WOMAC-PF) at 3 months. The secondary outcomes included performance-based tests germane to knee replacement and additional surveys of physical function. Data were analyzed by linear mixed models and responder analysis.

RESULTS

A total of 240 participants (mean [SD] age, 70 [7] years; 61.7% female) were allocated to physical therapy (n = 96), community exercise (n = 96), or control (n = 48). All 3 arms demonstrated clinically important improvement. At 3 months, between-arm analyses for the WOMAC-PF demonstrated no differences between physical therapy and community (-2.2; 98.3% CI, -4.5 to 0.1), physical therapy and control (-2.1; 98.3% CI, -4.9 to 0.7), and community and control (0.1; 98.3% CI, -2.7 to 2.9). Performance-based tests demonstrated greater improvement in the physical therapy arm compared with both the community (0.1 z score units; 98.3% CI, 0.0-0.2) and control (0.3 z score units; 98.3% CI, 0.1-0.4) arms and the community arm compared with the control arm (0.2 z score units; 98.3% CI, 0.0-0.3). The physical therapy arm had more than 17.7% responders than the community arm and more than 19.0% responders than the control arm. There was no difference in responder rates between the community and control arms.

CONCLUSIONS AND RELEVANCE

Based on the primary outcome, participation in late-stage exercise programs after TKR offered no benefit over usual care. The benefits of physical therapy identified by the secondary outcomes and responder analysis require confirmation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02237911.