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Dubin JA, Hameed D, Bains SS, Monárrez R, Swartz GN, DeRogatis M, Mont MA, Nace J, Delanois RE. A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00320-6. [PMID: 38604277 DOI: 10.1016/j.arth.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis. METHODS Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM. RESULTS The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision. CONCLUSIONS The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.
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Affiliation(s)
- Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Daniel Hameed
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Rubén Monárrez
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Gabrielle N Swartz
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael DeRogatis
- Department of Orthopaedics, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Cheesman QT, Ponzio DY, Thalody HE, Lau VW, Post ZD, Ong A. Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series. Cureus 2024; 16:e53113. [PMID: 38414679 PMCID: PMC10898921 DOI: 10.7759/cureus.53113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following TKA.
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Affiliation(s)
| | - Danielle Y Ponzio
- Orthopedic Surgery, Rothman Orthopedic Institute, Egg Harbor Township, USA
| | - Hope E Thalody
- Orthopedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Vincent W Lau
- Orthopedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Zachary D Post
- Orthopedic Surgery, Rothman Orthopedic Institute, Egg Harbor Township, USA
| | - Alvin Ong
- Orthopedic Surgery, Rothman Orthopedic Institute, Egg Harbor Township, USA
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3
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Rauzi MR, Foran JRH, Bade MJ. Multimodal conservative management of arthrofibrosis after total knee arthroplasty compared to manipulation under anesthesia: a feasibility study with retrospective cohort comparison. Pilot Feasibility Stud 2022; 8:71. [PMID: 35337388 PMCID: PMC8953056 DOI: 10.1186/s40814-022-01026-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
Background The ideal treatment of early-stage arthrofibrosis after total knee arthroplasty is unclear. The purpose of this study was to determine the treatment effect, including variability, and feasibility of a multimodal physical therapy program as compared to manipulation under anesthesia. Methods This was a prospective feasibility study with a retrospective cohort comparison. Ten consecutive patients (aged 64 ± 9 years, 7 females) with early-stage arthrofibrosis were enrolled 6 weeks after primary total knee arthroplasty and participated in the multimodal physical therapy program. The multimodal physical therapy program consisted of manual therapy, therapeutic exercise, and static progressive splinting delivered over 4 weeks. The outcomes included knee range of motion (ROM), adherence, patient satisfaction, and safety. Data were compared to a retrospective cohort of 31 patients with arthrofibrosis (aged 65 ± 9 years, 20 females) who underwent manipulation under anesthesia followed by physical therapy. Results Overall, knee ROM outcomes were similar between multimodal physical therapy (110° ± 14) and manipulation under anesthesia (109° ± 11). Seven out of ten patients achieved functional ROM (≥ 110°) and avoided manipulation under anesthesia with the multimodal physical therapy program. Three out of 10 multimodal physical therapy patients required manipulation under anesthesia secondary to failure to demonstrate progress within 4 weeks of the multimodal physical therapy program. Adherence to the multimodal physical therapy program was 87 ± 9%. The median patient satisfaction with the multimodal physical therapy program was “very satisfied.” Safety concerns were minimal. Conclusion The use of the multimodal physical therapy program is feasible for treating early-stage arthrofibrosis after total knee arthroplasty, with 70% of patients avoiding manipulation under anesthesia. Randomized controlled trials are needed to determine the efficacy of the multimodal physical therapy program and to determine the optimal patient selection for the multimodal physical therapy program versus manipulation under anesthesia. Trial registration ClinicalTrials.gov, NCT04837872. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01026-y.
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Affiliation(s)
- Michelle R Rauzi
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, 13121 E 17th Ave, Aurora, CO, 80045, USA
| | - Jared R H Foran
- Panorama Orthopedics & Spine Center, 660 Golden Ridge Rd. #250, Golden, CO, 80401, USA
| | - Michael J Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, 13121 E 17th Ave, Aurora, CO, 80045, USA. .,Veterans Affairs Geriatric Research, Education and Clinical Center, VA Eastern Colorado Healthcare System, 13611 East Colfax, Aurora, CO, 80045, USA.
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Takada S, Setoyama K, Norimatsu K, Otsuka S, Nakanishi K, Tani A, Nakakogawa T, Matsuzaki R, Matsuoka T, Sakakima H, Tancharoen S, Maruyama I, Tanaka E, Kikuchi K, Uchikado H. E8002 Reduces Adhesion Formation and Improves Joint Mobility in a Rat Model of Knee Arthrofibrosis. Int J Mol Sci 2022; 23:ijms23031239. [PMID: 35163163 PMCID: PMC8835358 DOI: 10.3390/ijms23031239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/26/2022] Open
Abstract
Knee arthrofibrosis is a common complication of knee surgery, caused by excessive scar tissue, which results in functional disability. However, no curative treatment has been established. E8002 is an anti-adhesion material that contains L-ascorbic acid, an antioxidant. We aimed to evaluate the efficacy of E8002 for the prevention of knee arthrofibrosis in a rat model, comprising injury to the surface of the femur and quadriceps muscle 1 cm proximal to the patella. Sixteen male, 8-week-old Sprague Dawley rats were studied: in the Adhesion group, haemorrhagic injury was induced to the quadriceps and bone, and in the E8002 group, an adhesion-preventing film was implanted between the quadriceps and femur after injury. Six weeks following injury, the restriction of knee flexion owing to fibrotic scarring had not worsened in the E8002 group but had worsened in the Adhesion group. The area of fibrotic scarring was smaller in the E8002 group than in the Adhesion group (p < 0.05). In addition, the numbers of fibroblasts (p < 0.05) and myofibroblasts (p < 0.01) in the fibrotic scar were lower in the E8002 group. Thus, E8002 reduces myofibroblast proliferation and fibrotic scar formation and improves the range of motion of the joint in a model of knee injury.
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Affiliation(s)
- Seiya Takada
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Kentaro Setoyama
- Division of Laboratory Animal Science, Natural Science Center for Research and Education, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan;
| | - Kosuke Norimatsu
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Shotaro Otsuka
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Kazuki Nakanishi
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Akira Tani
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Tomomi Nakakogawa
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Ryoma Matsuzaki
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Teruki Matsuoka
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Harutoshi Sakakima
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Salunya Tancharoen
- Department of Pharmacology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand;
| | - Ikuro Maruyama
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Eiichiro Tanaka
- Division of Brain Science, Department of Physiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan;
| | - Kiyoshi Kikuchi
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
- Division of Brain Science, Department of Physiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan;
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
- Correspondence: (K.K.); (H.U.); Tel.: +81-942-31-7542 (K.K.); +81-92-477-2355 (H.U.); Fax: +81-942-31-7695 (K.K.); +81-92-477-2325 (H.U.)
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
- Uchikado Neuro-Spine Clinic, 1-2-3 Naka, Hakata-ku, Fukuoka 812-0893, Japan
- Correspondence: (K.K.); (H.U.); Tel.: +81-942-31-7542 (K.K.); +81-92-477-2355 (H.U.); Fax: +81-942-31-7695 (K.K.); +81-92-477-2325 (H.U.)
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Bäcker HC, Freibott CE, Swart E, Perka C, Jobin CM, Rosenwasser MP. A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness.
Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).
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Londhe SB, Shah RV, Doshi AP, Londhe SS, Subhedar K, Iyengar K, Mukkannavar P. Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. ARTHROPLASTY 2021; 3:10. [PMID: 35236438 PMCID: PMC8796486 DOI: 10.1186/s42836-020-00063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022] Open
Abstract
Abstract The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. Methods A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients’ age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. Results In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). Conclusion After total knee arthroplasty, frequent physiotherapist’s instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. Level of evidence Therapeutic study, Level IIa.
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Affiliation(s)
- Sanjay Bhalchandra Londhe
- Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra, 400069, India.
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Aspinall SK, Bamber ZA, Hignett SM, Godsiff SP, Wheeler PC, Fong DT. Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review. J Orthop Translat 2021; 27:119-131. [PMID: 33659182 PMCID: PMC7878963 DOI: 10.1016/j.jot.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 11/08/2020] [Indexed: 12/04/2022] Open
Abstract
AIMS This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works. MATERIALS AND METHODS Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included. RESULTS A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p < 0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices. CONCLUSION The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.
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Affiliation(s)
- Sara K. Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Zoe A. Bamber
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Division of Orthopaedics, Trauma and Sports Medicine, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sue M. Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Steven P. Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Bhave A, Sodhi N, Anis HK, Ehiorobo JO, Mont MA. Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S256. [PMID: 31728380 DOI: 10.21037/atm.2019.06.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The current literature supports static progressive stretch (SPS) orthoses as the consensus modality to treat joint stiffness as an adjunct to manual therapy. Over 50 published studies prove the efficacy and safety of this modality as an adjunct to therapy to improve range of motion (ROM) as well as decrease stiffness and pain. Data from a large prospective study on SPS effectiveness identified a 90% improvement in ROM, 84% reduction in stiffness and swelling, 70% reduction in pain, and no reports of complications or injury. Another 13 studies evaluating patients with knee stiffness have shown excellent results with SPS, and a reduced need for manipulation under anesthesia or additional surgeries. The bidirectional SPS device allows for ROM therapy in both flexion and extension, uses short, 5-minute incremental stretches for up to a 30-minute session applied 1 to 3 times per day for 8 weeks, though treatment might be needed for longer durations (8 to 12 weeks) in cases with chronic stiffness/contracture, to improve motion and significantly reduces need for manipulation or surgery for treatment of knee fibrosis. Earlier application of SPS therapy, even immediately postoperative following corrective surgery for motion loss, can greatly improve the results for patients who have limitations in knee motion.
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Affiliation(s)
- Anil Bhave
- Department of Physical Therapy, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, New York, NY, USA
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Thompson R, Novikov D, Cizmic Z, Feng JE, Fideler K, Sayeed Z, Meftah M, Anoushiravani AA, Schwarzkopf R. Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management. Orthop Clin North Am 2019; 50:269-279. [PMID: 31084828 DOI: 10.1016/j.ocl.2019.02.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.
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Affiliation(s)
- Ryan Thompson
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - David Novikov
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Zlatan Cizmic
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - James E Feng
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Kathryn Fideler
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Zain Sayeed
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - Morteza Meftah
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstructive Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA.
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Chughtai M, Newman JM, Sultan AA, Samuel LT, Rabin J, Khlopas A, Bhave A, Mont MA. Astym ® therapy: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:70. [PMID: 30963065 DOI: 10.21037/atm.2018.11.49] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Soft tissue dysfunction can result from the degeneration of tissues as in the case of degenerative tendinopathy or from the build-up of problematic scar tissue, which can be the result of several aggravating factors, including overuse injuries, acute or chronic trauma, or as a result of surgery. This dysfunction often results in impaired movement, pain, and swelling of the affected area, which can lead to patient dissatisfaction and a lower quality of life. These soft tissue dysfunctions also have a marked economic impact. Although a number of traditional treatments attempt to address these issues, no optimal treatment choice has emerged. Traditional treatments are not always successful, can be invasive, and can consume many medical resources. A relatively new treatment approach, Astym therapy, is a potentially useful, non-invasive, more cost-effective option. This therapy was developed to address soft-tissue dysfunctions by stimulating the regeneration of soft tissues and the resorption of inappropriate scar tissue/fibrosis. It has been reported to help with the resorption and remodeling of abnormal tissue, thereby leading to improved motion, function and pain relief. The purpose of this analysis was to review the published literature related to Astym therapy on various musculoskeletal disorders. Specifically, we evaluated the effectiveness of this therapeutic method on disorders related to the: (I) knee; (II) upper extremity; (III) hamstring muscles; and (IV) ankle and Achilles tendon injuries.
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Affiliation(s)
- Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jared M Newman
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jacob Rabin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Anil Bhave
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
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DE SOUSA FILHO PEDROGUILMETEIXEIRA, CHISTÉ YURILUBIANA, ALBUQUERQUE RODRIGOSATTAMINIPIRESE, COBRA HUGOALEXANDREDEARAÚJOBARROS, BARRETTO JOÃOMAURÍCIO, CAVANELLAS NAASSONTRINDADE. LATE EVALUATION OF PATIENTS UNDERGOING MANIPULATION OF THE KNEE AFTER TOTAL ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2017; 25:253-257. [PMID: 29375254 PMCID: PMC5782858 DOI: 10.1590/1413-785220172506165770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: We compared gains in range of motion in patients who underwent manipulation within 12 weeks of total knee arthroplasty (TKA) and after this period. We also evaluated maintenance of the arc obtained from knee manipulation in late follow-up, along with factors associated with poorer outcomes. Method: The study was divided into two groups according to the time after TKA; the surgeries took place between January 2008 and December 2014. Results: When comparing the range of motion between early and late manipulations, the group that underwent manipulation within 12 weeks of the TKA exhibited better outcomes, but these were not statistically significant. We observed that 14.3% of cases retained the same range attained at the time of manipulation. In late evaluation after manipulation, 47.7% of the sample had a range of less than 90 degrees. The significant risk factors for recurrence of knee stiffness in the long term are poor range of motion before TKA and before manipulation, female sex, and secondary arthritis. Conclusion: Women previously diagnosed with secondary osteoarthritis and poor range of motion before TKA or manipulation are at higher risk for late stiffness. Level of Evidence III, Retrospective Comparative Study.
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Rutherford RW, Jennings JM, Dennis DA. Enhancing Recovery After Total Knee Arthroplasty. Orthop Clin North Am 2017; 48:391-400. [PMID: 28870300 DOI: 10.1016/j.ocl.2017.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There have been multiple successful efforts to improve and shorten the recovery period after elective total joint arthroplasty. The development of rapid recovery protocols through a multidisciplinary approach has occurred in recent years to improve patient satisfaction as well as outcomes. Bundled care payment programs and the practice of outpatient total joint arthroplasty have provided additional pressure and incentives for surgeons to provide high-quality care with low cost and complications. In this review, the evidence for modern practices are reviewed regarding patient selection and education, anesthetic techniques, perioperative pain management, intraoperative factors, blood management, and postoperative rehabilitation.
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Affiliation(s)
- Richard W Rutherford
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA.
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, 2535 S. Downing Street, Denver, CO 80210, USA; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
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Reduction of adhesion formation after knee surgery in a rat model by botulinum toxin A. Biosci Rep 2017; 37:BSR20160460. [PMID: 28115594 PMCID: PMC5398255 DOI: 10.1042/bsr20160460] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 11/17/2022] Open
Abstract
Adhesion of the knee is a major concern after knee surgery, the treatment of which is difficult. Botulinum toxin A (BTX-A) injection is demonstrated as efficient in treating knee adhesion after surgery. However, the treatment outcomes and the mechanism of action are not yet determined. The aim of the present study was to examine the effects and molecular mechanism of a BTX-A treatment in preventing adhesion of the knee. Twenty-four Wistar rats were randomly divided into a BTX-A treatment group and a control group. BTX-A or saline was injected into the cavity of the knee in the BTX-A treatment or control group respectively. Gross and histopathological examinations of interleukin 1 (IL-1) and fibroblast growth factor (FGF) levels, as well as fibroblast cell numbers, were assessed in the knee intra-articular adhesions in each group 6 weeks after recovery from the surgery. Macroscopic observations showed a significant reduction in adhesion severity in the BTX-A treatment group compared with the control group. In addition, the levels of IL-1 and FGF were lower and the number of fibroblasts was smaller in the BTX-A treatment group compared with those in the control group. BTX-A prevented intra-articular adhesion of knee in the rats, which might be associated with reduced expressions of IL-1 and FGF.
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Smith EB, Shafi KA, Greis AC, Maltenfort MG, Chen AF. Decreased flexion contracture after total knee arthroplasty using Botulinum toxin A: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2016; 24:3229-3234. [PMID: 27515301 DOI: 10.1007/s00167-016-4277-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Flexion contracture after total knee arthroplasty (TKA) can cause significant dissatisfaction. Botulinum toxin A has shown improved extension in patients with spastic flexion contractures after TKA. The purpose of this study was to evaluate whether Botulinum toxin A improves knee extension for any patient with flexion contractures following TKA. METHODS A prospective, double-blinded, randomized controlled trial was conducted. Fourteen patients (15 knees), with a flexion contracture (≥10°) one month postoperatively, were randomized to receive either Botulinum toxin A or saline placebo to the affected hamstrings. The subject, surgeon, and administering physiatrist were blinded to the treatment group throughout the study. Subject range of motion (ROM) was evaluated at 1, 6, and 12 months following injection. Differences were tested using mixed-effects regression to control for multiple measurements. RESULTS The initial post-operative flexion contracture averaged 19° ± 6° in the Botulinum toxin A group and 13° ± 3° in the saline group. Injections were performed 53 and 57 days after TKA in the Botulinum toxin A and saline groups, respectively. Post-injection extension improved to an average of 8, 5, and 1 degrees for BTX and 4, 2, and 1 degrees for SAL, at 1, 6, and 12 months, respectively, compared to pre-injection extension (p < 0.0001). Improvement in knee extension at 1 year improved 18° ± 7.5° for Botulinum toxin A and 12° ± 2° for saline (p = 0.04). No complications resulted from either injection. CONCLUSION Patients who received Botulinum toxin A or placebo were able to achieve near full extension one year after surgery. There was a statistically significant improvement in the amount of extension achieved at 1 year with Botulinum toxin A, but this may be of little clinical significance. Since achieving full extension is important for patient function and satisfaction, novel techniques to address this issue deserve special attention. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Eric B Smith
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA.
| | - Karim A Shafi
- Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ari C Greis
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
| | - Mitchell G Maltenfort
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
| | - Antonia F Chen
- Rothman Institute, 1118 West Baltimore Pike Health Center 4, 3rd Floor Media, Philadelphia, PA, 19063, USA
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Atluri K, De Jesus AM, Chinnathambi S, Brouillette MJ, Martin JA, Salem AK, Sander EA. Blebbistatin-Loaded Poly(d,l-lactide- co-glycolide) Particles For Treating Arthrofibrosis. ACS Biomater Sci Eng 2016; 2:1097-1107. [PMID: 33445238 DOI: 10.1021/acsbiomaterials.6b00082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Joint immobility is a debilitating complication of articular trauma that is characterized by thickening and stiffening of the joint capsule and the formation of fibrotic lesions inside joints. Capsule release surgery can temporarily restore mobility, but contraction often recurs due to the contractile activities of fibroblasts, which exert tension on the capsule ECM via nonmuscle myosin II. Based on these findings we hypothesized that blebbistatin, a drug that reversibly inhibits the activity of this protein, would relax ECM tension imposed by fibroblasts and reduce fibrosis. In this study, we characterized the effectiveness of blebbistatin as an anticontractile treatment. Given that sustained suppression of contractile activity may be required to achieve capsule release and reduce fibrosis, we compared the effects on fibroblast-mediated collagen ECM displacement of blebbistatin-loaded poly(lactide-co-gylcolide) (PLGA) particles versus bolus blebbistatin dosing. Time-lapse imaging of fluorescent microspheres embedded in collagen gels confirmed that PLGA/blebbistatin inhibited force generation and reduced both gel displacement and rate of displacement. In addition, collagen production at 10 days was significantly reduced. Taken together, these data indicate that blebbistatin-loaded PLGA particles can be used to inhibit fibroblast force-generation and reduce collagen production and lay the foundation for optimization of drug delivery technology for treating arthrofibrosis.
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Affiliation(s)
- K Atluri
- Division of Pharmaceutics and Translational Therapeutics, University of Iowa College of Pharmacy, 115 South Grand Avenue, Iowa City, Iowa 52242, United States
| | - A M De Jesus
- Department of Biomedical Engineering, University of Iowa College of Engineering, 1402 Seamans Center, Iowa City, Iowa 52242, United States
| | - S Chinnathambi
- Department of Biomedical Engineering, University of Iowa College of Engineering, 1402 Seamans Center, Iowa City, Iowa 52242, United States
| | - M J Brouillette
- Department of Orthopaedics and Rehabilitation, University of Iowa Roy J and Lucille A Carver College of Medicine, 25 South Grand Avenue, Iowa City, Iowa 52242, United States
| | - J A Martin
- Department of Orthopaedics and Rehabilitation, University of Iowa Roy J and Lucille A Carver College of Medicine, 25 South Grand Avenue, Iowa City, Iowa 52242, United States
| | - A K Salem
- Division of Pharmaceutics and Translational Therapeutics, University of Iowa College of Pharmacy, 115 South Grand Avenue, Iowa City, Iowa 52242, United States.,Department of Biomedical Engineering, University of Iowa College of Engineering, 1402 Seamans Center, Iowa City, Iowa 52242, United States
| | - E A Sander
- Department of Biomedical Engineering, University of Iowa College of Engineering, 1402 Seamans Center, Iowa City, Iowa 52242, United States
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Pereira LC, Jolles BM. The effect of end-of-range grade A+ knee mobilisation following acute primary total knee arthroplasty: A randomised controlled trial. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2015. [DOI: 10.12968/ijtr.2015.22.12.583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background/Aims: Although the number of total knee arthroplasty procedures being performed is increasing worldwide, the rehabilitation protocols following surgery are poorly studied in the literature. Research suggests that exercise therapy and joint mobilisation are recommended in the later stages of osteoarthritis. However, best practice for rehabilitation in the immediate postoperative period is yet to be determined. This prospective randomised controlled trial examined whether adding grade A+ joint mobilisation to the standard in-hospital rehabilitative approach would increase pain (based on recordings of pain intensity on the visual analogue scale) and improve range of motion in the knee. Methods: Participants (n=32; mean±SD age: 71.1± 8.9 years) undergoing primary total knee arthroplasty at a university hospital were randomly assigned to two equal groups. Measurements were recorded before surgery and on the first, third and seventh days following total knee arthroplasty. All participants received standard care postoperatively, with participants in the experimental group receiving additional grade A+ joint mobilisation for knee flexion and extension twice a day for 20 minutes using the JAS Knee system (Joint Active Systems®, Effingham, Illinois). Results: There were no statistically significant differences in visual analogue scale scores or range of motion in all measurements (p > 0.05). Increased range of motion at a faster pace was observed in the obese subgroup of patients (p = 0.016). Other factors such as age, body mass index, type of anaesthesia and implant model did not influence the final outcome. Conclusions: Early grade A+ joint mobilisation combined with the standard in-hospital rehabilitative approach is safe to be used during the post-acute phase of rehabilitation after total knee arthroplasty. Despite increasing trends in the obese subgroup of patients, adding grade A+ joint mobilisation to the standard protocol did not significantly improve overall range of motion. The results of this study and heterogeneities in the literature identify the need for further research and development in this area.
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Affiliation(s)
- Luis C Pereira
- Physiotherapist, University Hospital of Lausanne, Swiizerland
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Yoo JH, Oh JC, Oh HC, Park SH. Manipulation under Anesthesia for Stiffness after Total Knee Arthroplasty. Knee Surg Relat Res 2015; 27:233-9. [PMID: 26676186 PMCID: PMC4678244 DOI: 10.5792/ksrr.2015.27.4.233] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/01/2015] [Accepted: 08/17/2015] [Indexed: 11/18/2022] Open
Abstract
PURPOSE This study evaluated the incidence of manipulation under anesthesia (MUA) for stiffness after total knee arthroplasty (TKA) and the degree of joint motion recovery after MUA. MATERIALS AND METHODS A total of 4,449 TKAs (2,973 patients) were performed between March 2000 and August 2014. Cases that underwent MUA for stiffness after TKA were reviewed. TKAs were performed using the conventional procedure in 329 cases and using the minimally invasive procedure in 4,120 cases. The preoperative range of joint motion, timing of manipulation, diagnosis and the range of joint motion before and after MUA were retrospectively investigated. RESULTS MUA was carried out in 22 cases (16 patients), resulting in the incidence of 0.5%. The incidence after the conventional procedure was 1.2% and 0.4% after the minimally invasive procedure. In the manipulated knees, the preoperative range of motion (ROM) was 102.5°±26.7°, and the preoperative diagnosis was osteoarthritis in 19 cases, rheumatoid arthritis in two, and infection sequela in one. MUA was performed 4.7±3.0 weeks after TKA. The average ROM was 64.5°±13.5° before manipulation. At an average of 64.3±41.3 months after manipulation, the ROM was recovered to 113.4°±31.2°, which was an additional 49.9° improvement in flexion. CONCLUSIONS The satisfactory recovery of joint movement was achieved when MUA for stiffness was performed relatively early after TKA.
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Affiliation(s)
- Ju-Hyung Yoo
- Department of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Jin-Cheol Oh
- Department of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Hyun-Cheol Oh
- Department of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Sang-Hoon Park
- Department of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
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Williams FM, Kalson NS, Fabiane SM, Mann DA, Deehan DJ. Joint Stiffness Is Heritable and Associated with Fibrotic Conditions and Joint Replacement. PLoS One 2015. [PMID: 26197488 PMCID: PMC4509645 DOI: 10.1371/journal.pone.0133629] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Joint stiffness is a common, debilitating, age-related symptom, which may be seen after total joint replacement (TJR). Stiffness also occurs in fibrotic conditions such as shoulder capsulitis and Dupuytren's contracture. We speculated that the two traits (TJR and fibrotic disease) are linked pathogenically. METHODS Using the TwinsUK NIHR BRC BioResource we tested the hypotheses that 1) joint (hip and knee) stiffness, TJR (hip and knee), and fibrotic conditions are associated and 2) genetic factors contribute to them. RESULTS Participating twins (n = 9718) had completed self-reported questionnaires on the traits of interest. All three traits were significantly associated with increasing age and body mass index (BMI), as well as female sex, on univariate analysis. Multivariable logistic regression analyses showed a significant association between TJR and joint stiffness (OR = 3.96, 95% confidence interval, CI 2.77-5.68) and between fibrotic conditions and joint stiffness (OR = 2.39, 1.74-3.29), adjusting for age, sex, BMI and twin relatedness. Monozygotic versus dizygotic intraclass correlations gave heritability estimates for TJR = 46% and joint stiffness = 32%. CONCLUSION That fibrotic conditions, joint stiffness and TJR are significantly associated suggests a common disease process, possibly fibrosis, which is genetically mediated.
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Affiliation(s)
- Frances M. Williams
- Department of Twin Research & Genetic Epidemiology, King’s College London, London United Kingdom
| | - Nicholas S. Kalson
- Department of Orthopaedics, The Royal Victoria Infirmary and the Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Fibrosis Research Group, Institute of Cellular Medicine, University of Newcastle, Newcasltle upon Tyne, United Kingdom
- * E-mail:
| | - Stella M. Fabiane
- Department of Twin Research & Genetic Epidemiology, King’s College London, London United Kingdom
| | - Derek A. Mann
- Fibrosis Research Group, Institute of Cellular Medicine, University of Newcastle, Newcasltle upon Tyne, United Kingdom
| | - David J. Deehan
- Department of Orthopaedics, The Royal Victoria Infirmary and the Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Fibrosis Research Group, Institute of Cellular Medicine, University of Newcastle, Newcasltle upon Tyne, United Kingdom
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Lavernia CJ, Villa JM, Iacobelli DA. What is the role of mental health in primary total knee arthroplasty? Clin Orthop Relat Res 2015; 473:159-63. [PMID: 25002217 PMCID: PMC4390930 DOI: 10.1007/s11999-014-3769-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Psychological distress has been associated with inferior scores for pain after total knee arthroplasty (TKA). However, its relationships with scores and arthrofibrosis after TKA remain unclear. QUESTION/PURPOSES The objectives of this study were (1) to assess patient-reported outcomes (PROs), including Knee Society (KS) scores, of those patients who developed arthrofibrosis and underwent manipulation and compare them with a control group; and (2) in patients with arthrofibrosis who underwent manipulation, to determine PROs and KS scores of those with psychological distress and those without it. METHODS During a 17-year period (August 1992 to October 2009), a total of 1952 TKAs were performed and included in our prospectively collected joint registry database; 1248 procedures had a postoperative followup of at least 2 years (mean, 5 years; range, 2-16 years). Among them, 57 knees (53 patients) developed arthrofibrosis and underwent manipulation under anesthesia after the index procedure. This group was compared with a matched group (by age, sex, race, and ethnicity) of 63 knees (58 patients) without arthrofibrosis. Demographics, preoperative and postoperative Quality of Well-Being scale (QWB-7), SF-36, WOMAC, and The KS knee and function scores were prospectively collected and retrospectively analyzed. Patients with <52 points on the SF-36 Mental Component Summary subscale were considered in psychological distress for all comparisons. Active knee flexion and KS range of motion (ROM) were used as objective motion measures. Minimum followup was 2 years (mean, 5 years; range, 2-16 years). RESULTS Patients who developed arthrofibrosis had worse KS function scores before TKA than did patients in the nonarthrofibrosis control group (mean 27, SD 20.5 versus 37, SD 19.3; p=0.006). Patients with arthrofibrosis and psychological distress, before TKA and when compared with patients with arthrofibrosis but without distress, had worse QWB-7 (0.490 versus 0.547; p<0.001) and worse WOMAC stiffness (4.92, versus 3.22; p=0.005), respectively. Postoperatively, patients with arthrofibrosis and distress also had worse QWB-7 (0.537 versus 0.627; p=0.002). CONCLUSIONS Patients with arthrofibrosis and psychological distress perceived themselves preoperatively as having worse knee and overall health status than those with arthrofibrosis but without distress. In view of this, expectations after TKA should be particularly addressed in those patients with poor function and psychological distress. Further investigations, making use of tools specifically designed to ascertain depression, are warranted. LEVEL OF EVIDENCE Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carlos J. Lavernia
- />The Center for Advanced Orthopedics at Larkin, 7000 SW 62nd Avenue, Suite 600, South Miami, FL 33143 USA
| | - Jesus M. Villa
- />Arthritis Surgery Research Foundation, South Miami, FL USA
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Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty? Clin Orthop Relat Res 2015; 473:143-7. [PMID: 25002219 PMCID: PMC4390931 DOI: 10.1007/s11999-014-3772-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND One of the most important goals of primary total knee arthroplasty (TKA) is to achieve a functional range of motion (ROM). However, up to 20% of patients fail to do so, which can impair activities of daily living. QUESTIONS/PURPOSES The purpose of this study was to evaluate the effect of various (1) demographic factors; (2) comorbidities; and (3) knee-specific factors on the frequency of manipulation under anesthesia, which was used as an indicator of knee stiffness after a primary TKA. METHODS We evaluated the registries of two high-volume centers and reviewed all 3182 TKAs that were performed between 2005 and 2011 to identify all patients who had undergone manipulation under anesthesia (MUA). A total of 156 knees in 133 patients underwent MUA after an index arthroplasty. These patients were compared in a one-to-four ratio with a group of patients with satisfactory ROM drawn from the same database who met prespecified criteria and who had not undergone MUA. Effects of various factors, including age, sex, body mass index, race, comorbidities, and the underlying cause of knee arthritis, were compared between these two cohorts using multivariable logistic regressions. RESULTS After controlling for various confounding, nonwhite race was associated with an increase (odds ratio [OR], 2.01; p=0.03), and age≥65 years (OR, 0.17; 95% confidence interval [CI], 0.04-0.74; p=0.0179) was associated with a reduction in the incidence of MUA. In comorbidities, diabetes (OR, 1.72; 95% CI, 1.02-2.32; p=0.03), high cholesterol levels (OR, 2.70; p=0.03), and tobacco smoking (OR, 1.59; 95% CI, 1.03-2.47; p=0.03) were associated with an increase in frequency of MUA. In knee-specific factors, preoperative knee ROM of less than 100° (OR, 0.80; p<0.0001) and knee osteonecrosis (p=3.61; 95% CI, 1.29-10.1; p=0.014) were associated with increased frequency of MUA. CONCLUSIONS We identified several demographic, medical, and knee-specific factors that were associated with poor postoperative ROM in our patients undergoing TKA. Patients who have multiple risk factors may benefit from preoperative counseling to set realistic ROM expectations. LEVEL OF EVIDENCE Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Manó S, Pálinkás J, Szabó J, Nagy JT, Bakó K, Csernátony Z. Application of a vibrating device for the prevention of flexion contracture after total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:167-72. [PMID: 24777702 DOI: 10.1007/s00590-014-1466-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/15/2014] [Indexed: 11/26/2022]
Abstract
Our research team developed a new, heel support-based static and vibrating complementary treatment method for the prevention of flexion contractures often arising after total knee arthroplasty. We examined the efficiency of the method performing a randomized clinical trial with 144 patients undergoing total knee replacement. Seventy-nine patients were treated for 1 week with a generally used continuous passive motion (CPM) device complemented with our new method, which was based on the application of a static and an alternating heel support. The 65 patients in the control group were treated with only a CPM device as in usual clinical practice. The femoro-tibial angle was measured immediately following surgery, and after 1 week of treatment. At the end of the 1 week treatment, the target extension angle (0° ± 5°) was achieved by significantly more patients with the new combined method. This way the elevated heel rest and the vibrating device proved to be a good adjunct treatment along with the CPM used in routine clinical practice in the first place for the prevention of flexion contractures.
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Affiliation(s)
- Sándor Manó
- Department of Orthopaedic Surgery, Clinical Center, University of Debrecen, 98 Nagyerdei krt, Debrecen, 4032, Hungary,
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McElroy MJ, Johnson AJ, Zywiel MG, Mont MA. Devices for the prevention and treatment of knee stiffness after total knee arthroplasty. Expert Rev Med Devices 2014; 8:57-65. [DOI: 10.1586/erd.10.71] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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SOLIMENO L, LUCK J, FONDANESCHE C, MCLAUGHLIN P, NARAYAN P, SABBOUR A, SOHAIL T, PASTA G. Knee arthropathy: when things go wrong. Haemophilia 2012; 18 Suppl 4:105-11. [DOI: 10.1111/j.1365-2516.2012.02834.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naylor JM, Ko V, Rougellis S, Green N, Hackett D, Magrath A, Barnett A, Kim G, White M, Nathan P, Harmer A, Mackey M, Heard R, Yeo AET, Adie S, Harris IA, Mittal R, Cho A. Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 1. J Eval Clin Pract 2012; 18:644-51. [PMID: 21414107 DOI: 10.1111/j.1365-2753.2011.01655.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Knee range of motion (ROM) at the point of discharge from acute care is used as a clinical indicator to benchmark performance between hospital services after total knee replacement (TKR). The utility of the current benchmark, including whether discharge ROM varies between hospitals, is unknown. This study aimed to determine whether the benchmark [≥80 degrees flexion and ≤5 degrees fixed flexion (extension)] is realistic and whether the service provider is a predictor of knee ROM. METHODS A prospective, observational cohort study was conducted involving 176 TKR patients from four hospitals. Knee ROM was photographically assessed preoperatively and at discharge. 'Hospital', typical patient demographic data and preoperative ROM were identified a priori as potential predictors of knee ROM. RESULTS Overall, 2% [95% CI (confidence interval) 1-6] of patients attained the ROM benchmark. Individual hospital attainment of the benchmark ranged 0-7% with a significant difference (P = 0.047) evident between the best performer and the remaining hospitals. The overall rates of attainment of the individual flexion (25%, 95% CI 19-32) and extension (15%, 95% CI 10-21) components were similarly low, although the scatter between hospitals was large [flexion (2-47%); extension (8-44%)]. Preoperative flexion and hospital were significant (P = 0.002) predictors of discharge flexion, explaining 21% of the variance. Similarly, hospital and preoperative extension together with gender were significant (P < 0.001) predictors of discharge extension, explaining 26% of the variance. CONCLUSIONS A small minority of patients attained the knee ROM benchmark, indicating the existing standard is unrealistic. Nevertheless, that 'hospital' is an important predictor confirms the potential of ROM for benchmarking purposes. Differences in physiotherapy practices may contribute to inter-hospital variation in discharge knee ROM together with other undefined factors. The causal relationships explaining the variation and the relationship between discharge ROM and longer-term outcome are avenues for future exploration which will help define the clinical relevance of the indicator.
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Affiliation(s)
- Justine M Naylor
- South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
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A comparative study of the preventive effects of mitomycin C and chitosan on intraarticular adhesion after knee surgery in rabbits. Cell Biochem Biophys 2012; 62:101-5. [PMID: 22170604 DOI: 10.1007/s12013-011-9266-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
We sought to compare the preventive effects of mitomycin-C(MMC) and chitosan on intraarticular adhesion after knee surgery in rabbits. For this purpose, 48 New-Zealand rabbits were randomly and equally divided into MMC, chitosan, and control groups. Approximately 10 × 10 mm(2) of the cortical bone was removed from both sides of left femoral condyle and the cancellous bone underneath was exposed. The decorticated areas were topically treated with MMC and chitosan while control group was treated with physiological saline. The lower left limb was fixed in flexed position with Kirschner-wire for 4 weeks postoperatively. After 4 weeks, gross and histopathological examination, biochemical analysis, and fibroblast counts were performed on knee intraarticular adhesion in each group. The data show mild membrane-like fibrous intraarticular adhesion, presented in loose, in MMC group. There was moderate intraarticular adhesion in chitosan group while in controls; there was large-size compact fibrous tissue adhesion. Hydroxyproline contents and fibroblast quantity of MMC and chitosan groups were lower (P < 0.05) than that of control group. We, therefore, concluded that MMC and chitosan could prevent intraarticular adhesion of the knee in rabbits by inhibiting fibroblast proliferation and reducing collagenous fiber formation while MMC had a better preventive effect than that of chitosan.
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Abstract
BACKGROUND Conservative treatment protocols to effectively treat knee flexion motion restrictions are dependent in part on the torque applied to the joint. HYPOTHESES Clinicians apply greater torque with the test leg in a simulated prone position than in a seated position. Clinicians also apply greater torque than a dynamic splint or a static progressive stretch brace. Finally, clinicians apply a torque equal to the high-intensity stretch device. STUDY DESIGN bservational study. METHODS An instrumented test leg was used to record peak torque applied by 14 licensed clinicians (7 women, 7 men; age, 44.3 ± 10.2 years; height, 172.9 ± 13.2 cm; weight, 72.6 ± 13.0 kg) during knee flexion mobilizations and 3 types of mechanical therapy (dynamic splint, static progressive stretch, and high-intensity stretch). RESULTS The dynamic splint applied 5.1 ± 0.1 N·m, while the static progressive stretch brace applied 20.8 ± 2.2 N·m. Clinicians applied 49.5 ± 22.4 N·m with the test leg in a seated position and 55.8 ± 22.0 N·m with the leg in a prone position. The high-intensity stretch device applied up to 214.7 ± 29.2 N·m. All comparisons were statistically significant (P ≤ 0.02) with the exception of the 2 testing positions (P = 0.94). CONCLUSIONS The results demonstrate that the torques applied to the knee differ between passive stretching therapies. Clinicians should be cognizant of these torque differences when constructing treatment protocols for patients with limited knee flexion range of motion.
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Affiliation(s)
| | - Cale A. Jacobs
- ERMI, Inc, Atlanta, Georgia
- Address correspondence to Cale A. Jacobs, PhD, ERMI, Inc, 441 Armour Place NE, Atlanta, GA 30324 (e-mail: )
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The painful knee after TKA: a diagnostic algorithm for failure analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19:1442-52. [PMID: 21822665 DOI: 10.1007/s00167-011-1634-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
Abstract
Pain after total knee arthroplasty (TKA) represents a common observation in about 20% of the patients after surgery. Some of these painful knees require early revision surgery within 5 years. Obvious causes of failure might be identified with clinical examinations and standard radiographs only, whereas the unexplained painful TKA still remains a challenge for the surgeon. It is generally accepted that a clear understanding of the failure mechanism in each case is required prior considering revision surgery. A practical 10-step diagnostic algorithm is described for failure analysis in more detail. The evaluation of a painful TKA includes an extended history, analysis of the type of pain, psychological exploration, thorough clinical examination including spine, hip and ankle, laboratory tests, joint aspiration and test infiltration, radiographic analysis and special imaging techniques. It is also important to enquire about the length and type of conservative therapy. Using this diagnostic algorithm, a sufficient failure analysis is possible in almost all patients with painful TKA.
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Arthroscopic arthrolysis for arthrofibrosis of the knee after total knee replacement. HSS J 2011; 7:130-3. [PMID: 22754412 PMCID: PMC3145854 DOI: 10.1007/s11420-011-9202-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 03/30/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arthrofibrosis is an uncommon but potentially debilitating complication following total knee replacement which can result in chronic pain and poor recovery of range of motion. The treatment of this condition remains difficult and controversial. QUESTIONS/AIMS OF STUDY: We reviewed our results of arthroscopic arthrolysis of arthrofibrosis of the knee after total knee replacement to assess the potential for this technique to improve range of motion and provide improvement in knee function and pain as measured by the Knee Society Score (KSS). METHODS Eight patients were treated for arthrofibrosis after total knee replacement with arthroscopic management. The patients included five females and three males. The average age was 67.4 years. Initial rehabilitation efforts, which included manipulation under anesthesia, had failed. Arthroscopic arthrolysis was performed to release fibrous bands in the suprapatellar pouch and to reestablish the medial and lateral gutters. Lateral release of the patellar retinaculum was performed. Intensive physiotherapy and continuous passive motion began immediately post-operatively. The average follow-up was 37.4 months. The KSS was used for assessment of pain and function before arthroscopy and at the latest follow-up. RESULTS Six of the eight patients experienced improvement in the KSS. The average functional score showed improvement from 68 points pre-operatively to 86 at the time of final follow-up. The average pain scores improved from 30 points pre-operatively to 41 at the time of final follow-up. CONCLUSIONS Arthroscopic management can be beneficial for patients suffering from arthrofibrosis following total knee replacement. Pain and KSS clinical scores can markedly improve.
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Schallberger A, Jacobi M, Wahl P, Maestretti G, Jakob RP. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years. Knee Surg Sports Traumatol Arthrosc 2011; 19:122-7. [PMID: 20821190 DOI: 10.1007/s00167-010-1256-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Accepted: 08/16/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE High tibial osteotomy is a well-established method for the treatment of medial unicompartmental osteoarthritis of the knee. METHODS We analysed retrospectively the long-term outcome of open and closing wedge valgisation high tibial osteotomies. Out of 71 patients, 54 (76%) were available for the study. Survival rates and the influence of the osteotomy type were investigated. Secondary outcome measures were the course of radiological leg axis and osteoarthritis as well as score outcomes. RESULTS During a median follow-up of 16.5 years (IQR 14.5-17.9; range 13-21), 13 patients (24%) underwent conversion to total knee arthroplasty; the other 41 patients (76%, survivor group) were studied by score follow-up as well as clinical and radiological examinations. Osteotomy survival was of 98% after 5 years, 92% after 10 years and 71% after 15 years. Comparison between open and closing wedge high tibial osteotomy showed no significant difference in survival and score outcome. The median Visual Analogue Score (VAS) was 0 (IQR 0-1; range 0-4), the Satisfaction Index was 80% (IQR 63-89; range 30-100), the median Knee Injury and Osteoarthritis Outcome Score was 71 (IQR 49-82; range 9-100) and the median Western Ontario and McMaster Universities Osteoarthritis index was 84 (IQR 66-96; range 9-100). Radiological evaluation showed only a slight progression of the degree of osteoarthritis following the Kellgren and Lawrence classification. In each case, the axis passed through the healthy compartment or at least through the centre of the knee. CONCLUSION Open and closing wedge high tibial osteotomies are a successful choice of treatment for unicompartmental degenerative diseases with associated varus in active patients. Survival of both techniques is comparable in our series and is associated with low pain scores, high satisfaction and high activity levels of the survivors.
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Affiliation(s)
- Alex Schallberger
- Department of Orthopaedic Surgery, Hôpital Cantonal Fribourg, 1708 Fribourg, Switzerland
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Stratford PW, Kennedy DM, Robarts SF. Modelling knee range of motion post arthroplasty: clinical applications. Physiother Can 2010; 62:378-87. [PMID: 21886379 DOI: 10.3138/physio.62.4.378] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To model change in knee range of motion (ROM) post total knee arthroplasty (TKA) and to show how this information can be incorporated into clinical decision making. METHOD We applied a variable-occasion repeated-measures study design. Patients' knee flexion and extension ROM were assessed pre- and post arthroplasty over the ensuing 60 weeks. We examined change in ROM post TKA using linear and nonlinear mixed-effects modelling, and examined whether age, body mass index, prearthroplasty ROM, and gender were determinants of recovery in post-arthroplasty ROM. RESULTS Of 93 eligible patients, 74 provided pre- and post-arthroplasty data. A random intercept nonlinear model fit the flexion data best, and a random intercept linear model fit the extension data best. Pre-arthroplasty ROM was found to be a determinant of recovery in ROM post arthroplasty. This finding was common to both flexion and extension models. CONCLUSIONS Our study showed that the greatest improvement for knee ROM took place during the first 12 weeks post arthroplasty. Of the variables examined, only pre-arthroplasty ROM was a determinant of outcome (p<0.05). The study results provide clinicians with data to determine expected rates of improvement for patients as well as the projected maximum ROM, facilitating improved clinical decision making.
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Affiliation(s)
- Paul W Stratford
- Paul W. Stratford, PT, MSc: Professor, School of Rehabilitation Science; Associate Member, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
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Dempsey AL, Branch TP, Mills T, Karsch RM. High-intensity mechanical therapy for loss of knee extension for worker's compensation and non-compensation patients. BMC Sports Sci Med Rehabil 2010; 2:26. [PMID: 20939921 PMCID: PMC2964642 DOI: 10.1186/1758-2555-2-26] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 10/12/2010] [Indexed: 12/31/2022]
Abstract
Background Knee flexion contractures have been associated with increased pain and a reduced ability to perform activities of daily living. Contractures can be treated either surgically or conservatively, but these treatment options may not be as successful with worker's compensation patients. The purposes of retrospective review were to 1) determine the efficacy of using adjunctive high-intensity stretch (HIS) mechanical therapy to treat flexion contractures, and 2) compare the results between groups of worker's compensation and non-compensation patients. Methods Fifty-six patients (19 women, 37 men, age = 51.5 ± 17.0 years) with flexion contractures were treated with HIS mechanical therapy as an adjunct to outpatient physical therapy. Mechanical therapy was only prescribed for those patients whose motion had reached a plateau when treated with physical therapy alone. Patients were asked to perform six, 10-minute bouts of end-range stretching per day with the ERMI Knee Extensionater(r) (ERMI, Inc., Atlanta, GA). Passive knee extension was recorded during the postoperative visit that mechanical therapy was prescribed, 3 months after beginning mechanical therapy, and at the most recent follow-up. We used a mixed-model 2 × 3 ANOVA (group × time) to evaluate the change in passive knee extension between groups over time. Results Regardless of group, the use of adjunctive HIS mechanical therapy resulted in passive knee extension deficits that significantly improved from 10.5° ± 5.2° at the initial visit to 2.6° ± 3.5° at the 3 month visit (p < 0.001). The degree of extension was maintained at the most recent follow-up (2.0° ± 2.9°), which was significantly greater than the initial visit (p < 0.001), but did not differ from the 3 month visit (p = 0.23). The gains in knee extension did not differ between worker's compensation and non-compensation patients (p = 0.56). Conclusions We conclude that the adjunctive use of HIS mechanical therapy is an effective treatment option for patients with knee flexion contractures, regardless of whether the patient is being treated as part of a worker's compensation claim or not.
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Affiliation(s)
- Amanda L Dempsey
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, 138 Leader Ave,, Lexington, KY 40506-9983, USA.
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Stephenson JJ, Quimbo RA, Gu T. Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population. Curr Med Res Opin 2010; 26:1109-18. [PMID: 20225995 DOI: 10.1185/03007991003676479] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if differences in costs and risks of re-hospitalization and/or re-operation exist between arthrofibrosis patients treated with low intensity stretch (LIS) or high intensity stretch (HIS) mechanical therapies, or physical therapy alone (No Device). STUDY DESIGN This observational cohort study utilized administrative claims data to identify arthrofibrosis patients, age <65 years, with continuous enrollment for the 6 months prior to and following the index knee event date. METHODS The index knee event was defined as the knee injury/surgery preceding device use for the LIS and HIS groups and the knee injury/surgery prior to the diagnosis of arthrofibrosis for the No Device group. Knee-attributable medical costs (KAMC), accrued over 6-month pre- and post-index periods, as well as risks of re-operation, re-injury, and re-hospitalization were compared between groups. Multivariate models were used to evaluate group differences in utilization and costs when controlling for age, sex, and comorbidities. RESULTS A total of 60 359 patients (143 HIS; 607 LIS; 59 609 No Device) met the inclusion criteria. Unadjusted post-index KAMC were significantly less (p < 0.0001) among HIS patients ($8213 +/- 10 576) relative to LIS ($16 861 +/- 17 857) and No Device ($9345 +/- 14 120) patients. A significantly greater percentage of LIS Device patients had total knee replacements than HIS Device or No Device patients, and the LIS group had a significantly higher percentage of patients with musculoskeletal disease. When controlling for these group differences, the multivariate predictive model results were similar to the unadjusted results, with greater post-index KAMC for the LIS patients (24%, p = 0.025) and No Device (9%, p = 0.323) relative to HIS patients. No Device patients were 71% (p < 0.0001) more likely to have a subsequent knee event than HIS patients, and HIS patients had significantly lower rates of re-hospitalization than LIS and No Device patients (p < 0.0001). CONCLUSIONS Patients treated with HIS mechanical therapy demonstrated significantly reduced rates of re-hospitalization which corresponded to reduced knee-attributable medical costs. LIMITATIONS Limitations of this study include those inherent in the use of retrospective claims data to identify the cohorts and for analytic purposes. The authors attempted to control for these as much as possible with the multivariate analyses, and inclusion of the model covariates specified above demonstrated a scaled deviance of 1.16 indicating a reasonable goodness-of-fit for the selected model covariates.
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McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave A. Evaluation of a custom device for the treatment of flexion contractures after total knee arthroplasty. Clin Orthop Relat Res 2009; 467:1485-92. [PMID: 19333671 PMCID: PMC2674191 DOI: 10.1007/s11999-009-0804-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 03/09/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Knee flexion contractures can severely impair function after total knee arthroplasties. We evaluated the use of a custom-molded knee device to treat 47 patients who had knee flexion contractures (mean, 22 degrees; range, 10 degrees-40 degrees) after primary or revision total knee arthroplasties and who had failed conventional therapeutic methods. The device was used for 30 to 45 minutes per session two to three times per day in conjunction with standard physical therapy modalities two to three times per week. Twenty-seven of 29 patients who underwent primary total knee arthroplasty and 13 of 18 patients who underwent revisions achieved full extension after a mean treatment time of 9 weeks (range, 6-16 weeks). Full knee extension was maintained at a minimum followup of 18 months (mean, 24 months; range, 18-36 months). The mean Knee Society knee and functional scores improved from 50 points and 34 points to 91 points and 89 points, respectively. This protocol had comparable rates of improvement in knee extension with less treatment time when compared with other nonoperative treatments reported in the literature. The custom knee device may be a useful adjunct to a physical therapy regimen for knee flexion contractures after total knee arthroplasty. LEVEL OF EVIDENCE Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mike S. McGrath
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Michael A. Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Junaed A. Siddiqui
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Erin Baker
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Anil Bhave
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
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Bonutti PM, McGrath MS, Ulrich SD, McKenzie SA, Seyler TM, Mont MA. Static progressive stretch for the treatment of knee stiffness. Knee 2008; 15:272-6. [PMID: 18538574 DOI: 10.1016/j.knee.2008.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 03/27/2008] [Accepted: 04/11/2008] [Indexed: 02/02/2023]
Abstract
Persistent knee stiffness is common after knee arthroplasties, cruciate ligament repairs, and trauma. Static progressive stretch protocols have shown success in treating contractures of the elbow, ankle, and knee in case reports and small case series. This study evaluated static progressive stretch as a treatment method for patients who had refractory knee stiffness, and compared the outcomes to published results of other therapeutic modalities. Forty-one patients who had knee stiffness and who had not improved with conventional physical therapy modalities were treated with a patient-directed orthosis that utilized the principles of static progressive stretch. After a mean of 9 weeks of use (range, 3 to 27 weeks), the total arc of motion increased by a mean of 33 degrees (range, 0 to 85 degrees ). Forty of 41 patients had increased motion at a mean final follow-up time of 1 year (range, 6 months to 2 years), and 93% were satisfied with the results. The outcomes were comparable to other nonoperative treatments reported in the literature, but the results in the present study occurred in a shorter mean treatment time. An orthosis that utilizes the principles of static progressive stretch may be a successful treatment for improving the range of motion and satisfaction of patients who have knee contractures.
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Affiliation(s)
- Peter M Bonutti
- Bonutti Clinic, 1303 West Evergreen Avenue, Effingham, Illinois 62401, United States
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