Physical performance tests, self-reported outcomes, and accidental falls before and after total knee arthroplasty: an exploratory study

Association between postoperative fall history and toe grip strength in patients after total knee arthroplasty: A prospective observational study

BACKGROUND

Factors associated with falls after total knee arthroplasty (TKA) have been rarely reported. The aim of this study was to identify factors that influence the incidence of falls after TKA, focusing on toe grip strength (TGS) in particular, which has been associated with falls in older adults.

METHODS

217 patients who underwent TKA were included and followed up for 1 year. Main study outcome measures were the presence or absence of falls within 1 year after TKA. Multiple logistic regression analysis was used with postoperative falls as the dependent variable and preoperative falls and postoperative TGS on the affected sides as independent variables.

RESULTS

170 (43 and 127 in the fall and non-fall groups) patients were included in the analysis. The presence of a preoperative falls history before TKA and a weak postoperative affected TGS indicated an increased susceptibility of the patient to fall postoperatively.

CONCLUSIONS

Results of the current study revealed the association between postoperative TGS and postoperative falls. We highlight the importance of preoperative fall monitoring and postoperative TGS evaluation to prevent falls after TKA.

Does Total Knee Arthroplasty Positively Affect Body Static-Dynamic Balance and Fall Risk Parameters in Patients With Satisfactory Functional Scores?

Objective The aim of this study was to determine the balance problems and risk of falling by using digital or computerized methods in patients who underwent total knee arthroplasty (TKA) and have satisfactory functional scores in the early postoperative period. Methodology A total of 31 participants (24 women, seven men; mean age: 61.93 ±10.75 years; range: 49-82 years) who underwent unilateral TKA were included. The fall risk was evaluated using the time up-and-go (TUG) test and computerized platforms. Patient-reported pain, stiffness, and physical functional outcome measures [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score (OKS)] and posture (New York Posture Rating Chart) were evaluated. Results Based on the WOMAC scores, there was a significant impact on self-reported pain (p˂0.001), function (p=0.001), and stiffness (p=0.001) between preoperative and postoperative results. The OKS (p=0.006) and the TUG score (p=0.004) improved significantly, but the posture scores remained the same after the surgery. There was a statistically significant difference between the preoperative and third-month postoperative test results of the stabilometric test, bipedal opened eye, bipedal closed eye, monopedal right, and monopedal left foot static balance tests (p˂0.05). However, the disequilibrium and equilibrium dynamic balance values ​​remained unchanged three months after TKA. Conclusions Satisfactory functional scores according to WOMAC or OKS were achieved in the early postoperative period. However, posture and dynamic balance problems related to falling risk continued to persist in the same period. Although the TUG test results were statistically significant, they also showed fall risk values. Fall risk and postural problems should be analyzed objectively using computerized methods. Early rehabilitation programs after TKA in elderly individuals should be designed accordingly and close attention must be paid to fall risks.

Factors affecting short-term functional gain following total knee arthroplasty in patients aged from 75 years at a postacute rehabilitation setting

The intensive rehabilitation of older patients after total knee arthroplasty (TKA) is vital for short-term improvement in mobility and daily living activities. We aimed to investigate the effectiveness of multidisciplinary rehabilitation and assess the early postoperative predictors that are associated with functional gain in TKA patients aged from 75 years in a postacute care setting. This study included 190 patients following primary TKA who were admitted at the postacute rehabilitation hospital. The main outcome measures were the motor component of functional independence measure (M-FIM), M-FIM effectiveness, numerical rating scale, knee extension strength and range of motion, 10-m walk test, Berg balance scale (BBS), and mini-mental state examination (MMSE). The functional gain between patient age groups of ≥75 (n = 105) and <75 (n = 85) years were compared. Although patients aged ≥75 years showed lower improvement in BBS score compared with <75 years, the M-FIM gains and other physical functions were similar in both age groups. In multivariate analysis, the results for M-FIM at admission (β: -0.703; P = 0.001), BBS (β: 0.342; P = 0.032) and MMSE (β: 0.446; P = 0.021) were independently associated with functional gain in the patients following TKA aged ≥75 years. Multidisciplinary inpatient rehabilitation was beneficial for basic functional gain except for improvement in balance ability in patients after TKA aged ≥75 years. Functional level, balance ability and cognitive status in the early postoperative period can be useful predictors for short-term functional gain in the postacute care phase.

Physical Activity Mediates the Relationship between Gait Function and Fall Incidence after Total Knee Arthroplasty

The present study aims to examine (1) the preoperative factors that can predict postoperative falls, (2) whether postoperative physical activity (PA) mediates the relationship between fall incidence and gait function, and (3) whether postoperative PA levels are associated with fall risk in total knee arthroplasty (TKA) patients. Ninety-six patients (mean age: 72.0 ± 6.1 years) who were observed postoperatively for 6 months were selected. Timed up and go (TUG) was assessed as an indicator of gait function. Fall incidence and PA were investigated for 6 months post-TKA. The body mass index, history of preoperative falls, knee pain, knee extensor strength, range of motion in knee flexion, and modified gait efficacy scale were evaluated. Additionally, postoperative PA levels were categorized into three groups-low: <3,000, moderate: 3,000 to 4,000, and high: ≥4,000 steps/day. The relative fall incidence rate was calculated according to the total number of falls normalized for every 1,000 steps/day for 6 months postoperatively. Twenty-five (26.0%) of the 96 patients had at least one fall. The TUG, knee pain, and knee extensor strength were identified preoperatively as significant variables affecting postoperative falls. The mediated effects model revealed that postoperative fall incidence was predicted by preoperative TUG and postoperative PA. Postoperative PA was significantly associated with preoperative TUG. Moreover, both the preoperative TUG and postoperative PA were selected as significant variables for predicting fall incidence. Thus, postoperative PA mediates the relationship between gait function and fall incidence after TKA. Furthermore, the relative fall incidence rate associated with a low PA level was significantly higher than that associated with moderate and high PA levels. In conclusion, preoperative assessments of TUG performance, muscle strength, and knee pain were effective in predicting fall risk. Additionally, an increase in PA could contribute to reducing fall risk in TKA patients. Therefore, our results suggest that preoperative screening for fall predictors and managing postoperative PA could reduce the fall incidence in TKA patients.

Effects of total knee arthroplasty for primary knee osteoarthritis on postural balance: A systematic review

BACKGROUND

Knee osteoarthritis is often related to physical function impairment. Although total knee arthroplasty is considered effective for advanced cases of knee osteoarthritis, its effects on postural balance is a topic of debate.

RESEARCH QUESTION

What are the effects of total knee arthroplasty for primary knee osteoarthritis on postural balance compared to preoperative status and/or to healthy controls?.

METHODS

Longitudinal studies (with more than 1-month follow-up) assessing postural balance measures (either clinical-based such as balance scales or laboratory-based such as postural sway) were considered eligible and selected in a 2-phase process. Six main electronic databases were searched, complemented by 3 grey literature sources. The risk of bias was evaluated using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

A total of 19 studies were included for qualitative synthesis, of which 14 had low and 5 had a moderate risk of bias. The follow-up period ranged from 1-24 months. Most studies (n = 11) presented comparisons to preoperative status only. From these, 7 studies reported relevant improvements in postural balance, 2 reported partial improvements, and 2 no improvements. The remaining studies (n = 8) presented comparisons to healthy controls and, although improvements following total knee arthroplasty were consistently observed, only one study reported postural balance measures comparable to that of controls.

CONCLUSIONS

The majority of studies reported relevant improvements (especially in clinical-based measures) compared to preoperative evaluations, although inconsistencies were found possibly due to variability in studies' populations, assessment tools, and follow-up times. Despite this, persistent deficits in postural balance were commonly observed when compared to healthy controls.

SIGNIFICANCE

This evidence synthesis could better inform clinicians and researchers about the therapeutic effects and limitations of total knee arthroplasty concerning postural balance. Standardization of assessment tools is recommended to strengthen the certainty of cumulative evidence.

Improving Interpretation of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Scale for Specific Tasks in Community-Dwelling Older Adults

BACKGROUND AND PURPOSE

New generic patient-reported outcomes like the Patient-Reported Outcomes Measurement Information System (PROMIS) are available to physical therapists to assess physical function. However, the interpretation of the PROMIS Physical Function (PF) T-score is abstract because it references the United States average and not specific tasks. The purposes of this study were to (1) determine convergent validity of the PROMIS PF scale with physical performance tests; (2) compare predicted performance test values to normative data; and (3) identify sets of PROMIS PF items similar to performance tests that also scale in increasing difficulty and align with normative data.

METHODS

Community-dwelling older adults (n = 45; age = 77.1 ± 4.6 years) were recruited for this cross-sectional analysis of PROMIS PF and physical performance tests. The modified Physical Performance Test (mPPT), a multicomponent test of mostly timed items, was completed during the same session as the PROMIS PF scale. Regression analysis examined the relationship of mPPT total and component scores (walking velocity, stair ascent, and 5 times sit to stand) with the PROMIS PF scale T-scores. Normative data were compared with regression-predicted mPPT timed performance across PROMIS PF T-scores. The PROMIS PF items most similar to walking, stair ascent, or sit to stand were identified and then PROMIS PF model parameter-calibrated T-scores for these items were compared alongside normative data.

RESULTS AND DISCUSSION

There were statistically significant correlations (r = 0.32-0.64) between PROMIS PF T-score and mPPT total and component scores. Regression-predicted times for walking, stair ascent, and sit-to-stand tasks (based on T-scores) aligned with published normative values for older adults. Selected PF items for stair ascent and walking scaled well to discriminate increasing difficulty; however, sit-to-stand items discriminated only lower levels of functioning.

CONCLUSIONS

The PROMIS PF T-scores showed convergent validity with physical performance and aligned with published normative data. While the findings are not predictive of individual performance, they improve clinical interpretation by estimating a range of expected performance for walking, stair ascent, and sit to stand. These findings support application of T-scores in physical therapy testing, goal setting, and wellness plans of care for community-dwelling older adults.

A systematic review and meta-analysis of fall incidence and risk factors in elderly patients after total joint arthroplasty

BACKGROUND

Falls in the elderly have become a serious social problem worldwide. Approximately a third of persons fall at least once in the year after total joint arthroplasty (TJA), but preventing and treating falls is still challenging in clinical practice. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of falls after TJA. The present study aimed to quantitatively and comprehensively conclude the risk factors of falls after TJA in elderly patients.

METHODS

The electronic databases to be searched include CNKI, Embase, Medline, and Cochrane central database (all up to November 2018). All studies on the risk factors of falls after TJA in elderly patients without language restriction were reviewed. Process of evaluation of identified studies and extraction of data were independently conducted by 2 reviewers, qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis completed. All analyses were performed by the software Stata 11.0.

RESULTS

A total of 14 studies were included, which altogether included 1284456 patients with TJA, of them 12879 cases of falls occurred after surgery, suggesting the accumulated incidence of 13.1% and the prevalence of in-hospital falls was 1.0%. This study has provided evidence for the preventing of falls in the elderly patients who were underwent TJA. Outcome measures include advanced age, female, Overweight (BMI≥25 kg/m), falls history, use of walking aid, diabetes, cardiac disease, hypertension, COPD and depressive symptoms. The ABC Scale was significantly negatively correlated with falls after lower extremity joint replacement.

CONCLUSIONS

Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent falls after TJA.

Total Joint Arthroplasty Is Associated With a Decreased Risk of Traumatic Falls: An Analysis of 499,094 Cases

INTRODUCTION

The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA.

METHODS

The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs).

RESULTS

Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1).

CONCLUSION

TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis.

LEVEL OF EVIDENCE

Level III Retrospective Case-control study.

The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.

OBJECTIVES

This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.

METHODS

Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion.

PARTICIPANTS

Elderly individuals (65 + years) who underwent total knee arthroplasty.

INTERVENTIONS

Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

SYNTHESIS METHODS

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I². A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.

RESULTS

Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I² = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I² = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I² = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I² = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I² = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I² = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I² = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r² = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r² = 0.02; standardised β = 0.13; P = 0.48).

LIMITATIONS

A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.

CONCLUSION

Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

Falls After Total Knee Arthroplasty: Frequency, Circumstances, and Associated Factors-A Prospective Cohort Study

BACKGROUND

Individuals with total knee arthroplasty (TKA) often experience pain and reduced balance control, which may predispose them to greater fall risk.

OBJECTIVE

The objective of this study was to determine the frequency and circumstance of falls and fall-related risk factors within a 6-month follow-up period in individuals after TKA.

DESIGN

This study was a prospective cohort study.

METHODS

Knee proprioception, the Balance Systems Evaluation Test, knee pain, knee extension and flexion muscle strength, knee range of motion, and balance confidence were evaluated in 134 individuals (39 men, 95 women; mean age = 66.3 years [SD = 6.6 years]) 4 weeks after TKA. Monthly follow-up sessions, via face-to-face or telephone interviews, were implemented to obtain data on fall incidence over 6 months.

RESULTS

Twenty-three individuals after TKA (17.2%) sustained at least 1 fall during the 6-month follow-up period. The median time of the first fall episode was 15 weeks after TKA. Of the 31 fall episodes, most occurred during walking (67.7%). Slipping (35.5%) and tripping (35.5%) were identified as the most frequent causes of falling. Most falls occurred at home (45.2%) or another indoor environment (29.0%). Multivariate binary logistic regression revealed that younger age (odds ratio: 0.91), reduced proprioception of the knee that had undergone surgery ("operated knee") (odds ratio: 1.62), reduced sensory orientation (odds ratio: 0.92), and greater operated knee pain (odds ratio: 1.68) were significantly associated with more falls during the follow-up period.

LIMITATIONS

The results of this study may be generalizable up to 6 months after TKA.

CONCLUSIONS

Intervention efforts should target deficits in knee proprioception and sensory orientation and operated knee pain to prevent future falls in individuals with TKA.

Risk of falls in patients with knee osteoarthritis undergoing total knee arthroplasty: A systematic review and best evidence synthesis

Objectives

Falls occur frequently in patients with impaired ambulation and may dramatically affect the elderly population. Aim was to document the incidence of falls in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA), and to identify factors and treatments that may influence the risk of falls.

Methods

A systematic literature search was conducted on three medical electronic databases, PubMed, PeDRO, and Cochrane Collaboration. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used. Risk of bias analysis and best evidence synthesis were performed. The main aspects related to falls were analyzed: prevalence, risk factors, correlation with clinical outcome, effect of treatments.

Results

The systematic review identified 11 papers on 1237 patients. Pre-operative fall prevalence ranged from 23% to 63%, while post-operative values ranged from 12% to 38%. Moderate evidence was found on no influence of clinical scales, no BMI differences between "faller" and "non-faller", and on influence of limited pre-operative range of motion. Conflicting evidence was found for sex, history of previous falls, age, kyphosis, muscle weakness, fear of falling, depression, balance, gait impairment. No evidence was found for the effectiveness of surgical or rehabilitative strategies on falls reduction.

Conclusions

OA patients undergoing TKA are at high risk of falls, which is reduced but still present after surgery. Although some risk factors were identified, there are no studies demonstrating the possibility of reducing the incidence of this deleterious event, which warrants further research efforts to better manage this fragile population of elderly patients.

Review of perioperative falls

Falls are a known public health problem, and there is increasing recognition of the importance of perioperative falls for risk prediction and quality assessment. Our objective was to review existing literature regarding the occurrence, injuries, and risk factors of preoperative and postoperative falls. A systematized search of PubMed entries between 1947 and November 2015 produced 24 articles that met inclusion criteria. Most studied orthopaedic surgery patients older than 65 yr. Four were rated 'good' quality. Interrater reliability for the quality assessment was moderate (κ = 0.77). In the 3-12 months before surgery, the proportion of preoperative patients who fell ranged from 24 to 48%. Injuries were common (70%). The rate of postoperative falls ranged from 0.8 to 16.3 per 1000 person-days, with a gradual decline in the months after surgery. Injuries from postoperative falls occurred in 10-70% of fallers, and 5-20% experienced a severe injury. Risk factors were not well studied. Prospective studies reported a higher percentage of falls and fall-related injuries than retrospective studies, suggesting that there may be underdetection of falls and injuries with retrospective studies. Perioperative falls were more common than falls reported in the general community, even up to 12 months after surgery. Surgery-related falls may therefore occur beyond the hospitalization period. Future studies should use a prospective design, validated definitions, and broader populations to study perioperative falls. In particular, investigations of risk factors and follow-up after hospitalization are needed.

REGISTRY NUMBER

PROSPERO registration number CRD42015029971.

Back Stiffness Is Associated with Physical Health and Low Back Pain-Related Disability in Community-Dwelling Older Adults

Objective

Back stiffness is a common complaint among older adults with low back pain. Nonetheless, self-reported back stiffness has received little exploration in this patient population. The purpose of this study was to examine the associations of self-reported low back stiffness with physical health and low back pain-related disability among older adults with low back pain.

Design

Cross-sectional analysis.

Subjects

Data included in this study were obtained from the Retirement Community Back Pain Study, a population-based survey of older adults.

Methods

Participants completed the Medical Outcomes Survey Short-Form 36 and the modified Oswestry Low Back Pain Questionnaire. Physical health, derived from the Short Form-36, was represented by the physical component summary score. Back stiffness was rated on a 0-10 scale, where 0 indicated "no back stiffness."

Results

Covariates-that is, intensity and duration of low back pain, age, sex, weight, education level, and comorbidities-explained 27% of the variance in physical health ( P  < 0.0001) and 38% of the variance in low back pain-related disability ( P  = 0.0002). Self-reported stiffness explained an additional 6% of the variance in physical health ( P  < 0.0001) and 10% of the variance in low back pain-related disability ( P  < 0.0001).

Conclusions

Back stiffness in older, community-dwelling adults with low back pain may help explain physical health and low back pain-related disability, above and beyond demographics and pain. Future longitudinal research is needed to evaluate low back stiffness as a predictor of physical health and disability. Ultimately, assessment and treatment of back stiffness in older adults with low back pain may improve patient outcomes.

The effect of primary total knee arthroplasty on the incidence of falls and balance-related functions in patients with osteoarthritis

Knee osteoarthritis (OA) is an established risk factor for falls and balance impairment. This study investigated the incidence of falls, balance-related outcomes and risk factors for falls before and after primary total knee arthroplasty (TKA). Three hundred seventy-six OA patients scheduled to undergo TKA were included. Falls data within the preoperative, first postoperative and second postoperative years were collected, balance-related functions were assessed using the Assessment of Quality of Life (AQoL), WOMAC, Falls Efficacy Scale International (FES-I), Activities-specific Balance Confidence (ABC), knee extension strength, Berg Balance Scale (BBS) and Timed Up and Go (TUG) before surgery and 1 and 2 years after surgery. Compared with preoperative values, the incidence of falls significantly decreased (14.89%, 6.23% and 3.14% within the preoperative, first postoperative and second postoperative years, respectively) and the AQoL, WOMAC, FES-I, ABC, knee extension strength, BBS and TUG significantly improved after TKA. Logistic regression analysis revealed that Kellgren-Lawrence grade ≥ 3 of the contralateral knee was an independent risk factor for falls before and after TKA. Conclusively, primary TKA is associated with a reduced incidence of falls and improved balance-related functions, and the contralateral knee should be considered in the design of fall-prevention strategies in patients with OA.

A Review on Bone Mineral Density Loss in Total Knee Replacements Leading to Increased Fracture Risk

The link between low bone mineral density (BMD) scores leading to greater fracture risk is well established in the literature; what is not fully understood is the impact of total knee replacements/revisions or arthroplasties on BMD levels. This literature review attempts to answer this question. Several different databases using specific key terms were searched, with additional papers retrieved via bibliographic review. Based on the available evidence, total knee replacements/revisions and arthroplasties lower BMD and thus increase fracture risk. This review also addresses the possible implications of this research and possible options to reduce this risk.

Do Pilates-based exercises following total knee arthroplasty improve postural control and quality of life?

PURPOSE

The aim of this prospective, randomized, controlled study was to investigate the effects of the addition of Pilates-based exercises to standard exercise programs performed after total knee arthroplasty on quality of life and balance.

METHOD

Forty-six volunteers were divided into two groups. The control group (n = 17) was assigned a standard exercise program after discharge; the study group (n = 17) was assigned Pilates-based exercises along with the standard exercise program. We carried out clinical evaluations of all patients on the day of discharge and after the completion of the 6-week exercise program. We also recorded sociodemographic data, Berg Balance test scores, and Short Form-36 (SF-36) health-related quality of life measurements.

RESULTS

When we compared the differences between pre- and post-treatment balance scores of the groups, we found a significant change in favor of the Pilates-based exercise group (13.64 ± 1.45; p < 0.01). The changes in the pre- and post-treatment SF-36 scores of the Pilates-based exercises group were found to be significant in terms of physical function (p = 0.001), physical role restriction (p = 0.01), and physical component score (p = 0.001).

CONCLUSIONS

Pilates-based exercises performed along with standard exercise programs were more effective for improving balance and quality of life than standard exercise programs alone.

The effect of total knee arthroplasty on patients' balance and incidence of falls: a systematic review

PURPOSE

Despite the high incidence of falls in patients with OA, few studies have explored whether falls risk is affected after patients undergo total knee arthroplasty (TKA). Therefore, the aim of this systematic review was to identify the extent of the effects of TKA on balance and incidence of falls by critically reviewing the available literature.

METHODS

A systematic review of published literature sources was conducted up to March 2014. All studies assessing balance and incidence of falls after TKA (without physiotherapeutic intervention) were included. The methodological quality of each study was reviewed using the Critical Appraisal Skill Programme tool.

RESULTS

Thirteen studies were included, comprising of ten cohort studies (Level II) and three studies with Level of evidence III.

CONCLUSIONS

Findings provide evidence that TKA improves significantly single-limb standing balance (~60%) and dynamic balance up to 1-year following surgery (Level of evidence II). Moreover, TKA influences positively fear of falling and incidence of falls by switching 54.2 % of pre-operative fallers to post-operative non-fallers (Level of evidence II-III). It is highlighted that knee extension strength, proprioception and symmetrization of postural strategies have not fully recovered post-TKA and influence balance performance. Clinically, these persistent deficits need to be mitigated by physiotherapy even before TKA takes place.

Depression and anxiety after total joint replacement among older adults: a meta-analysis

OBJECTIVE

Patients usually experience good physical recovery after total joint replacement (TJR); however, it is unclear whether mood also improves. The current meta-analysis examined changes in depression and anxiety following TJR in older (≥50 years) patients in order to address this gap in the literature.

METHODS

Data from 26 studies (4045 TJR, 55 controls) that assessed depression and/or anxiety pre- and post-surgery in TJR patients, with or without a control group, were analyzed. Prevalence rates and Cohen's d effect sizes were used to evaluate changes in the prevalence and severity of depression/anxiety, respectively.

RESULTS

Approximately 23% of TJR patients had clinically significant levels of depression prior to surgery, which decreased to 13% one year later. The prevalence of anxiety could not be evaluated due to the limited available data. TJR patients did not show any clinically meaningful reductions in symptoms of depression or anxiety, following surgery. Compared to controls, there was no difference in symptom progression over time; although only one study examined this.

CONCLUSIONS

TJR patients appear to have higher rates of clinically significant symptoms of depression before and after surgery, compared to the general population, however more research with adequate control groups is needed to confirm this. Only a modest improvement in the severity of depression and anxiety symptoms was noted post-surgery. However, existing research is limited; preventing definite conclusions regarding the impact of TJR on mood.

Selecting, assessing and interpreting measures of function for patients with severe hip pathology: The need for caution

INTRODUCTION

It is not always possible to use a combination of patient-reported outcome measures (PROMs), performance tests and clinician-administrated measures to assess physical function prior to hip surgery. We hypothesised that there would be low correlations between these three types of measure and that they would be associated with different patients' characteristics.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of the preoperative information of 125 participants listed for hip replacement. The WOMAC-function subscale, Harris Hip Score (HHS) and walk, step and balance tests were assessed by questionnaire or during a clinic visit. Participant's socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients. Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures.

RESULTS

None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (<0.90). Associations between patient's characteristics and functional scores varied by type of measure. Psychological status was associated with the PROM (P-value<0.0001) but not with the other measures. Age was associated with the performance test measures (P-value ranging from ≤0.01 to <0.0001) but not with the PROM. The clinician-administered measure was not associated with age or psychological status.

DISCUSSION

Substantial discrepancies exist when assessing hip function using a PROM, functional test or a clinician-administered test. Moreover, these assessment methods are influenced differently by patient's characteristics. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective.

LEVEL OF EVIDENCE

III, observational cross-sectional study.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Incidence, risk factors and the healthcare cost of falls postdischarge after elective total hip and total knee replacement surgery: protocol for a prospective observational cohort study

INTRODUCTION

The number of major joint replacement procedures continues to increase in Australia. The primary aim of this study is to determine the incidence of falls in the first 12 months after discharge from hospital in a cohort of older patients who undergo elective total hip or total knee replacement.

METHODS AND ANALYSES

A prospective longitudinal observational cohort study starting in July 2015, enrolling patients aged ≥60 years who are admitted for elective major joint replacement (n=267 total hip replacement, n=267 total knee replacement) and are to be discharged to the community. Participants are followed up for 12 months after hospital discharge. The primary outcome measure is the rate of falls per thousand patient-days. Falls data will be collected by 2 methods: issuing a falls diary to each participant and telephoning participants monthly after discharge. Secondary outcomes include the rate of injurious falls and health-related quality of life. Patient-rated outcomes will be measured using the Oxford Hip or Oxford Knee score. Generalised linear mixed modelling will be used to examine the falls outcomes in the 12 months after discharge and to examine patient and clinical characteristics predictive of falls. An economic evaluation will be conducted to describe the nature of healthcare costs in the first 12 months after elective joint replacement and estimate costs directly attributable to fall events.

ETHICS AND DISSEMINATION

The results will be disseminated through local site networks and will inform future services to support older people undergoing hip or knee joint replacement and also through peer-reviewed publications and medical conferences. This study has been approved by The University of Notre Dame Australia and local hospital human research ethics committees.

TRIAL REGISTRATION NUMBER

ACTRN12615000653561; Pre-results.

Are people following hip and knee arthroplasty at greater risk of experiencing a fall and fracture? Data from the Osteoarthritis Initiative

INTRODUCTION

Falls are a major challenge for older people and are a significant source of mortality and morbidity. There has been uncertainty as to whether people with total hip (THA) or knee (TKA) arthroplasty have a greater risk of falls and associated fractures. This analysis was to explore this question with a large community dataset.

MATERIALS AND METHODS

Data from all people enroled onto the US Osteoarthritis Initiative programme who had undergone a THA (n = 104) or TKA (n = 165), within a 12-month period, were compared to those who had not undergone an arthroplasty (n = 4631). Data were collected on: the number of participants who reported a fall within a 12-month period; the frequency of falls in this period; and whether a fracture was sustained during this period. Odd ratios were calculated for the probability of experiencing a fall or fracture between the groups.

RESULTS

There was no statistical difference in falls between people following THA (OR 0.90; 95 % CI 0.58-1.41) or TKA (OR 0.95; 0.67-1.35) compared to a non-arthroplasty cohort. Whilst there was no statistical difference in fracture risk between people following TKA compared to non-arthroplasty individuals (OR 1.25; 95 % CI 0.57-2.70), those who underwent THA had a 65 % lower chance of experiencing a fracture in the initial 12 post-operative months compared to the non-THA cohort (OR 0.35; 95 % CI 0.19-0.65; p < 0.01).

CONCLUSIONS

There appears a lower chance of experiencing a fracture for people following THA compared to those who have not.

No differences in clinical outcomes between fixed- and mobile-bearing computer-assisted total knee arthroplasties and no correlations between navigation data and clinical scores

PURPOSE

The theoretical advantages of mobile-bearing (MB) designs over the conventional fixed bearings (FBs) for total knee arthroplasty (TKA) have not been proved yet through clinical studies. The aim of the study was to test whether the MB design has advantages in terms of better clinical outcomes when compared to FB. Furthermore, the relationships between intra-operative obtained implant positioning data and the clinical scores were analysed.

METHODS

A total of 99 patients were randomized into the FB or the MB group. All patients received the same posterior cruciate retaining implants and were operated with the use of a computer-assisted navigation system. The clinical outcomes of both groups were compared pre-operatively, at 1 year, and at a mean follow-up time of 4 years after surgery.

RESULTS

The MB implants showed no advantages over the FB when comparing the Knee Society Scores, the Oxford Score, the range of movement (ROM) and pain intensity of the patients in both groups at 1 and 4 years after surgery. There were no relationships between the computer navigation data and the clinical scores.

CONCLUSIONS

In view of the 4-year results, there is no evidence to support the recommendation of one design over the other in terms of better clinical outcome scores, higher ROM or lower pain rates. Long-term follow-up results may be necessary, including survival rates. Further research comparing different TKA designs should also include standardized performance-based tests.

LEVEL OF EVIDENCE

Prospective study (Randomized controlled trial with adequate statistical power to detect differences), Level I.

Predicting acute recovery of physical function following total knee joint arthroplasty

The objective was to explore predictors of physical function during acute in-patient rehabilitation within a few days after TKA. Physical function status of participants (n = 72) three days after total knee arthroplasty (TKA) was measured using the Timed Up and Go Test (TUG) and the function subscale of the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC-function). Potential predictors of physical function were measured day one post-TKA. Their relationship with physical function was examined using backward elimination, multiple regression analyses. Older age and increased comorbidity were associated (R(2) = 0.20) with worse TUG times. Increased pain severity was associated (R(2) = 0.08) with worse WOMAC-function scores. Age, comorbidity, and pain severity should be considered when predicting which patients will struggle with acute recovery post-TKA.