AB1495 THE QUALITY OF REPORTING IN RANDOMIZED CONTROLLED TRIALS OF STRENGTHENING EXERCISES IN TOTAL KNEE ARTHROPLASTY

Background

End-stage knee osteoarthritis (KOA) is a significant health issue worldwide resulting in severe pain and disability. Total knee arthroplasty (TKA) leads to significant improvements in pain and the performance of functional activities such as walking for patients with end-stage KOA. Although TKA reduces pain and improves perceived function, patients continue to exhibit reduced muscle strength, voluntary muscle activation, and functional performance even years after surgery (1). In addition, quarantine, and related social restrictions due to the current Covid-19 pandemic may have affected the recovery of patients undergoing TKA due to limited access to exercise, physiotherapy, face-to-face follow-up, and medical services (2).Limited recovery after TKA will require intensive rehabilitation programs in the future. Strengthening exercises(SE) are the most effective intervention for improving muscle strength and functionality and have been recommended in the guidelines for KOA management and in clinical reviews for TKA rehabilitation (3). Randomized controlled trials (RCTs) are the gold standard for assessing the effects of health care interventions. However, RCTs may yield misleading results if they lack methodological rigors(4). RCTs provide the highest quality clinical evidence in the selection of the SE method to be applied (5). However, there are no studies examining the quality of RCTs related to SE in patients with TKA.

Objectives

The aim of this study was to assess the reporting quality of RCTs of SE in patients with TKA.

Methods

RCTs published between 2002 and 2021 were sourced from clinical trial registers, PubMed, and the Cochrane Reviews. RCTs were included if they involved SE in patients who underwent TKA. Analysis was carried out with two assessment tools: PEDro scale and 9-items from CONSORT(6). In addition, we have identified some key methodological elements and examined their relationship to their methodological quality.

Results

We found 35 RCTs that included SE in individuals with TKA. The mean PEDro score was 6.40 ± 1, 73. The most common deficient PEDro Items were: Blinding of all therapists who administered the therapy (14,2 %: 5/35 trials), allocation was concealed (31,4 %; 11/35 trials), blinding of all subjects (31,4 %: 11/35 trials). The most common deficient CONSORT Criteria were: Statistical adjustment for multiple primary outcomes (40 %; 14/35 trials), funding sources (40 %; 14/35 trials) and identification as a randomized trial in the title (62,85%; 22/35 trials). Of the key methodological factors we identified, only exercise duration (weeks) was associated with PEDro score (R2 =.169, p<0.01).

Conclusion

Our results show that the quality of reporting in the literature on RCTs of SE in patients with TKA is insufficient. In order to increase muscle strength after TKA, the lack of face-to-face programs due to COVID-19 should be eliminated with telerehabilitation methods, video conferencing platforms and virtual reality applications, and high-quality RCTs should be planned where these programs are examined.

References

[1]Ciolac EG, et al. Clinics (Sao Paulo). 2011;66(12):2079-84.

[2]MacDonald, D. J. et al. Bone & joint open, 2021;2(6), 380–387.

[3]Unver B, et al. Arch Gerontol Geriatr. 2016;64:45-50.

[4]Ntala C, et al. Prim Care Respir J. 2013;22(4):417-24.

[5]Karpouzis F, et al. Chiropr Man Therap. 2016 Jun 9;24:19.

[6]Gonzalez GZ, et al. Arch Phys Med Rehabil. 2018 Jan;99(1):129-136.

Disclosure of Interests

None declared

AB1494 THE QUALITY OF REPORTING IN RANDOMIZED CONTROLLED TRIALS OF BALANCE EXERCISES IN TOTAL KNEE ARTHROPLASTY

Background

Total knee arthroplasty (TKA) is used to treat patients with end-stage osteoarthritis who experience pain and struggle to perform activities of daily living owing to having degenerative knee joints. Although TKA can improve the quality of life of patients, some may experience a decrease in their proprioception and the ability to balance after surgery (1). Decreased balance ability makes it difficult to undertake daily life activities in patients after TKA, impairs walking capacity and increases the risk of falling (2). Almost all studies which investigate the risk of falling conclude that physical activity(PA) are effective methods in order to maintain an intact balance control and prevent falls(4). Today, however, measures aimed at controlling COVID-19 include quarantines that lead to PA restrictions (5). In these days when PA cannot be increased due to quarantines, the most effective way to prevent falls in TKA patients may be to apply balance exercises (3). The “gold standard” in clinical trials are randomized controlled trials(RCTs) in which healthcare professionals make decisions about the safety and efficacy of treatments. However, poorly designed and reported RCTs can give misleading results. Methodological quality (MQ) assessment of clinical trials is important because it can prevent erroneous results in clinical practice and improve the quality of medical care. (6) Although RCTs provide the highest quality clinical evidence selection of balance exercises(BE) to be applied, there is no study in the literature investigating the MQ of RCTs of BE in TKA patients.

Objectives

The aim was to investigate assess the reporting MQ of RCTs of BE in patients with TKA.

Methods

We analyzed 17 published full-text reports of RCTs using BE in patients who underwent TKA. RCTs were sourced from PubMed, the Cochrane Reviews and PEDro Database. The PEDro scale and the 9-item CONSORT (7) were used to evaluate the MQ of the studies.

Results

The mean PEDro score was 6,64 ± 1,57. Classification of RCTs according to total PEDro score revealed that 1 study was classified as excellent, 13 studies as good, and 3 as fair. The least fulfilled criteria in the PEDro scale were: Blinding of all therapists who administered the therapy (1[5.88%]), allocation was concealed (5[29.4%]) and blinding of all subjects (7[41.17%]). The adherence of the reports to CONSORT items ranged from 41.17 % to 100%. The most underreported CONSORT items were: funding sources (7[41.17%]), statistical adjustment for multiple primary outcomes (8[47.05%]), and number of primary outcomes (8[47.05%]).

Conclusion

Our findings show that the quality of reporting for RCTs of BE in TKA patients is not high quality. Since it is not possible to improve balance with PA today, when there are quarantine due to COVID-19, patients should be encouraged to participate in BE programs with telerehabilitation, home-based or web-based exercises, and high quality RCTs should be planned in these programs.

References

[1]Lee, H. G., et al International journal of environmental research and public health, 2021;18(5), 2513.

[2]Matsumoto H, et al. Arch Orthop Trauma Surg. 2012;132(4):555–63.

[3]Doma K, et al. Sports Med. 2018 Oct;48(10):2367-2385.

[4]Thomas, E., et al. Medicine, 2019;98(27), e16218.

[5]Füzéki, E., et al. Journal of occupational medicine and toxicology (London, England), 2020;15, 25.

[6]McCormick F, et al. J Shoulder Elbow Surg. 2013 Sep;22(9):1180-5

[7]Gonzalez GZ, et al. Arch Phys Med Rehabil. 2018 Jan;99(1):129-136.

Disclosure of Interests

None declared

AB0975 Minimal Clinically Important Difference of Total Knee Artroplasty Patient-Reported Outcome Measures

Background

Total knee arthroplasty (TKA) is one of the commonest operations performed for end-stage osteoarthritis. Patient-reported outcome scales (PROMs) are optimal measures of the patient’ aspects of their current condition and response to treatment. However, a statistically significant change does not always mean or create an effect that clinically meaningful. Clinicians can use a greater change than minimal clinically important difference (MCID) value as a meaningful change in patients with TKA [1]. Nevertheless, there are variations in MCID values in studies analyzing the same outcome measures or patient populations.

Objectives

The aim of this study is to create a global summary of literature of the MCID for PROMs for TKA.

Methods

A comprehensive literature search administered using PubMed database from their years of inception to January 2022. Original articles calculating MCID of PROMs for TKA were identified, and the full texts of these publications, as well as their bibliographies were reviewed. Keywords included “outcome scale,” “TKA,” and “MCID.”

Results

This review examined 43 studies, in which 15 different outcome scales were administered to patients with TKA. MCIDs of the PROMs had distinct value or measurement process depending on the patients and clinical context. Distribution-based and anchor-based approaches were the most commonly used methods for calculating MCID. According to the analysis’; the WOMAC, KOOS, SF-12 and KSS were the most commonly used scales and there were so little research regarding the MCID of outcome instruments for TKA.

Conclusion

The reporting of outcomes in TKA were traditionally focused on implant survivorship and objective outcomes such as radiographic alignment, range of motion and, knee stability. However, patients and clinicans can have different perceptions of outcome, especially in the domains of subjective quality of life [2]. Therefore, it is recommended to use a combination of both objective and subjective measures to assess outcomes after TKA.

In general, a wide range of MCID values was observed according to the scales. This can be due to the heterogenity in patient’ clinical conditions recruited for the studies. Apart from the differences, MCIDs of the Oxford Knee Score and KOOS were lower than the WOMAC score therefore we can interpret that they are more sensitive as an outcome scale.

However, the MCID values must be interpreted in light of all variables, including the participants which were administered to. Each method for determining MCID has advantages and disadvantages, and the best way to calculate an MCID is to combine the results of both methods. The MCID is not flawless in detecting a clinically significant change, as sensitivity and specificity play a role.

References

[1]Tubach F, Ravaud P, Beaton D et al. Minimal clinically important improvement and patient acceptable symptom state for subjective outcome measures in rheumatic disorders. 2007; 34: 1188-1193.

[2]Zacharia B, Paul M, Thanveeruddin Sherule M. Patient-based outcome analysis is important to determine the success of total knee arthroplasty: result of a focus group discussion. Med Devices (Auckl) 2016; 9: 125-130.

Disclosure of Interests

None declared

AB1000 Reliability and Validity of the Cone Evasion Walk Test in Patients With Total Knee Arthroplasty: A Pilot Study

Background

Total knee arthroplasty (TKA) is the gold-standard procedure for end-stage knee osteoarthritis, however, some residuel problems may still continue and cause a variety of dysfunctions, such as impaired strength, proprioception, gait, balance, postural instability, and, impaired ability to avoid obstacles while walking. Tripping over an obstacle is the most frequent cause of falls 1 and falls can limit daily activities and induce post-fall syndromes, such as dependence, loss of autonomy, immobilization, and depression 2. The Cone Evasion Walk test (CEW) to assess fall risk by the ability to evade obstacles, (ICF-code d455), which requires attentional, perceptual, and several neuromusculoskeletal and movement related functions 3. However, there is no study investigating the reliability and validity of the CEW in TKA patients.

Objectives

The aim of the study is to investigate the reliability and validity of the CEW in patients with TKA.

Methods

Twenty patients with TKA included in the study. The CEW, the Timed Up And Go Test (TUG) and the Hospital for Special Surgery (HSS) Knee Score administered to the patients. Patients rested between the tests for an hour.

Results

Mean age was 68.1 ± 2.59 years and the mean HSS Knee Score was 85.43± 3.47. The relative (ICC coefficient) and absolute (SEM and SRD95) reliability values were 0.98, 1.01, and 2.75 respectively. The Spearman correlation coefficient of the CEW with the TUG was 0.72.

Conclusion

Based on the current findings, the CEW has excellent reliability, high validity and responsiveness in evaluating dynamic balance and obstacle avoidance in patients with TKA. The minimal clinically important difference of CEW in TKA patients is 2.75 and it may be concluded that the fact that this value is low, indicates the sensitivity of the test. Therefore, the CEW can identify even small alterations in the functional status, can be reliably used for post-operative surveillance of TKA to observe patient results, and the usage of the CEW for assessing the fall risk and mobility in the community may be a better predictor of the patients’ current condition.

References

[1]Mauer AC, Draganich LF, Pandya N, Hofer J, Piotrowski GA. Bilateral Total Knee Arthroplasty Increases the Propensity to Trip on an Obstacle. Clinical Orthopaedics and Related Research. 2005;NA;(433):160-165. doi:10.1097/01.blo.0000150569.93262.64

[2]Park SH. Tools for assessing fall risk in the elderly: a systematic review and meta-analysis. Aging Clinical and Experimental Research. 2018;30(1):1-16. doi:10.1007/s40520-017-0749-0

[3]Sjöholm H, Hägg S, Nyberg L, Rolander B, Kammerlind AS. The Cone Evasion Walk test: Reliability and validity in acute stroke. Physiotherapy Research International. 2019;24(1):e1744. doi:10.1002/pri.1744

Disclosure of Interests

None declared

AB0584 THE QUALITY OF REPORTING IN RANDOMIZED CONTROLLED TRIALS OF HOME BASED REHABILITATION FOR KNEE OSTEOARTHRITIS: UTILIZING PEDRO SCORE AND CONSORT CRITERIA

Background:

Osteoarthritis of the knee (KOA) is a very common rheumatic disease, and its global burden is gradually increasing (1). The benefits of exercise in patients with KOA are supported by high-level evidence and take their place in primary care therapy (2). Today, coronavirus disease 2019 has developed as a pandemic all over the world, creating difficulties in healthcare and highlighting home-based rehabilitation (HBR) (3). Randomized controlled trials (RCTs) are considered the gold standard for evaluating the effects of clinical interventions, but poorly reported results can have negative consequences. The Physiotherapy Evidence Database (PEDro) evaluates the methodological quality of RCTs (4). The CONSORT (Consolidated Standards of Reporting Trials) statement has been developed to improve the reporting quality of RCTs (5).There are no studies examining the quality of RCTs related to HBR in patients with KOA.

Objectives:

The aim of this study was to assess the reporting quality of HBR trials for KOA, and explore the factors associated with the reporting.

Methods:

Two independent researchers investigated HBR RCTs in patients with KOA published between 1999 and 2020 were sourced from PubMed, the Cochrane Reviews and Web of Science. Each researcher evaluated the methodological quality of the included studies using the PEDro scoring and reporting aspects using 9 items from CONSORT. The relationship between adherence to the CONSORT criteria and the PEDro score were evaluated.

Results:

Twenty-five RCTs met our eligibility criteria. The mean PEDro score of studies is 5.76 ± 1.48. Only one study found high quality (PEDro score: ≥ 9). The PEDro scores were: randomization type (96%, 24/25) and baseline comparability (92%, 23/25); all studies described group comparisons and variablity measures. In contrast, concealed allocation (18%, 7/25), blinding of participants (16%, 4/25) and therapists (0%) were not included in most studies. The CONSORT criteria were: flow diagram (92%, 23/25), sample size, subgroup analysis and sources of funding (56%, 11/25 for all three), while the majority of studies the trial registration number (16%, 4/25) was not available. A high level of correlation was found between meeting the CONSORT criteria and PEDro scores (r=0.820, p<0.001).

Conclusion:

The majority of RCTs based on HBR for KOA are low-to-modarate quality studies based on the PEDro score. Adherence to the CONSORT criteria is linked to high quality scores. If the studies are planned and written in accordance with the CONSORT criteria, we think that better quality studies will emerge.

References:

[1]Safiri S, Kolahi AA, Smith E, Hill C, Bettampadi D, Mansournia MA, et al. Global, regional and national burden of osteoarthritis 1990-2017: a systematic analysis of the Global Burden of Disease Study 2017. Ann Rheum Dis. 2020;79(6):819-28.

[2]Skou ST, Pedersen BK, Abbott JH, Patterson B, Barton C. Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis. J Orthop Sport Phys. 2018;48(6):439-47.

[3]Karasavvidis T, Hirschmann MT, Kort NP, Terzidis I, Totlis T. Home-based management of knee osteoarthritis during COVID-19 pandemic: literature review and evidence-based recommendations. J Exp Orthop. 2020;7(1):52.

[4]Sherrington C, Herbert RD, Maher CG, Moseley AM. PEDro. A database of randomized trials and systematic reviews in physiotherapy. Man Ther. 2000;5(4):223-6.

[5]Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2012;10(1):28-55.

Disclosure of Interests:

None declared.

AB0883 RELIABILITY OF THE MODIFIED FOUR SQUARE STEP TEST IN PATIENTS WITH REVISION TOTAL KNEE ARTHROPLASTY

Background:

Patients with total knee arthroplasty (TKA) often experience pain and reduced balance control, which may predispose them to greater fall risk. The patients with revision total knee arthrooplasty (rTKA), have more pain, stiffness and physical dysfunction and less postoperative improvement compared to the patients with TKA [1]. Falls in people with gait or balance disorders have significant consequences. Fear of falling can also predispose people to inactivity, which can lead to problems of debilitation, increased handicap, and disability by itself. Most of the falls take place in the course of movement, and the trips and slips were determined as the most common cause of elderly falls. Trips are responsible of falls between 40% to 60% and slips between 10% to 15%, showing that the capability to take a quick step would prevent many falls [2]. Literature has found stepping speed to the different directions declines with aging and are lesser for fallers than for nonfallers [3].

Modified four square step test (mFSST) was developed to assessing fall risk and dynamic balance by scoring time while participants stepping in multiple directions but its reliability has not been investigated in patients undergoing rTKA.

Objectives:

The aims of this study were to determine the test-retest reliability and the minimal clinically important change (MCID) of the mFSST in patients with rTKA

Methods:

mFSST administered on 22 patients undergoing rTKA. mFSST is performed by using tapes to make one horizontal and one vertical line like a cross to create 4 quadrants. Patients’ performances were timed as patients were successfully stepping clockwise and counter-clockwise while avoid touching on tapes, turning their body or losing balance. Two trials performed and patients rested between trials and were encouraged to rest as often as they required to prevent fatigue.

Results:

ICC(2.1)for mFSST was 0.83. The standard error of measurement and MCID were 0.67 and 1.85 respectively (95 %. confidence level).

Conclusion:

The mFSST has a good test-retest reliability in patients with rTKA. It is a reliable and responsive tool for measuring fall risk, dynamic balance and mobility. The mFSST is an excellent measure of gait variability, stepping in multipl directions and dynamic balance, also can easily identify real clinically important changes in patients with rTKA in simple environments and minimal equipment.

References:

[1]Järvenpää J, Kettunen J, Miettinen H, Kröger H. The clinical outcome of revision knee replacement after unicompartmental knee arthroplasty versus primary total knee arthroplasty: 8–17 years follow-up study of 49 patients. International Orthopaedics 2010; 34: 649-653.

[2]Cumming RG, Klineberg RJ. Fall frequency and characteristics and the risk of hip fractures. Journal of the American Geriatrics Society 1994; 42: 774-778.

[3]Medell JL, Alexander NB. A clinical measure of maximal and rapid stepping in older women. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2000; 55: M429-M433.

Disclosure of Interests:

None declared

AB0882 RELIABILITY OF THE 3-M BACKWARDS WALK TEST IN PATIENTS WITH REVISION TOTAL KNEE ARTHROPLASTY

Background:

Total knee arthroplasty (TKA) is an effective treatment for patients suffering from end-stage osteoarthritis with 10- to 15-year implant survivorship rates exceeding 90%. Infection, osteolysis due to polyethylene wear, loosening, stiffness and instability may cause to implant failure and revision of the TKA (rTKA). However, up to 20% of patients continue to have postoperative pain, functional limitations and low treatment satisfaction and 24% of patients were not able to walk unaided with no limp or a slight limp after TKA [1].

Falls and related traumas can produce “fracture, dislocation, crushing, and other injuries” [2]. Falls often occur due to impaired physical function which includes changes in lower knee joint angle, weakened lower limb muscles, peripheral nerve blockade, deformity of the foot limited balance and gait.

Several measures of fall risk have been previously developed however, recent research has demonstrated that backwards walking is more sensitive at identifying changes in mobility and balance compared to forward walking. Backwards walking is necessary to perform such tasks as backing up to a chair, opening up a door or getting out of the way of a sudden obstacle.

3-M Backwards Walk Test (3MBWT) is used to evaluate walking skills, fall risk and dynamic balance. The 3MBWT demonstrated similar or better diagnostic accuracy for falls in the past year than the most commonly used measures and found to be reliable in healthy subjects. [3] However, its reliability in rTKA has not been investigated.

Objectives:

The purposes of this study were to determine the test-retest reliability and the minimal clinically important difference (MCID) of the 3MBWT in patients with rTKA

Methods:

Twenty-two patients with rTKA, operated on by the same surgeon, were included. For the 3MBWT, a distance of 3 meters was marked with tape and participants were asked to align their heels with the black tape. They were instructed to walk backwards as quickly. Patients performed trials for 3MBWT twice on the same day. Between the trials, patients waited for an hour on sitting position to prevent fatigue.

Results:

The 3MBWT showed an excellent test-retest reliability. Intraclass correlation coefficient ICC for 3MBWT was 0.97. The standard error of measurement and MCID at the 95% confidence level for 3MBWT were 1,08 and 2,99 respectively.

Conclusion:

The 3MBWT has an excellent test-retest reliability in patients with rTKA. It is an effective and reliable tool for measuring fall risk, dynamic balance and walking skills. As a clinical test, the 3MBWT is easy to score, has no cost, needs no special equipment and can be applied in a short time as part of the routine medical examination.

References:

[1]Shan L, Shan B, Suzuki A et al. Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. JBJS 2015; 97: 156-168.

[2]Johnson RL, Duncan CM, Ahn KS et al. Fall-Prevention Strategies and Patient Characteristics That Impact Fall Rates After Total Knee Arthroplasty. Anesthesia & Analgesia 2014; 119: 1113-1118.

[3]Carter V, Jain T, James J et al. The 3-m Backwards Walk and Retrospective Falls: Diagnostic Accuracy of a Novel Clinical Measure. J Geriatr Phys Ther 2017.

Disclosure of Interests:

None declared

AB0881 COMPARISION OF FUNCTIONAL OUTCOMES BETWEEN PRIMARY AND REVISION TOTAL KNEE ARTHROPLASTY

Background:

Total knee arthroplasty (TKA) is the gold-standard treatment for end-stage knee osteoarthritis (OA). An increase in the prevalance of primary and revision TKA is projected due to aging of the population, increase in the obesity and OA prevalence, patients‘ quality of life perceptions and primary TKA procedures. Although TKA reliably improves pain and function; gait ability and function are still low compared to normal levels [1]. It is important to understand the prognosis to decide to undergo a rTKA (revision total knee arthroplasty) or enhance treatment protocols [2].

Objectives:

The aim of the study is to compare the functional results of primary and revision TKA.

Methods:

Hospital Of Special Surgery knee score (HSS), The Figure-Of-8 Walk Test (F8WT), The Modified Four Step Square Test (mFSST) and the 3-Meter Backwards Walk Test (3MBWT) were used for function assessment.

Table 1.

Characteristics of the patients

TKArTKApHSS83.00 (74.00-90.00)78.50 (68.75-90.25)0.179Age-years65.00 (57.00 – 70.25)69.00 (59.50-75.75)0.178BMI-kg/cm230.90 28.41 -34.65)31.61 (25.54-36.41)0.748Time after surgery-years2.00 (1.50-4.25)3.00 (2.00-6.50)0.038Female25 (80.6 %)20 (69.0 %)0.296Male6 (19.4 %)9 (31.0 %)Pain0.00 (0.00-0.00)0.00 (0.00-0.75)0.127

*p<0.05

Table 2.

Functional Performances Of The Patients

TKArTKAP3MBWT6.2 (3.80-8.69)7.68 (6.10- 11.25)0.042*mFSST10.20 (9.00-12.98)13.10 (11.25-15.07)0.001*F8WT6.23 (4.74-8.6)9.11 (7.15-12.05)0.001*

*p<0.05

Conclusion:

Functional status, fall risk, balance and walking skills of the rTKA patients were lower than the TKA patients. rTKA patients experience longer operation time, hospital stay and make fewer functional gains. Improvement after rTKA is also reported to be lower than TKA and balance could be worsened or does not improve after TKA [2].

Walking skills of the rTKA patients were worse than the TKA patients which may cause rTKA patients to be more cautious and tentative due to fear of falling and failure of the implant leading a more impaired function [2]. rTKA patients’ balance was lower and had more fall risk than the patients with TKA. These may be due to the recurrent incision of soft tissues causing a loss of more mechanoreceptors and a greater impairment of proprioception. These findings can help clinicians to make a more informed decision for both primary and revision procedures [3].

References:

[1]Jiang Y, Sanchez-Santos MT, Judge AD et al. Predictors of Patient-Reported Pain and Functional Outcomes Over 10 Years After Primary Total Knee Arthroplasty: A Prospective Cohort Study. J Arthroplasty 2017; 32: 92-100.e102.

[2]Vincent KR, Vincent HK, Lee LW, Alfano AP. Inpatient rehabilitation outcomes in primary and revision total knee arthroplasty patients. Clin Orthop Relat Res 2006; 446: 201-207.

[3]Wodowski AJ, Swigler CW, Liu H et al. Proprioception and knee arthroplasty: a literature review. Orthopedic Clinics 2016; 47: 301-309.

Disclosure of Interests:

None declared

AB1293-HPR DETERMINING FUNCTIONAL MOBILITY AND BALANCE FOR PATIENTS AFTER TOTAL KNEE ARTHROPLASTY: RELIABILITY OF L-TEST

Background:

Total knee arthroplasty (TKA) is a very common procedure, particularly implemented for the treatment of knee osteoarthritis (OA). Patient expectations after TKA surgery now include being able to enjoy appropriate recreational activities representing ambulatory activities beyond that of just pain relief and adequate knee motion (1). Since recreational activity comprises of more complex functions and requires longer standing durations, walking for 6-meter in a straight line in the timed up and go test (TUG) does not fully reflect the functional capacity of patients with TKA, and TUG test may be limited to detect the balance and mobility capacity in TKA patients (2, 3). As such, there is a need to determine more effective and functional evaluation tools that better reflect realistic situations in order to assess ambulatory performance level for patients with TKA. However, no studies have been conducted in patients with TKA to examine the applicability of the L-test, which assesses ambulation of individuals and consists of complex mobilization activity.

Objectives:

The purposes of this study were to determine the test-retest reliability and the minimal detectable change (MDC) of the L-test for TKA patients.

Methods:

Twenty-four patients with TKA due to knee OA, operated by the same surgeon, were included in this study. Patients performed trials for L-test twice on the same day. Between the first and second trials, patients waited for an hour on sitting position to prevent fatigue. The tester recorded the performance time while the participant was asked to get up from a chair, walk 3 m in a straight line, turn right, continue walking for 7 m in a straight line, turn left, walk back along the same path and sit down in the chair at their usual walking speed. Prior to the real testing session, the L-test was demonstrated by the tester and all participants were allowed to a practice trial.

Results:

The L-test showed an excellent test-retest reliability (ICC2,1= 0,98) in this study. Standard error of measurement (SEM) and MDC95for L-test were 1,01 second and 2,8 second, respectively.

Conclusion:

This study found that the L-test is a reliable test for patients following TKA. Overall, the excellent test-retest reliability of the L-test indicates that it may be an applicable standardized method to assess TKA patients who are able to walk greater distances and have better gait in more functional situations. Clinicians and researchers can be confident that changes in L-test time above 2,8 seconds, represent a “real” clinical change in an individual patient with TKA. We, therefore, recommend the use of L-test as complementary outcome measures for balance and functional evaluation in TKA patients.

References:

[1]Swinkels, A., & Allain, T. J. (2013). Physical performance tests, self-reported outcomes, and accidental falls before and after total knee arthroplasty: an exploratory study. Physiotherapy theory and practice, 29(6), 432-442.

[2]Deathe, A. B., & Miller, W. C. (2005). The L test of functional mobility: measurement properties of a modified version of the timed “up & go” test designed for people with lower-limb amputations. Physical therapy, 85(7), 626-635.

[3]Kim, J. S., Chu, D. Y., & Jeon, H. S. (2015). Reliability and validity of the L test in participants with chronic stroke. Physiotherapy, 101(2), 161-165.

Disclosure of Interests:

None declared

AB1284-HPR RELIABILITY OF STEP TEST IN SUBJECTS WITH TOTAL KNEE ARTHROPLASTY

Background:

Patients with TKA show impairments in standing balance up to 1 year after surgery. The impaired standing balance in TKA patients was found to be associated with falls risk and decreased functional level. Assessing of standing balance with objective and reliable assessments tools would therefore be extremely useful for determining accurate exercise program, and risks of falling, especially during the rehabilitative period when ambulation is at its most unsteady (1, 2). The stepping maneuver requires adequate strength and motor control to stabilize the body over the stance limb while the other leg is stepping, therefore the Step Test (ST) provides significant information for dynamic standing balance and lower limb motor control (3). The reliability of ST is reported in patient groups such as stroke, however, there is not any study that investigates the reliability of ST in patients with TKA in the current literature.

Objectives:

The purposes of this study were to determine the test-retest reliability and the minimal detectable change (MDC) of the ST in patients with TKA.

Methods:

40 patients with TKA due to knee osteoarthritis, operated by the same surgeon, were included in this study. Patients performed trials for ST twice on the same day. Between the first and second trials, patients waited for an hour on sitting position to prevent fatigue. The ST assesses an individual’s ability to place one foot onto a 7.5-cm-high step and then back down to the floor repeatedly as fast as possible for 15 seconds. The score is the number of steps completed in the 15-second period for each lower extremity. Scores for each lower extremity were recorded separately. Prior to the testing, the ST was demonstrated by the tester and all participants were allowed to a practice trial.

Results:

The ST showed an excellent test-retest reliability (ICC2,1=0.95) in this study. Standard error of measurement (SEM) and MDC95for ST were 0.37 and 1.02, respectively.

Conclusion:

This study found that the ST has an excellent test–retest reliability in patients with TKA. It is an effective and reliable tool for measuring dynamic standing balance and participant falls. As a performance-based clinical test, the ST is easy to score, can be applied in a short time as part of the routine medical examination. Therefore, inclusion of ST into a more comprehensive battery of performance-based measures of standing balance and lower limb motor control function in subjects with TKA should be considered.

References:

[1]Si, H. B., Zeng, Y., Zhong, J., et al. (2017). The effect of primary total knee arthroplasty on the incidence of falls and balance-related functions in patients with osteoarthritis. Scientific reports, 7(1), 1-9.

[2]Moutzouri, M., Gleeson, N., Billis, E., et al. (2017). The effect of total knee arthroplasty on patients’ balance and incidence of falls: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 25(11), 3439-3451.

[3]Hill, K. D., Bernhardt, J., McGann, A. M., et al. (1996). A new test of dynamic standing balance for stroke patients: reliability, validity and comparison with healthy elderly. Physiotherapy Canada, 48(4), 257-262.

Disclosure of Interests:

None declared

Similar effects of two different external supports on wrist joint position sense in healthy subjects: A randomized clinical trial

The hand is one of the most injured organs. Proprioceptive rehabilitation decreases the incidence of injury while using external supports can increase proprioception. The aim of this study was to investigate the effects of taping and elastic bandaging on wrist joint position sense (proprioception) in healthy individuals. Sixty-eight healthy students were included in our study and randomized into two groups. External supports were to apply to the dominant hand for 24hours in both groups. Joint position sense was evaluated with an angle reproduction test before applying the external support and 20 minutes after and then 24hours later with the external support and after removing it. There were significant improvements in joint position sense 20 minutes after applying the external support and 24hours later (P<0.05). Although a significant decrease in joint position sense was observed after removing the external support compared to while wearing it (P<0.05), there was a significant improvement in the joint position sense relative to the pre-study assessment (P<0.05). In between group comparisons, the only significant difference was observed 20 minutes after the external support was applied: the taping group had better results in joint flexion position sense than the bandaging group (P<0.05), but in the other assessments there were no significant differences between two groups (P>0.05). It was found that two different types of external support can improve the wrist joint's position sense in healthy subjects. These procedures can be used as a supplemental treatment in wrist rehabilitation.

Inter- and intra-tester reliability of sensibility testing in digital nerve repair

The aim of this study was to investigate the inter- and intra-tester reliability of the static two-point discrimination and Semmes-Weinstein monofilament tests in digital nerve repair. A total of 100 digital nerves from 67 patients were included into the study. An experienced orthopaedic surgeon and a physiotherapist examined the sensory nerve recovery. The reproducibility score of both tests was at a poor level, but the reliability of the Semmes-Weinstein monofilament test was higher than the static two-point discrimination test. These tests should not be used alone in the quantitative monitoring of sensory recovery, but should be interpreted with the clinical findings.Level 3 non-randomized controlled study.

A brief report on managing infected nonunion of a high tibial osteotomy in two stages: a case series involving seven knees

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review. Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR.

Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up

OBJECTIVE

The goal of this study has been to determine whether hyaluronic acid (HA) or exercise therapy can improve functional parameters in patients with osteoarthritis (OA) of the ankle.

METHODS

In a prospective clinical trial, 43 ankles (30 patients) with radiographic Kellgren Lawrence grade III OA were randomized to receive three intra-articular HA injections, with one-week interval of or exercise therapy for six weeks. Patients were evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and followed-up after 12 months.

RESULTS

Total AOFAS Ankle-Hindfoot score of OA patients has improved in both groups, varying from 61.6+/-16.8 to 90.1+/-9.7 with HA treatment and from 72.1+/-16.6 to 87.5+/-17.5 using exercise therapy at the end of the trial (p<0.01). There were no statistically significant differences between the groups.

CONCLUSION

This prospective randomized trial confirmed that, both HA injections and exercise therapy provide functional improvement. However, larger trials with longer follow-up are necessary for more definite conclusions.

Comparison of two hyaluronan drugs in patients with advanced osteoarthritis of the knee. A prospective, randomized, double-blind study with long term follow-up

OBJECTIVES

To compare the long-term effects of high and low molecular weight hyaluronic acid (HA) applications in severe (Kellgren Lawrence stage III) osteoarthritis (OA) of the knee.

METHODS

In a prospective clinical trial 184 knees (92 patients) with radiographic Kellgren Lawrence stage III OA were randomized to receive either 3 intra-articular high molecular weight HA (Hylan G-F 20) injections or 3 low molecular weight HA (Orthovisc) injections at one-week intervals. Patients were evaluated by the Hospital for Special Surgery (HSS) Knee Score and were followed-up for 12 months.

RESULTS

The total HSS score in high molecular weight HA patients improved from 71.8+/-11.6 to 86.7+/-11.6 and in low molecular weight HA patients from 66.7+/-11.0 to 86.6+/-9.1 at the end of the trial (p < 0.01). There were no statistically significant differences between the groups and both had improved in all parameters at the latest follow-up (p = 0.000).

CONCLUSIONS

Three intra-articular injections at intervals of 1 week of both HA preparations resulted in a pronounced reduction in pain and improved function as measured by the HSS score during a period of 52 weeks, without complications.

Postoperative immobilisation orthosis for surgically corrected hallux valgus

A postoperative immobilisation orthosis was developed at the School of Physical Therapy and Rehabilitation, Department of Orthotics and Prosthetics, and applied from the first postoperative day as an alternative device for ambulation of patients who have undergone hallux valgus surgery while maintaining the corrected position. The orthosis is constructed with polyethylene thermoplastic sheet of 3mm thickness and Velcro. During the ambulation period, there was no complication or complaint due to its application and the position of the great toe was maintained. The time of the orthotic application was six weeks. The orthosis has allowed patients to walk with full weight bearing from the postoperative first day without any complication or recurrence.

Normal ranges of ulnar and radial deviation with reference to ulnar variance

We aimed to determine the normal ranges of radial and ulnar deviation of the wrist in relation to the ulnar variance. A total of 102 healthy subjects (204 wrists) were included in the study. The ranges of radial and ulnar deviation of the wrists were measured using a universal goniometer. Ulnar variance was assessed manually or radiographically, and recorded as ulna minus, ulna plus or ulna minus/plus. When the ranges of radial and ulnar deviation were compared with ulnar variance, ulnar deviation was greater in ulna minus subjects and radial deviation was greater in ulna minus/plus subjects. There was no significant difference in the total range of radio-ulnar deviation. The results of this study indicate that ulnar deviation is greater in ulna minus wrists, and we suggest that ulnar variance should be recorded alongside measurements of radial and ulnar deviation.

Dokuz Eylül University (DEU) orthosis: an orthotic method of preventing ankle equinus during tibial lengthening

An orthosis developed in Dokuz Eylül University (DEU) at the School of Physical Therapy and Rehabilitation, Department of Orthotics and Prostheticsis is described. It is applied as a non-invasive device attached to the distal ring of the Ilizarov external fixator to keep the ankle joint in a neutral position and prevent ankle equinus during tibial lengthening with Ilizarov technique. This minimises additional invasive techniques such as heel cord release and prophylactic pinning of the heel and the foot, and manipulation under anaesthesia. It may also be detached by the physiotherapist or patient when physical therapy is needed during the lengthening procedure.

Simplified citrate anticoagulation for high-flux hemodialysis

In a randomized crossover trial, we compared a simple citrate anticoagulation protocol for high-flux hemodialysis with standard anticoagulation by low-molecular-weight heparin (dalteparin). Primary end points were urea reduction rate (URR), Kt/V, and control of electrolyte and acid-base homeostasis. Secondary end points were bleeding time at vascular puncture sites and markers of activation of platelets, coagulation, and fibrinolysis. Solute removal during citrate dialysis was excellent (URR, 0.71 +/- 0.06; Kt/V, 1.55 +/- 0.3) and similar to results of conventional bicarbonate hemodialysis anticoagulation with dalteparin (URR, 0.72 +/- 0.04; Kt/V, 1.56 +/- 0.2). Electrolyte control was effective with both anticoagulation regimens, and total and ionized calcium, sodium, potassium, and phosphate concentrations at the end of dialysis did not differ. Alkalemia was less frequent after citrate than conventional dialysis (pH 7.5 in 25% versus 62% of patients; mean pH at end of dialysis, 7.46 +/- 0.06 versus 7.51 +/- 0.07; P < 0.01). Bleeding time at puncture sites was shorter by 30% after citrate compared with dalteparin anticoagulation (5.43 +/- 2.80 versus 7.86 +/- 2.93 minutes; P < 0.001). Activation of platelets, coagulation, and fibrinolysis was modest for both treatments and occurred mainly within the dialyzer during dalteparin treatment and in the vascular-access region during citrate anticoagulation. Citrate-related adverse events were not observed. We conclude that citrate anticoagulation for high-flux hemodialysis is feasible and safe using a simple infusion protocol.

Expanding our interventional skills: placement of totally implantable injection ports by internists/intensivists

Totally implantable injection ports are usually placed by surgeons or radiologists using fluoroscopic guidance. In a prospective study we evaluated the efficacy of percutaneous insertion of these devices without the use of fluoroscopic control by internists/intensivists experienced in the placement of permanent cuffed catheters. The supraclavicular approach to the subclavian vein was chosen for first line puncture site because of its low rate of malpositions and complications. 101 ports were inserted in 101 consecutive patients, 96 from the supraclavicular approach. Difficulties in introducing the catheter through the peel-away sheath, misplacement into adjacent vessels, secondary migration, or fragmentation of a line were not observed. Function was excellent in all ports. Three pneumothoraces (3%) and three arterial punctures (3%), none of which required intervention, were recorded. Two ports (2%) had to be revised, one due to local hematoma and another because of inadequate catheter length. Catheter survival was 94% in a 30-month observation period. Placement of totally implantable port systems by internists/intensivists experienced in placing central venous lines is safe and efficient, thus the implantation can easily be performed with minimal technical expenditure in the setting of an intensive care unit. The supraclavicular approach is suitable for insertion of permanent infusion port systems without fluoroscopic control.