A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE.

BACKGROUND: High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3-10 years) and long term (>10 years) follow up in patients with TKA. METHODS: Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284. RESULTS: Five cohort studies and one case-control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4-12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24-1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34-5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2-4.7, level of certainty: low). CONCLUSION: During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.

Recovery of knee range of motion after total knee arthroplasty in the first postoperative weeks: poor recovery can be detected early.

PURPOSE: The aim of this study was to analyze in detail how knee flexion and extension progress in the first 8 weeks after primary total knee arthroplasty (TKA). The secondary goal was to compare knee range of motion (ROM) recovery patterns between patients with normal and delayed ROM recovery 8 weeks after TKA. METHODS: This prospective clinical trial included all patients who underwent a primary unilateral TKA between February and December 2016 with weekly ROM data documented by the treating outpatient physical therapists (n = 137). Goniometry was used to measure knee ROM preoperatively, postoperatively on day 1 and weekly until follow-up at the orthopedic clinic 8 weeks after surgery. ROM recovery patterns were compared between patients with sufficient (≥ 90°) or insufficient (< 90°) knee flexion 8 weeks after TKA. RESULTS: Knee flexion recovered from a median of 80° in the first postoperative week to 110° 8 weeks after surgery and knee extension from a mean of - 10.7° to - 3.2°. Recovery was nonlinear, with greatest improvements in the first 4 weeks for knee flexion. In contrast to patients with sufficient knee flexion 8 weeks postoperatively, the insufficient group (n = 8, 5.8%) had poor knee flexion on the first postoperative day and from week 4 to week 8 almost no improvement or even worsening of knee flexion. CONCLUSIONS: Both knee flexion and extension recover in a nonlinear manner after TKA surgery. Poor postoperative knee function can be detected early, using ROM data from the first postoperative day up to the fourth week.

Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature.

INTRODUCTION: The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery. METHODS: A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA. RESULTS: Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA. CONCLUSION: Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.

The rate of dislocation is not increased when minimal precautions are used after total hip arthroplasty using the posterolateral approach: a prospective, comparative safety study.

AIMS: In order to prevent dislocation of the hip after total hip arthroplasty (THA), patients have to adhere to precautions in the early post-operative period. The hypothesis of this study was that a protocol with minimal precautions after primary THA using the posterolateral approach would not increase the short-term (less than three months) risk of dislocation. PATIENTS AND METHODS: We prospectively monitored a group of unselected patients undergoing primary THA managed with standard precautions (n = 109, median age 68.9 years; interquartile range (IQR) 61.2 to 77.3) and a group who were managed with fewer precautions (n = 108, median age 67.2 years; IQR 59.8 to 73.2). There were no significant differences between the groups in relation to predisposing risk factors. The diameter of the femoral head ranged from 28 mm to 36 mm; meticulous soft-tissue repair was undertaken in all patients. The medical records were reviewed and all patients were contacted three months post-operatively to confirm whether they had experienced a dislocation. RESULTS: There were no dislocations in the less restricted group and one in the more restricted group (p = 0.32). CONCLUSION: For experienced surgeons using the posterolateral approach at THA and femoral heads of diameter ≥ 28 mm, it appears safe to manage patients in the immediate post-operative period with minimal precautions to protect against dislocation. Larger studies with adequate statistical power are needed to verify this conclusion. TAKE HOME MESSAGE: Experienced orthopaedic surgeons using the posterolateral approach for THA should not fear an increased dislocation rate if they manage their patients with a minimal precautions protocol. Cite this article: Bone Joint J 2016;98-B:589-94.