Participation in sports after hip and knee arthroplasty: review of literature and survey of surgeon preferences.

OBJECTIVE: To summarize previously published findings and to present the opinions of a group of reconstructive orthopedic surgeons from a single institution on participation in sports after hip or knee arthroplasty. DESIGN: We reviewed the literature pertaining to participation in sports after hip or knee arthroplasty and surveyed a group of orthopedic surgeons about their recommendations for resumption of various sports activities by patients who had undergone total hip or knee arthroplasty. MATERIAL AND METHODS: A computerized literature search was performed, and salient issues about participation in sports after joint replacement procedures were synthesized. At the Mayo Clinic, 28 orthopedic surgeons (13 consultants and 15 fellows or residents) completed a single-page questionnaire that requested a recommendation ("yes," "no," or "depends") about patients resuming participation in 28 common sports after recovery from total hip or knee arthroplasty. Staff surgeon responses were compared with responses from fellows and residents by using the Mann-Whitney U test. Sports in which 75% of surgeons would not allow participation were identified as "not recommended," whereas sports in which 75% of surgeons would allow participation were labeled as "recommended." RESULTS: Fellows and residents were less likely than staff surgeons to allow return to cross-country skiing after total knee arthroplasty. Otherwise, responses from consultant surgeons and from fellows and residents did not differ significantly. Recommended sports included sailing, swimming laps, scuba diving, cycling, golfing, and bowling after hip and knee replacement procedures and also cross-country skiing after knee arthroplasty. Sports not recommended after hip or knee arthroplasty were running, waterskiing, football, baseball, basketball, hockey, handball, karate, soccer, and racquetball. CONCLUSION: After hip or knee arthroplasty, participation in no-impact or low-impact sports can be encouraged, but participation in high-impact sports should be prohibited.

Total knee arthroplasty: a population-based study.

Total knee arthroplasty (TKA) is being used increasingly for the management of chronic arthritis of the knee. In this report, we review the frequency of application of TKA in the population of Olmsted County, Minnesota, from 1971 through 1986. The utilization rate of TKA increased from 20.5 per 100,000 person-years for 1971 through 1974 to 60.8 per 100,000 for 1983 through 1986. Although rates were higher in women, they increased with advancing age in both sexes. Rates between the urban and rural populations of Olmsted County did not differ. The two most common underlying diseases that necessitated TKA were osteoarthritis and rheumatoid arthritis; they were the cause of more than 90% of all operations. By extrapolating the rates of TKA in Olmsted County to the total 1986 US population, we estimate a need for at least 143,000 TKAs annually at a direct cost of more than $2.3 billion each year.

Inter-rater reliability for function and strength measurements in the acute care hospital after elective hip and knee arthroplasty.

OBJECTIVE: To determine the inter-rater reliability of function and strength measurements in patients undergoing elective hip and knee arthroplasty in an acute care setting. METHOD: Forty-four patients underwent either total hip or knee arthroplasty. Patients were rated by 4 occupational therapists and 7 physical therapists on their performance of 5 functional tasks: lower extremity dressing, toilet transfer, supine-to-sit transfer, sit-to-stand transfer, and ambulation to 100 feet. Strength measurements of the quadriceps femoris muscle were measured quantitatively with a Microfet hand-held dynamometer. Data were analyzed to determine the interrater reliability using the Kappa statistic (K) for the functional tasks and the intra-class correlation coefficient (ICC) for the strength measurements. RESULTS: A high level of inter-rater reliability was achieved for lower extremity dressing, toilet transfer, supine-to-sit transfer, sit-to-stand transfer, and ambulation to 100 feet, as evidenced by K values between 0.75 and 0.99. Reliability was also excellent for quantitative strength measurements using the dynamometer, with an ICC of 0.94. CONCLUSION: This study demonstrated excellent interrater reliability with measurements of function and strength post-operatively after elective hip and knee arthroplasty. The practical implication is that by using a standardized measurement tool in the acute care setting, the treatment team can more reliably assess patients' progress, which may aid clinical decision making.

The role of manipulation following total knee replacement.

During a twelve-month period, 23 per cent of a series of knees undergoing total replacement were manipulated two weeks postoperatively to increase flexion. While manipulation achieved an immediate increase in flexion from a mean of 71 degrees to a mean of 108 degree, by one week after manipulation the mean flexion was reduced to 88 degrees. By one year postoperatively, the manipulated knees were found to have a range of motion similar to that of their non-manipulated counterparts. Such factors as preoperative flexion and diagnosis appear to be the major determinants of ultimate flexion, and they seem to offset the temporarily increased flexion afforded by manipulation. The primary reason for manipulation is to facilitate the postoperative rehabilitation program for patients with painful, limited motion of the knee.

The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty.

A prospective, controlled, randomized trial of continuous passive motion and immobilization after knee arthroplasty revealed that continuous passive motion significantly improved early and late flexion of the knee, reduced the duration of stay in the hospital, and did not increase the incidence of superficial infection or problems with wound-healing. Flexion of the knee beyond 40 degrees progressively diminished viability of the edges of the wound, particularly the lateral edge. On the basis of these results, a protocol for continuous passive motion was designed to minimize the detrimental effects on viability of the wound.

Quantitative gait analysis after total knee arthroplasty for monarticular degenerative arthritis.

By quantitative gait analysis, we characterized the functional results of total knee arthroplasty in a group of twelve elderly patients with isolated degenerative arthritis of one knee. All patients had had a standard replacement arthroplasty performed at least two years before the study. In the gait analysis we used high-speed movie cameras synchronized with force platforms and electromyograms to provide kinetic and kinematic data. The data were compared with those obtained from an age-matched control group. In the patients most of the measurements of gait had been restored to normal levels. These measurements included: velocity; stride length; arcs of motion of the hip, knee, and ankle bilaterally; phasic muscle activity; and the amount of mechanical work performed. There were three patterns of external torque across the implants and in the control knee which were comparable in magnitude but varied in relative frequency between the two groups. As compared with the controls, the patients spent approximately 30 per cent more time in double-limb stance and had prolonged cycle times. These findings may have been the result of muscle weakness, neural impairment, or habit, but the cause could not be determined by this study.

Total knee-replacement arthroplasty. Results with the intramedullary adjustable total knee prosthesis.

One hundred and thirty knees (112 patients) in which the intramedullary adjustable total knee prosthesis was inserted were followed for four to nine years. This prosthesis is designed to permit unconstrained rotation and includes a metal tray supporting the high-density-polyethylene tibial component as well as an intramedullary stem and two condylar intramedullary projections on both the femoral component and the tibial component. Using a rating system in which pain, function, stability, and motion each was graded independently on a scale of 1 to 6, the preoperative scores were 73 per cent poor and 27 per cent fair, while the postoperative scores were 77 per cent good, 15 per cent fair, and 8 per cent poor. If only the patients with unilateral or bilateral involvement of the knee without other functional disabilities were considered, four to nine years after the arthroplasty 92 per cent could be classified as good; 5 per cent, as fair; and 3 per cent, as poor. There were two deaths (one due to pulmonary embolism and the other, to overwhelming sepsis after attempted arthrodesis for a deep would infection) and five deep infections, four of which necessitated reoperation for arthrodesis. In addition, reoperations were necessary in five other knees: in two for secondary closure of the wound, in one for evacuation of a hematoma, in one for synovectomy and skin-grafting because of infection, and in one for recentralization of the patella. At final evaluation, 117 knees had radiographs of sufficiently good quality for assessment, and thirty-seven (32 per cent) of these showed evidence of a nonprogressive radiolucent line about the tibial component. In addition, two were considered clinically loose (one due to a traumatic injury and the other, to malpositioning of the tibial component).

Patient-perceived functional outcomes associated with elective hip and knee arthroplasties.

The purpose of this study was to determine the effect elective hip and knee arthroplasties had on functional activities of daily living and if the background variables of age, gender, and surgery location can be used to predict functional outcome after these types of surgeries. Data were collected from 43 subjects, 6 to 35 months after they had elective hip or knee arthroplasties. The subjects responded to a mail survey that defined before surgery and after recovery functioning in relation to 22 activities of daily living representing personal care, housework-yard work, and recreation-social activities. Approximately 65% of the subjects reported no change in their ability to perform the 22 surveyed activities. Psychosocial variables appeared to be significant determinants of function. When the selected background data were compared with surgery results, women performed significantly better than men (p less than .05), but age and surgery location were not significant variables affecting outcome.

Reliability, validity, and responsiveness of functional tests in patients with total joint replacement.

BACKGROUND AND PURPOSE: High-quality measurements are needed to develop meaningful clinical practice databases to assess the effectiveness of physical therapy. This study determined the reliability, validity, and responsiveness of measurements obtained with five functional tests graded with the newly developed Iowa Level of Assistance Scale. SUBJECTS AND METHODS: Eighty-six patients with total hip or knee replacements were tested at various time periods during their hospitalization. Patients were tested for five functional activities by four therapists to establish the reliability and test responsiveness. The Harris Hip Rating Scale was administered to assess the validity of the functional score. RESULTS: The weighted Kappa statistic supported good intratester (K = .79-.90) and moderate intertester (K = .48-.78) reliability. The correlation between the Harris Hip Rating Scale scores and the total functional scores was high (r = -.86). The total functional score was responsive to 4 days of therapy postoperatively. CONCLUSION AND DISCUSSION: The assessment of function using the Iowa Level of Assistance Scale was shown to be highly reliable, valid, and responsive in patients following total hip or knee replacements.

Short-term recovery from hip and knee arthroplasty.

There are many studies of long-term recovery from major point arthroplasty, but little is known about the first days and weeks after operation. We measured function, emotional state and life evaluation before arthroplasty and at seven and 50 days after in a consecutive series of 40 hip and 23 knee replacements. Pain was relieved significantly at seven days after hip arthroplasty and even more at 50 days. In knee patients, pain relief was modest and was not apparent until 50 days. Functional ability was much improved by 50 days in hip patients, but hardly changed in knee patients. Positive mood and life satisfaction did not improve in either group. Our findings will help with more accurate information for patients before operation and also in judging the rate of recovery.

Knee arthroplasty using a cementless PCA prosthesis with a porous-coated central tibial stem. Clinical and radiographic review at five years.

In 44 consecutive patients, 60 porous-coated anatomic total knee (PCA) prostheses with a porous-coated central tibial stem were implanted without using cement. The clinical results and bony remodelling have been assessed after five years' follow-up. The average Hospital for Special Surgery knee score was 33.1 before operation and 95.7 at the latest follow-up, while the average range of movement improved from 63 degrees to 123 degrees. No subsidence or migration of the components was seen. A radiodense line appeared around the components at six months to one year after the operation and became more dense with time. There was no evidence of bone resorption related to stress-shielding in the tibial plateau.

A custom-made prosthesis for the treatment of supracondylar femoral fractures after total knee arthroplasty: report of four cases.

Four supracondylar femoral fractures following total knee arthroplasty, two because of intraoperative notching of the anterior femoral cortex and two because of osteoporosis, were revised using a custom-made prosthesis with femoral condyle section. At 1-6 year follow-up (median 3 years) after the revision, all patients had an excellent clinical result, although 2 had a prolonged rehabilitation period because of severe osteoporosis. At roentgenographic examination, no signs of loosening of the prostheses at the cement-bone interface were present.

Gait analysis in peripheral vascular insufficiency through-knee amputation.

Due to recent improvements in prosthetic limb componentry, through-the-knee (knee disarticulation) amputation has gained new interest for rehabilitation-minded amputation surgeons. Recent objective scientific studies from our gait analysis laboratory have described the walking characteristics of peripheral vascular insufficiency through-knee amputees, and have compared their function with similar patients amputated above (transfemoral), or below (trans-tibial), the knee joint. This paper provides a summary of that available information.

Total hip and knee replacement treatment programs: a report using consensus.

Physical therapists may use varied treatment protocols for the acute care of patients with to hip or knee replacements. The purpose of this study was to develop, via consensus, a standardized treatment program for patients receiving total hip or knee replacement for primary osteoarthritis. Eighteen clinicians nationwide participated in a three-round consensus process. In Round 1, over 80% of the panel identified exercise, transfers, ambulation, and discharge criteria as the important treatment categories. In Round 2, they reviewed the preliminary physical therapy treatment program and recommended additional exercise regimes. In Round 3, 76% of the panel accepted the final total hip replacement program while 70% of the panel accepted the total knee replacement program. Using the consensus development process, physical therapists may begin to define their treatment programs which is fundamental to establishing a baseline standard of care.

Rehabilitation parameters in total knee replacement patients undergoing epidural vs. conventional analgesia.

Epidural analgesia for total knee replacement (TKR) surgery has been proposed as a means of enhancing patient comfort, thereby expediting rehabilitation and reducing hospital stay. This study was done to determine differences in rehabilitation parameters of range of motion and mobility in patients receiving epidural vs. conventional (intravenous) analgesia following TKR surgery. Chart reviews were done of 52 patients who underwent consecutive unilateral TKR, with 26 patients in each analgesia group. There were 21 males and 31 females, ages 24-88 years (median 65), with diagnoses of osteoarthritis (45), rheumatoid arthritis (4), and other (3). The surgeon, procedure, type of prosthesis, and physical therapy protocol were the same for all subjects. Demographics, range of motion, distance walked, assistance required for gait and transfers, assistive device, and exercise competence data were studied at the first postoperative day and at time of discharge. No significant difference was found in the length of stay at the p < .05 level. Significant differences at the first postoperative day favored the epidural group: in knee flexion range--median difference was 0.26 rad [95% confidence interval (CI): 0.09-0.52, p < .05] ie., 15 degrees (95% CI: 5-30); in total range of motion--median difference was 0.30 rad (95% CI: 0.09-0.58, p < .05), ie., 17 degrees (95% CI: 5-33); and in assistance required for gait and transfers (p < .05). At discharge, the epidural group required significantly less assistance (p < .05). There was a trend toward greater walking distance in the epidural group, who walked a median of 15.2 m farther than the conventional analgesia group.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring outcome of total knee replacement using quality of life indices.

A series of 26 patients was studied before and after total knee replacement to determine the change in their quality of life, expressed as a gain in Quality Adjusted Life Years (QALYs). Global health status was assessed using the Nottingham Health Profile, disability by the Harris scale, pain by the McGill Pain Questionnaire, and anxiety and depression by the Hospital Anxiety and Depression Scale. Substantial reductions were found in pain, anxiety and depression, and a significant improvement was found in mobility. These data were used to generate a 'QALY' (Quality Adjusted Life Year) comparable to the measure used by Williams (1) in his comparative evaluation of medical and surgical treatments. A gain of only 0.42 QALY was found for knee replacement, which is about one-tenth the figure given by Williams for hip replacement. The difference appears to be attributable not to differences in the success of the operations, but rather to the scope that QALY calculations give for allocating comparable patients to different quality of life states. Tighter criteria are needed if QALYs are to be used to guide resource allocation.

Beneficial effects of continuous passive motion after total condylar knee arthroplasty.

A randomised, controlled study of the use of postoperative continuous passive motion (CPM) and immobilisation regimen after total condylar knee arthroplasty was performed. CPM resulted in a significant increase in both the early and late range of knee flexion. This increase occurred in both rheumatoid and osteoarthritic patients. The improvement of 10 degrees at 12 months allowed additional important function to be attained. CPM resulted in significantly earlier discharge from hospital. It did not increase the clinical incidence of wound healing problems, nor did it significantly increase the postoperative fixed flexion deformity or the extension lag. CPM can be recommended as a safe and effective modality to achieve more rapid and more successful postoperative rehabilitation after knee arthroplasty.

Epidural infusions of bupivacaine and fentanyl do not improve rehabilitation following one-stage bilateral total knee arthroplasty.

Epidural analgesia with local anaesthetic minimizes the catabolic response to surgery. To determine whether this could enhance the rate of recovery following orthopaedic surgery, 51 patients undergoing bilateral one-stage total knee arthroplasty were allocated to receive infusions of either continuous epidural bupivacaine/fentanyl or continuous intravenous fentanyl to compare the efficacy of these modes of pain relief on postoperative clinical outcomes and rates of rehabilitation. Infusions were maintained for 36 to 48 hours in a post-anaesthesia care unit (PACU). Postoperatively, pain relief (visual analogue scale), attainment of physical therapy goals and cardiopulmonary complications were measured daily for 7 days. Epidural analgesia with a combination of bupivacaine and fentanyl did not result in any measurable improvement in rehabilitation milestones or reduction in postoperative complications following bilateral total knee arthroplasty than with fentanyl infusions alone.

Interdisciplinary team approach in the rehabilitation of hip and knee arthroplasties.

Use of an interdisciplinary case management team approach in the treatment of patients with hip or knee arthroplasty has resulted in a decrease in length of stay and achievement of functional outcomes at the authors' center. Case management was used to standardize patient care and to measure each patient's progress toward independence against established criteria of treatment outcomes. Outcomes established for physical therapy were ambulation distance, performance of a home exercise program, stair climbing, amount of active knee flexion (for knee arthroplasties), and incorporation of hip precautions. Outcomes for occupational therapy were bed mobility, chair transfers, toilet transfers, and activities of daily living with emphasis on lower extremity dressing. The case management team consists of an occupational therapist, an occupational therapy assistant, a physical therapist, and two nurses. The specific role of the occupational therapy personnel in this team approach is to maximize, by discharge, a patient's functional level of independence in activities of daily living. Data from a 6-month period indicated that occupational therapy goals were achieved for 79% of the 33 knee arthroplasty patients and 73% of the 37 hip arthroplasty patients.

Preliminary results of Miller-Galante uncemented total knee arthroplasty.

From July 1984 through February 1986, a total of 46 knees were placed in 42 patients. The average age of all patients was 58 years (range, 32 to 68). Osteoarthritis was the diagnosis in 38 knees, traumatic arthritis in 5, and rheumatoid arthritis in 3. During follow up, averaging 3.6 years (range, 2.0 to 4.5), the total knee score based on a modified Hospital for Special Surgery knee rating scale improved from a preoperative average of 59 to 93 postoperatively. Radiographically, partial radiolucencies (less than 1 mm) were present in at least one view in 72% of the knees in which the interface was well visualized. No radiolucencies were progressive. Complications occurred mainly in the patellar components, as 17% of metal-backed uncemented patellae required revision to cemented non-metal backed components. There were no deep infections. The authors remain cautiously optimistic while awaiting long-term follow up.