Use of Remote Physiologic and Therapeutic Monitoring Following Total Knee Arthroplasty.

INTRODUCTION: Remote physiologic monitoring (RPM), or remote therapeutic monitoring (RTM), has grown exponentially for the management of chronic medical diseases in Medicare patients. More recently, the application of this technology has ventured into the orthopaedic arena, and more specifically, for total joint arthroplasty. Platforms to expedite this monitoring can provide continuous biodata feedback on digital biomarkers to patients and surgeons, which can potentially help improve and create novel patient-specific recovery pathways. Furthermore, various devices developed for this monitoring might help obviate the need for frequent emergency room visits, readmissions, and prolonged outpatient physical therapy sessions, as well as reduce complications and increase patient satisfaction scores after total joint arthroplasty surgery. However, while there are a number of potential benefits to technology for this type of care, its application following total knee arthroplasty has not been well-studied. Therefore, after an overview of the usage of RPM and RTM, the purpose of this study was to review the current literature regarding three common remote monitoring technologies: 1) smartphone apps; 2) wearables; and 3) combined smartphone apps and wearables. We also considered the potential financial implications of remote physiologic monitoring. MATERIALS AND METHODS: A comprehensive search of the PubMed, Cochrane Library, MedLine, and Web of Science databases was performed. Three main subgroups of monitoring devices were included for analysis: smartphone apps, wearable devices, and combined wearable plus smartphone app platforms. Searches focused on remote physiologic monitoring, patient-specific advantages, financial advantages, billing and coding options, as well as overall efficacy of platforms. RESULTS: The current review found smartphone apps, wearables, and combined smartphone app and wearable platform technologies to be advantageous in the postoperative period following total knee arthroplasty. The wearable components can provide highly accurate and reproducible data, which the user-friendly smartphone app can relay to the patient so they can easily understand their progress. Additionally, through the apps, patients can directly access their surgical team. By constantly collecting and evaluating range of motion and functional data, the surgical team can identify if the patient is appropriately progressing through treatment or if further intervention is warranted. CONCLUSION: The incorporation of the remote physiologic monitoring devices during the post-total knee arthroplasty period shows strong promise as a progress-tracking modality. Published benefits include reduced physical therapy visits, decreased pain scores and reliance on opioids, increased activity levels as assessed by step counts, increased ability to follow less well-performing patients, reduced readmissions, reduced in-person clinic visits, and decreased postoperative costs.

Pain Management Strategies To Reduce Opioid Use Following Total Knee Arthroplasty.

INTRODUCTION: Due to the rising concern regarding excessive opioid use, several alternative pain control options have been developed for total knee arthroplasty (TKA). Therefore, the purpose of this article was to review non-narcotic treatments to manage pain after TKA. Specifically, we evaluated: 1) acetaminophen; 2) cyclooxygenase-2 (cox-2) inhibitors; 3) gabapentinoids; 4) dexmedetomidine, 5) nerve blocks; 6) local analgesic infiltration; 7) transcutaneous electrical nerve stimulation (TENS); and 8) perioperative bracing. MATERIALS AND METHODS: A literature search was conducted using the PubMed and EBSCO host electronic databases. All available studies between 1998 and 2018 were evaluated. Searches were performed using the following terms: total knee arthroplasty (title), acetaminophen (title), cyclooxygenase-2 inhibitors (title), gabapentinoids (title), nerve blocks (title), local analgesic infiltration (title), transcutaneous electrical nerve stimulation (title), knee (title), postoperative outcome (title), opioids (title), analgesics (title), alternative (title), heroin (title), chronic pain (title), opioid overdose (title), and cost (title). After full-text analysis of 273 reports that satisfied the search criteria, 58 studies were included in this review. RESULTS: There is conflicting evidence on acetaminophen and gabapentinoids, with some studies reporting opioid use reduction with their use; whereas, others found no difference. Cox-2 inhibitors can potentially reduce opioid requirements and improve pain scores following TKA; however, they are associated with several side effects. Dexmedetomidine has been associated with reduced postoperative opioid consumption, but it has limited applications as it is associated with several major side effects. Neuraxial anesthesia can potentially help control postoperative pain; however, there is a limited effective window and identifying the specific nerve can be challenging. Local infiltrating analgesia have been found to help relieve pain in the early postoperative period. Multiple studies have identified substantial reductions in pain with knee braces. The non-invasive and non-pharmacologic nature of this treatment option makes it very safe and effective for the generalized TKA population. CONCLUSION: The optimal solution for postoperative TKA pain management has yet to be determined. Although several options exist, many of them have been associated with adverse effects limiting their generalizability. Knee braces, however, have been identified as one potentially successful option. Importantly, knee braces are safe for the majority of patients and should be widely recommended for patient use.

The Role of Virtual Rehabilitation in Total Knee and Hip Arthroplasty.

Virtual rehabilitation therapies have been developed to focus on improving care for those suffering from various musculoskeletal disorders. There has been evidence suggesting that real-time virtual rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these conditions. This study specifically evaluated the use of a virtual physical therapy/rehabilitation platform for use during the postoperative period after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of this technology has the potential benefits that allow for patient adherence, cost reductions, and coordination of care.

Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, and Rotation: A Comparative, Gait-Analysis Study.

INTRODUCTION: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared. MATERIALS AND METHODS: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts. RESULTS: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66° , [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects. CONCLUSION: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.

Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty.

INTRODUCTION: Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM). MATERIALS AND METHODS: This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed. RESULTS: Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001). CONCLUSION: This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.

Periprosthetic joint infection.

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review.

BACKGROUND: Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA). METHODS: A search for "knee" and "cryotherapy" using PubMed, EBSCO Host, and SCOPUS was performed, yielding 187 initial reports. After selecting for RCTs relevant to our study, 16 studies were included. RESULTS: Of the 8 studies that compared the immediate postoperative outcomes between patients who did and did not receive cryotherapy, 5 studies favored cryotherapy (2 cold packs and 3 continuous cold flow devices). Of the 6 studies comparing the use of cold packs and continuous cold flow devices in patients who underwent UKA or TKA, 3 favor the use of continuous flow devices. There was no difference in pain, postoperative opioid consumption, or drain output between 2 different temperature settings of continuous cold flow device. CONCLUSION: The optimal device to use may be one that offers continuous circulating cold flow, as there were more studies demonstrating better outcomes. In addition, the pain relieving effects of cryotherapy may help minimize pain medication use, such as with opioids, which are associated with numerous potential side effects as well as dependence and addiction. Meta-analysis on the most recent RCTs should be performed next.

Impact of Physical Activity and Body Mass Index in Cardiovascular and Musculoskeletal Health: A Review.

Due to an increasing elderly population coupled with a growing obesity epidemic, there has been an increased prevalence in cardiovascular and musculoskeletal diseases. This has led to an increased burden in healthcare expenditures, now estimated to be over 17.8% of gross domestic product. As a result, physical activity has been increasingly encouraged due to its potential prophylactic effects on health. Recent reports have demonstrated a relationship between physical activity and body mass index (BMI) on cardiovascular and musculoskeletal health. However, the effect of the combination of the two have not been reported. Therefore, the purpose of this review was to assess the effect of various levels of physical activity on: 1) cardiovascular disease risk; and 2) the development of musculoskeletal disease (osteoarthritis [OA]) when accounting for various levels of BMIs. A total of 143 abstracts were identified for cardiovascular health and 55 abstracts for musculoskeletal health. Upon review, 11 reports were included for final evaluation. Despite patient BMI, physical activity was associated with a decreased risk of cardiovascular events. Additionally, moderate levels of physical activity were demonstrated to be protective against the development of OA; however, the levels of physical activity necessary to be beneficial were not fully elucidated. This suggests that the prophylactic effects of physical activity were maintained despite patient BMI. Future studies are needed to explore the appropriate levels of physical activity for optimal effectiveness when stratifying by patient BMI.

What is the Impact of Body Mass Index on Cardiovascular and Musculoskeletal Health?

Obesity has become a major public health concern over the past several decades and has been shown to be associated with type 2 diabetes, cardiovascular diseases, dyslipidemia, hypertension, osteoarthritis (OA), and certain types of cancer. The impact of excess weight on cardiovascular and musculoskeletal health is not well-summarized in the literature, and there are some contradictory reports. Therefore, the purpose of this study was to assess the impact of body mass index (BMI) on: 1) cardiovascular outcomes; 2) osteoarthritis risk and progression; and 3) total knee arthroplasty outcomes (TKA). Three literature searches were performed to identify clinical studies that assessed how BMI affects cardiovascular and musculoskeletal health. We included reports published within last five years. A total of 138 studies on cardiovascular health and 140 studies on musculoskeletal health were identified. After reviewing the abstracts and related citations from the references, there were 29 studies included in the present study. The effect of varying levels of BMI have demonstrated a relationship to cardiovascular disease, osteoarthritis, and TKA outcomes. The evidence suggests that as BMI increases, the chance of developing cardiovascular disease, OA, and negative TKA outcomes also increases. Furthermore, there appears to be a negative effect with being underweight on outcomes as well, suggesting that being at "normal" weight may optimize outcomes. However, there are several reports which make these findings more complicated. Several beneficial factors associated with higher BMI include increased muscle mass and strength, which can potentially be beneficial through better cardiorespiratory fitness or hormonal effects. Additionally, several studies suggest that improving fitness is more important than intentional weight loss for cardiovascular health and osteoarthritis. Therefore, future studies are warranted to assess the combination of BMI and activity to assess the optimal balance and how they affect cardiovascular and musculoskeletal outcomes.

Cryotherapy Treatment After Arthroscopic Knee Debridement and ACL Reconstruction: A Review.

Pain, swelling, and inflammation of the knee joint and its surrounding soft-tissue structures are common during the postoperative period after arthroscopic knee debridement and anterior cruciate ligament reconstruction. These challenges can make patient recovery difficult immediately after surgery. Several options exist, however, to help patients overcome these challenges. Cryotherapy has been noted to decrease pain, swelling, and inflammation. However, while a number of studies exist characterizing the use of cryotherapy after knee surgery, no definitive cryotherapy devices and modalities have been identified. Therefore, the purpose of this review was to evaluate randomized controlled trials to assess the use of cryotherapy after: 1) arthroscopic debridement; and 2) anterior cruciate ligament reconstruction.

Does Obesity Affect Outcomes in Patients Undergoing Innovative Multi-Modal Physical Therapy Following Primary Total Knee Arthroplasty?

INTRODUCTION: Knee stiffness following total knee arthroplasty (TKA) is a common complication, especially in obese patients. The initial, non-operative treatments for this complication includes splinting and physical therapy. If these measures fail, manipulation under anesthesia (MUA) or surgical exploration can be considered to restore range of motion (ROM). However, it is generally desirable to avoid these procedures. For these reasons, newer physical therapy protocols have been developed. However, it is unknown whether these protocols are efficacious for obese patients. Therefore, the purpose of this study was to evaluate and compare: 1) ROM; 2) the rate of MUA; 3) number of physical therapy visits; and 4) costs in patients who underwent innovative multimodal physical therapy (IMPT) and were either obese or non-obese. MATERIALS AND METHODS: A review of a consecutive series of patients undergoing TKA at a single center within a three-year period was performed. All patients received IMPT post-TKA. Patients were divided into obese (body mass index (BMI >30kg/m2) and non-obese (BMI <30 kg/m2) groups. One-hundred and forty-nine patients underwent TKA and had a mean age of 67 years (range, 42 to 88 years). There were 48 patients in the non-obese group and 101 in the obese group. The obese group was significantly younger (mean, 60 years; range 38 to 54 years vs. mean, 69 years; range, 50 to 88 years), with a similar gender distribution. Comparisons of ROM, MUA, number of physical therapy visits, and costs were performed using Student's t-tests and Chi-square tests as appropriate. Cost-analysis was also performed based on the number of visits to physical therapy (PT). RESULTS: At latest follow-up, there were no significant differences in mean flexion (mean, 115°, range, 90 to 130° vs. mean, 113°, range 60 to 130°) and extension (mean, 0.81°, range, 0 to 10° vs. 0.54°, range 0 to 10°, p=0.469) between the two groups. The obese group had a 14% (n = 12) rate of MUA compared to 2% (n=1) in the non-obese group (p=0.045). Obese patients had a significantly higher number of mean visits to PT. There was significantly higher mean healthcare costs in the obese (mean, $3,919, range $1,043 to $11,749) as compared to the non-obese (mean, $2,950, range $741 to $7,865) group. DISCUSSION: Although both cohorts have similar mean ROM at final follow-up, the obese cohort had a significantly higher proportion of patients who underwent MUAs following TKA as compared to non-obese patients, despite IMPT. At latest follow-up, the ROM achieved between the two groups was similar. Obese patients required more PT visits resulting in significantly higher mean healthcare costs.

Use of an App-Controlled Neuromuscular Electrical Stimulation System for Improved Self-Management of Knee Conditions and Reduced Costs.

Patients suffering from quadriceps muscle weakness secondary to osteoarthritis or after surgeries, such as total knee arthroplasty, appear to benefit from the use of neuromuscular electrical stimulation (NMES), which can improve muscle strength and function, range of motion, exercise capacity, and quality of life. Several modalities exist that deliver this therapy. However, with the ever-increasing demand to improve clinical efficiency and costs, digitalize healthcare, optimize data collection, improve care coordination, and increase patient compliance and engagement, newer devices incorporating technologies that facilitate these demands are emerging. One of these devices, an app-controlled home-based NMES therapy system that allows patients to self-manage their condition and potentially increase adherence to the treatment, incorporates a smartphone-based application which allows a cloud-based portal that feeds real-time patient monitoring to physicians, allowing patients to be supported remotely and given feedback. This device is a step forward in improving both patient care and physician efficiency, as well as decreasing resource utilization, which potentially may reduce healthcare costs.

Quadriceps and Hamstring Muscle Strength Improves After Unicompartmental Knee Arthroplasty.

INTRODUCTION: The ability to reach functional capacity following knee arthroplasty depends on the strength of the quadriceps and hamstring muscles. Following total knee arthroplasty, weakness of these muscles can persist for up to one year postoperatively; however, this phenomenon is not well-studied in unicompartmental knee arthroplasty (UKA) patients. Therefore, we assessed: 1) quadriceps muscle strength; 2) hamstring muscle strength; and 3) correlation to functional outcomes. MATERIALS AND METHODS: A review of all patients with medial compartment osteoarthritis treated with UKA at a minimum of one-year follow-up was performed. This yielded 26 patients (32 knees), comprising of eight females and 18 males who had a mean age of 67 years (range, 47 to 83 years). Muscle strength was assessed pre-and postoperatively via dynamometer. Functional outcomes were assessed using Knee Society Scores (KSS). Comparisons of groups were performed by paired t-tests. RESULTS: At a minimum one-year postoperatively, quadriceps muscle strength was 27 Nm (range, 13 to 71Nm) and hamstring muscle strength was 19.5Nm (range, 7 to 81Nm). Quadriceps muscle strength increased by 40% (p=0.002) and hamstring muscle strength by 26% (p=0.057). The mean KSS pain was 97 points (range, 85 to 100 points) and mean KSS function was 90 points (range, 45 to 100 points) at the final follow-up. Range of motion was 125° (range, 110° to 135° ) at the final follow-up. The Pearson Correlation Coefficient for postoperative extension strength and postoperative flexion strength to postoperative KSS functional scores were 0.268 and 0.220 respectively. CONCLUSION: Within one-year following UKA, patients can expect restoration of quadriceps and hamstring muscle strength with a corresponding functional improvement. Although long-term follow-up is warranted to determine sustainability, the short-term results demonstrate excellent restoration of function.

Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy.

INTRODUCTION: This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. MATERIALS AND METHODS: We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. RESULTS: A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. CONCLUSION: Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.

Muscle strength and knee range of motion after femoral lengthening.

Background and purpose - Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthening would not result in a significant change in knee ROM or muscle strength. Patients and methods - This prospective study of 48 patients (mean age 27 (9-60) years) compared ROM and muscle strength before and after femoral lengthening. Patient age, amount of lengthening, percent lengthening, level of osteotomy, fixation time, and method of lengthening were also evaluated regarding knee ROM and strength. The average length of follow-up was 2.9 (2.0-4.7) years. Results - Mean amount of lengthening was 5.2 (2.4-11.0) cm. The difference between preoperative and final knee flexion ROM was 2° for the overall group. Congenital shortening cases lost an average of 5% or 6° of terminal knee flexion, developmental cases lost an average of 3% or 4°, and posttraumatic cases regained all motion. The difference in quadriceps strength at 45° preoperatively and after lengthening was not statistically or clinically significant (2.7 Nm; p = 0.06). Age, amount of lengthening, percent lengthening, osteotomy level, fixation time, and lengthening method had no statistically significant influence on knee ROM or quadriceps strength at final follow-up. Interpretation - Most variables had no effect on ROM or strength, and higher age did not appear to be a limiting factor for femoral lengthening. Patients with congenital causes were most affected in terms of knee flexion.

Can We Really "Feel" a Balanced Total Knee Arthroplasty?

BACKGROUND: Balancing techniques in total knee arthroplasty are often based on surgeons' subjective judgment. However, newer technologies have allowed for objective measurements of soft tissue balancing. This study compared the use of sensor technology to the 30-year surgeon experience regarding (1) compartment loads, (2) soft tissue releases, and (3) component rotational alignments. METHODS: Patients received either sensor-guided soft tissue balancing (n = 10) or manual gap balancing (n = 12). Wireless, intraoperative sensor tibial inserts were used to measure intracompartmental loads. The surgeon was blinded to values in the manual gap-balancing cohort. In the sensor cohort, the surgeon was unblinded, and implant trials were placed after normal releases were performed to guide further ligament releases after femoral and tibial resections, as needed. Load measurements were taken at 10°, 45°, and 90°. RESULTS: The sensor cohort had lower medial and lateral compartment loading at 10°, 45°, and 90°. The sensor group had lower mean differences in intercompartment loading at 10° (-5.6 vs -51.7 lbs), 45° (-9.8 vs -45.9 lbs), and 90° (-4.3 vs -27 lbs) compared to manually balanced patients. There were 10 additional soft tissue releases in the sensor cohort (2 initial ones before sensor use), compared to 2 releases in the gap-balanced cohort. In the gap-balanced cohort, tibial trays were positioned at a mean 9° external rotation, compared to a mean 1° internal rotation in the sensor-guided cohort. CONCLUSION: Sensor-balanced total knee arthroplasties provide objective feedback to perform releases and potentially improve knee balancing and rotational alignment. Future work may clarify whether these changes are beneficial for our patients.

Innovative Multi-Modal Physical Therapy Reduces Incidence of Manipulation Under Anesthesia (MUA) in Non-Obese Primary Total Knee Arthroplasty.

INTRODUCTION: Patients may experience knee stiffness following total knee arthroplasty (TKA). Non-operative measures, such as more physical therapy and special splints are warranted in such cases. In the event of failure of these measures to restore knee range of motion, more invasive procedures with higher risks, such as manipulation under anesthesia (MUA) or repeat surgery, can be utilized. Thus, it becomes essential to optimize their non-operative measures in order to avoid more invasive, riskier options. Therefore, the purpose of this study was to evaluate and compare: 1) range of motion, and 2) the rate of MUA in patients who either underwent a multi-modal physical therapy regimen (IMMPT) or standard-of-care post-operative therapy (standard) following primary total knee arthroplasty. MATERIALS AND METHODS: We analyzed all non-obese patients who underwent primary TKAs between January 2013 and December 2014 at our institution who started an outpatient physical therapy program within six weeks of their surgery (n = 127 knees). There were 86 women and 41 men who had a mean age of 67 years (range, 42 to 88 years). This cohort was stratified into those who underwent an IMMPT regimen at our institution (n= 47) and those who underwent standard therapy at an outside institution (N = 80). The range of motion and rate of manipulation between the two groups was compared by using Chi-square and Student's t-test, as appropriate. RESULTS: There were similar proportions of those who had an optimal range of motion (≥110 degrees flexion and ≤5 degrees extension) in the IMMPT group as compared to the standard physical therapy cohort (81% vs. 82%). The IMMPT cohort had a significantly lower proportion of patients who underwent MUA as compared to the standard therapy cohort (2% vs. 13%). CONCLUSIONS: This study shows an IMMPT protocol utilizing Astym® therapy (Performance Dynamics, Inc. Muncie, Indiana) is able to significantly reduce the rate of manipulation following a total knee arthroplasty. Furthermore, this IMMPT approach was also able to achieve similar range of motion to the standard physical therapy group while reducing the rate of manipulation, which may indicate similar efficacy in restoring range of motion. Comparative randomized studies are needed to determine the true benefit of this IMMPT protocol.

A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain.

OBJECTIVE: Transcutaneous electrical nerve stimulation (TENS) may provide a safe alternative to current side-effect-heavy narcotics and anti-inflammatories utilized in chronic low back pain. Therefore, we performed a meta-analysis to evaluate the efficacy of TENS for the treatment of chronic low back pain. MATERIALS AND METHODS: We included randomized controlled trials (RCTs), cohort studies, and randomized crossover studies on TENS for the management of low back pain. We utilized a visual analogue scale (VAS) for pain as our primary outcome. Effectiveness of treatment was quantified using improvement in outcome scores for each study. Of the studies that met the criteria, 13 allowed for calculation of weighted mean differences in pain reduction. We used a random model effect to evaluate changes in pain produced by the intervention. RESULTS: Included were nine level I and four level II, encompassing 267 patients (39% male) who had a mean follow-up of seven weeks (range; 2 to 24 weeks). The mean duration of treatment was six weeks (range; 2 to 24 weeks). The standardized mean difference in pain from pre- to post-treatment for TENS was 0.844, which demonstrated significant improvement of TENS on pain reduction. When subdividing treatment duration, patients that were treated for < 5 weeks had significant effects on pain, while those treated for > 5 weeks did not. CONCLUSION: Treatment of chronic low back pain with TENS demonstrated significant pain reduction. The application of TENS may lead to less pain medication usage and should be incorporated into the treatment armamentarium for chronic low back pain.

Novel Sensor Tibial Inserts in Total Knee Arthroplasty: A Review.

Traditional techniques to balance total knee arthroplasties are often subject to variability, as they are usually based on the surgeon's subjective assessment. Improperly balanced total knee arthroplasties can cause complications such as stiffness, pain, or instability, which may ultimately result in a revision procedure. In an effort to mitigate this, a tibial insert sensor technology has recently been developed to allow for quantifiable, objective measurements of soft-tissue balancing. A systematic review of the current literature was performed, highlighting the utility of this sensor tibial insert with focus on: (1) compartment loading pressures; (2) component orientations; and (3) clinical outcomes.

Normal Foot and Ankle Radiographic Angles, Measurements, and Reference Points.

The limb deformity-based principles originate from a standard set of lower extremity radiographic angles and reference points. Objective radiographic measures are the building blocks for surgical planning. Critical preoperative planning and intraoperative and postoperative evaluation of radiographs are essential for proper deformity planning and correction of all foot and ankle cases. A total of 33 angles and reference points were measured on 24 healthy feet. The radiographic measurements were performed on standard weightbearing anteroposterior, lateral, and axial views of the right foot. A total of 4 measurements were made from the axial view, 12 from the lateral view, and 17 from the anteroposterior view. All angles were measured by both senior authors twice, independent of each other. The radiographic angles and measurements presented in the present study demonstrate a comprehensive and useful set of standard angles, measures, and reference points that can be used in clinical and perioperative evaluation of the foot and ankle. The standard radiographic measures presented in the present study provide the foundation for understanding the osseous foot and ankle position in a normal population.