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.

Complex reconstructions in total knee arthroplasty. Anterior and posterior soft-tissue contracture.

Arthritic knee conditions leading to deformities of the anterior and posterior aspects of the knee joint require careful preoperative planning. Constrained condylar implants should be available in the operating room if asymmetrical soft-tissue laxity is produced as the deformities are corrected. The operative approach must be aggressive, and soft-tissue releases often have to be quite extensive to correct severe extension and flexion contractures. Soft tissues should never be released transversely but always in a subperiosteal fashion from the underlying bone. In this fashion, the implant will block open these soft-tissue cavities symmetrically and knee stability will be restored. Asymmetric soft-tissue imbalance from varus or valgus deformity must be corrected in combination with anterior and posterior soft-tissue management. Rehabilitation of these complex knees requires individualization and careful progression of motion and unsupported ambulation. Care must be taken to prevent wound problems, and rapid intervention is necessary should they occur. If the technical and rehabilitative aspects of these severe knee deformities are carried out successfully, excellent function is possible in this disabled group of patients.

Femoral rotational alignment using the tibial shaft axis in total knee arthroplasty.

The capability of determining femoral component rotation by using a posterior femoral condyle resection made perpendicular to the longitudinal tibial shaft axis in posterior cruciate retaining total knee arthroplasty was evaluated. From 100 consecutive cases, 54 used the femoral posterior condyle axis and 46 used an extramedullary alignment rod based on the tibial shaft axis. Seventy-two percent of total knee arthroplasties using the posterior condyle axis required lateral release versus 28% using the tibial shaft axis. Patellar fracture occurred in 7% using the posterior condyle axis versus none using the tibial shaft axis. Two patients had both techniques in opposite knees. Using computed tomography, the posterior condyle axis method gave a posterior condyle angle of 5 degrees and 4 degrees compared with the transepicondylar axis, whereas the tibial shaft axis technique measured 0 degrees and 1 degree. The posterior condyle resection using the tibial shaft axis restores the anatomic patellofemoral relationships, minimizing patellofemoral complications.

Surgical closing in primary total knee arthroplasties: flexion versus extension.

One hundred eight consecutive patients with primary osteoarthritis of the knee undergoing primary arthroplasty were compared retrospectively to determine whether surgical closure of the entire wound in flexion has any effect on range of motion postoperatively over a period of up to 6 months. The knees of the first 52 patients were surgically closed in extension. In the second group of 56 patients, the knees were closed in 90 degrees to 110 degrees flexion depending on the available motion of the joint. Although the patients were not randomized, the groups were closely matched in age, weight, height, and gender. Preoperative and postoperative patellar heights were similar in both groups. The patients were started on a continuous passive motion device in the recovery room. At all intervals the flexion measurements were significantly better in the flexion closure group. By 6 months the flexion closure group had surpassed their preoperative measurements, whereas the extension closure group had not yet achieved this goal. The flexion group required less home physical therapy than the extension group. Closing the knee in flexion permits the patients to regain knee motion faster with less effort, thereby saving money and enhancing patient satisfaction.

Knee closure in total knee replacement: a randomized prospective trial.

A randomized prospective study of 75 total knee replacements in 64 patients who were randomized to capsular closure with the knee in full extension or in flexion was done. Thirty-one knees received a posterior cruciate ligament retaining prosthesis and 44 knees received a posterior stabilized prosthesis. Preoperatively, there was no significant difference between the groups, and patients were stratified by surgeon and type of prosthesis. Postoperatively, all patients were evaluated by a physical therapist who did not know the type of prosthesis the patient received. In addition to the range of motion obtained at discharge; the number of days required to achieve unassisted transfer; the number of days required to achieve assisted and unassisted use of a walker, cane, and stairs; and the number of days to discharge from the hospital were recorded. All patients were also evaluated at 2 to 3 months postoperatively, and the Knee Society clinical rating system scores were compared. There was no statistically significant difference in any of the early rehabilitation parameters or in the 2- to 3-month followup data. Moreover, there was no statistically significant difference in the rate of complications. With stratification according to the type of prosthesis used or the surgeon performing the operation, there was still no statistically significant difference in any of the studied parameters. It was therefore concluded that the degree of knee flexion at the time of capsular closure in total knee replacement has no effect on early rehabilitation after total knee replacement.

Range of motion in total knee replacement.

This is a multicenter prospective clinical study using a modified Knee Society scoring system which evaluated the effect of age, gender, weight, preoperative range of motion and knee score, previous surgery, and modification of the posterior femoral condyle geometry on postoperative range of motion. The primary outcome variable was change in flexion. The data were collected from 5 surgeons using a single total knee system. The current study has 621 patients enrolled, of which 282 total knee replacements have followup of 12 months and 86 have followup of 24 months. Multivariate analysis was used to evaluate the data. The variables listed were examined as to their relationship to changes in flexion. Patients were divided into 3 groups: preoperative flexion less than 90 degrees, 91 degrees to 105 degrees, and greater than 105 degrees. When comparing the patients with preoperative motion less than 90 degrees to those with motion greater than 105 degrees, the first group improved 26 degrees more than the latter. They also improved 12 degrees more than the midrange group. The midrange group improved 14 degrees more than the upper range group. These values are all adjusted to eliminate differences due to the other variables. None of the other variables showed a significant correlation with the flexion outcome. To analyze the knee score, the group was also divided into 3 groups: preoperative score less than 27, 28 to 40, and greater than 40. The preoperative knee score was the best predictor of the postoperative knee score. The patients with preoperative knee scores below 27 improved 16 points more than those in the 27 to 40 range and 33 points greater than the greater than 40 group. To analyze functional evaluation, the patients were divided into 3 groups based on preoperative score: less than 40, 41 to 50, and greater than 50. Those in the less than 40 group improved 14 points more than the midrange group and 35 points more than the greater than 50 group. Analysis of delta range of motion and delta pain showed similar results. Age, weight, previous open surgical procedure, and altered femoral component contour, did not seem significantly correlated with changes in postoperative flexion. The best predictors of postoperative clinical results are the preoperative scores.

Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques.

This study was conducted to compare postoperative total knee arthroplasty rehabilitation protocols. The hypothesis of this study was that patients undergoing total knee arthroplasty could achieve range of motion and hospital discharge in the same period using a postoperative rehabilitation protocol that did not use a continuous passive motion machine. This randomized prospective study compared 46 total knee arthroplasties in which a continuous passive motion machine was used with 37 total knees that were rehabilitated with early passive flexion of the knee (named drop and dangle protocol). Postoperative physical therapy regimens were otherwise the same for both groups. Surgical technique was the same for both groups except for closure which was performed in the drop and dangle group with the knee at 90 degrees to 95 degrees flexion. Only patients with osteoarthritis were included in the study, and in both groups of patients received the same prosthetic components. Patients in the drop and dangle group were discharged from the hospital 1 day earlier (p = 0.01) and had a statistically better extension range of 2.8 degrees at 6 months (p = 0.03). Knees in the drop and dangle group had less drainage (p = 0.06). Range of motion and hospital discharge can be achieved in a similar time interval with the drop and dangle technique as with using a continuous passive motion device, and that such a device is not required for postoperative knee rehabilitation.

Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement.

To compare the effects of epidural anesthesia and general anesthesia on early postoperative outcomes after unilateral primary total knee replacement, 262 patients were randomly assigned to receive either epidural or general anesthesia. All patients received a common rehabilitation protocol including a standardized assessment of progress. One hundred eighty-eight patients received a common thromboembolic prophylaxis protocol with postoperative aspirin, and had a standardized surveillance protocol to detect thromboembolic complications. Deep vein thrombosis was determined by venography on the operative limb, and pulmonary embolism was determined by comparison of preoperative and postoperative lung perfusion scans. The epidural anesthesia group reached all rehabilitative milestones earlier postoperatively than did the general anesthesia group, with a statistically significant earlier attainment of stair climbing. The incidence of deep vein thrombosis was 40% with epidural anesthesia, and 48% with general anesthesia. There were no clots proximal to the popliteal veins. The incidence of pulmonary embolism on lung scan was 12% with epidural anesthesia and 9% with general anesthesia. Epidural anesthesia is associated with more rapid achievement of postoperative in hospital rehabilitation goals after total knee replacement. A minor reduction in postoperative deep vein thrombosis rate was observed with epidural anesthesia, but this did not reach statistical significance. No difference in early postoperative pulmonary embolism was observed between the 2 types of anesthesia.

Fresh look at rehabilitation of hip-replacement patients. Elderly care counts.

This article describes a charity-funded scheme in which patients who have had elective hip and knee replacement are discharged directly into nursing homes for rehabilitation. The patients are given appropriate support services and appear to benefit. Other positive outcomes were lower costs and reduced waiting lists.

[Knee joint endoprostheses]. / Endoprothesen am Kniegelenk.

The story of the total knee arthroplasty begins in the last century. But in 1971, Gunston shows the way of the modern knee arthroplasty and creates the concept of unconstrained arthroplasty. The indication of the total knee arthroplasty should be precise and rigorous. It's not possible to describe all the situations, where a total knee arthroplasty is indicated or not, but the clinical signs could be summarized in pain, stiffness, deformation with or without instability. We observed 10% of postoperative complications; most of them are secondary, but the infections and loosening remain the principal problem in 2% and in 5% of cases, respectively. If the results are now quite the same to those of total hip arthroscopy by survivorship analysis, the indication and the choice of the total knee prosthesis should be passed on a reflection, where the clinical and functional evaluation are the most important.

Megaprostheses after resection of distal femoral tumors. A rotating hinge design in 30 patients followed for 2-7 years.

Between 1981-1993, we inserted 32 Kinematic Rotating-Hinge Knee tumor prostheses in 30 patients, of which 2 concerned revisions of the same type of prosthesis. The diagnoses were 21 osteosarcomas, 2 chondrosarcomas, 2 Ewing's sarcomas, 2 metastatic breast carcinomas, 1 multiple myeloma, 1 giant cell tumor and 1 Gorham's disease. The median age was 25 (12-60) years and the median follow-up for survivors was 3.5 (2-6.6) years. There were 7 metastases and 1 local recurrence. 20 knees had excellent (MSTS) scores for motion (median flexion 120 degrees), 8 had good (84 degrees) and 4 had fair (45 degrees). The overall function was excellent in 6 cases, good in 14, fair in 9 and poor in 3. The radiographic assessment (ISOLS) gave "excellent" or "good" scores in 27 knees for bone remodelling, 31 for the interface, 28 for the anchorage, 31 for the implant body and 30 for the articulation. Extracortical bone bridging greater than 25% was observed in 18 of 27 prostheses.

Sports after total joint replacement.

Functional return after total joint replacement is the goal of the patient and orthopedic surgeon. Return to sports is possible and encouraged following replacement surgery. However, appropriate guidelines need to be followed to prevent complications. Overuse or a too rapid return to strenuous activity has been shown to result in an increased tendency for loosening of the prosthetic components. Recommendations for a safe return to sport activity are outlined.

[Results of early rehabilitation using various knee prosthesis models]. / Ergebnisse der Frührehabilitation bei Verwendung unterschiedlicher Knieendoprothesen-Modelle.

The present contribution deals with the early rehabilitation outcomes achieved using total knee arthroplasties with major differences in design. Hinged and unhinged total knee replacements are compared for a total of 100 patients included in the prospective study (48 hinged prostheses, and 52 unhinged ones). Evaluation of the functional and subjective parameters included shows that major improvements in total scores had been achieved in both groups already after 5 weeks, even more pronounced after 10 weeks. With a number of differences found for the various criteria assessed, it in particular is the fact of early stability of the joint in using the hinged prostheses that entails speedy progress and a good rehabilitation outcome. Due consideration of the different early outcomes for the various parameters, hence, is imperative in pre-operative decision-making.

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.

Implications of patient selection and surgical technique for primary total knee arthroplasty.

Between 1983 and 1992, one surgeon at Wheeling Hospital in Wheeling, W.Va., performed 121 primary cruciate-sparing total knee arthroplasties on patients with degenerative joint disease. Rigorous preoperative screening criteria and surgical protocol were developed to improve the clinical lifespan of the joint replacements. The average range of motion increased from 99.8 degrees to 107.1 degrees during a mean clinical follow-up period of 40.5 months (range 12-144 months). Among the 86 patients with a preoperative fixed flexion contracture, the average improvement in flexion was 12.0 degrees. Twelve of the patients developed postoperative medical complications, including two revisions of plastic tibial trays. The relatively low revision and complication rates are attributed to the experience of one surgeon utilizing similar guidelines for deliberate patient selection, preoperative educational programs, standardized operative protocol and surgical technique, and prosthesis familiarity.

Continuous passive motion compared to active physical therapy after knee arthroplasty: similar hospitalization times in a randomized study of 68 patients.

68 consecutive patients who had primary knee arthroplasties because of arthrosis were randomized to postoperative continuous passive motion (CPM) or active physical therapy (APT). Rehabilitation in both groups was initiated on the first postoperative day. The CPM group sustained less postoperative knee swelling with more rapid initial improvement in knee flexion than did the APT group, but there were no differences between the groups in knee flexion at discharge. Postoperative pain rating and hospitalization times were similar in the two groups.