RESUMEN

More than 20 million individuals in the United States are affected by knee osteoarthritis (OA), which can lead to altered biomechanics and excessive joint loading. The use of an unloader pneumatic brace with extension assist has been proposed as a nonoperative treatment modality that may improve gait mechanics and correct knee malalignment. We assessed the following parameters in patients who have knee OA treated with and without a brace: (1) changes in temporospatial parameters in gait; (2) knee range of motion, knee extension at heel strike, and foot placement; (3) knee joint moments and impulse; and (4) changes in dynamic stiffness and rate of change of knee flexion during midstance to terminal stance. This 2:1 prospective, randomized, single-blinded trial evaluated 36 patients (24 brace and 12 matching). OA knee patients were randomized to receive either a pneumatic unloader brace or a standard nonoperative treatment regimen as the matching cohort for a 3-month period. They underwent evaluation of gait parameters using a three-dimensional gait analysis system at their initial appointment and at 3 months follow-up. All the testing, pre- and postbracing were performed without wearing the brace to examine for retained effects. Treatment with the brace led to significant improvements versus standard treatment in various gait parameters. Patients in the brace group had improvements in walking speed, knee extension at heel strike, total range of motion, knee joint forces, and rate of knee flexion from midstance to terminal stance when compared with the matching cohort. Knee OA patients who used a pneumatic unloader brace for 3 months for at least 3 hours per day had significant improvements various gait parameters when compared with a standard nonoperative therapy cohort. Braced patients demonstrated gait-modifying affects when not wearing the brace. These results are encouraging and suggest that this device represents a promising treatment modality for knee OA that may improve gait, knee pain, and strength in knee OA patients.

Asunto(s)

RESUMEN

Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for both patients and providers. In addition, guidelines vary considerably between institutions, which often leave therapy regimens to the discretion of the provider. The lack of clear guidelines for rehabilitation may contribute to inadequate recovery of strength and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities currently available and to provide evidence regarding efficacy and practicality. Specifically, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance training, continuous passive motion, cold therapy and compression, neuromuscular electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-assisted soft-tissue therapy. Additionally, we proposed general recommendations for rehabilitation after TKA, and as we specifically described active and obese patients, we have included guidelines for these subsets as well. Our review examines the various rehabilitative modalities to offer suggestions for recovery of strength and range-of-motion after TKA, with a focus on the early incorporation of exercise therapy, balance training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation. Dedication and commitment to rehabilitation may help patients attain and exceed their preoperative activity levels.

Asunto(s)

Asunto(s)

RESUMEN

The demand for total knee arthroplasty (TKA) continues to grow exponentially, and this has been attributed to a higher prevalence of osteoarthritis and excellent procedural success. In particular, with increasing life expectancies and obesity rates, surgeons are seeing patients with a wider age range. Therefore, we assessed the effects of patient age on: (1) range of motion (ROM); (2) pain and function; (3) physical and mental status; and (4) activity levels following TKA. We assessed 278 TKA patients (108 men, 170 women), with subdivision into three age-specific groups: < 55, 55 to 74, and 75 years or older. ROM was assessed and functional outcomes were evaluated using the Knee Society scoring (KSS) system, the short form-36 (SF-36), and the lower extremity activity scale (LEAS). The patients were assessed preoperatively and postoperatively at 6 weeks, 3 months, 12 months, and then yearly thereafter until 7 years. All cohorts demonstrated improvements in ROM, with no significant differences between the age groups. For KSS objective, there were no significant differences between groups after 6-week follow-up, though in pain and motion, the 75 years and older had the highest mean score at final follow-up (97 points). In KSS function, the < 55 years group had highest scores at 2 (90 vs. 87 vs. 75 points) and 5-year follow-up (96 vs. 88 vs. 72 points). For SF-36 and LEAS, the 75 year and older cohorts had the lowest mean scores at various time points. In the mental component, those < 55 years had the lowest scores postoperatively. It is important to understand the effect of age on post-TKA outcomes, particularly as the cohort of these patients continues to grow. Our results demonstrate that comprehensive preoperative discussions and management are needed, particularly in those patients at either end of the age spectrum (< 55 or ≥ 75 years).

Asunto(s)

RESUMEN

The purpose of this study was to use a large hospital database to assess: (1) length of hospital stay (LOS) and (2) discharge status among patients undergoing total knee arthroplasty (TKA) with or without the use of a liposomal bupivacaine suspension injection. We utilized an all-payer hospital administrative database from July 1, 2013 to June 30, 2014. We then selected patients age 18 years or older who had an inpatient stay for TKA in the data window based on International Classification of Diseases, Ninth Revision (ICD-9) procedure codes (ICD-9-CM = 81.54), which resulted in 103,152 TKA patients. Patients who had nerve blocks were excluded, which resulted in 94,828 TKA patients. The TKA cohort who received a liposomal bupivacaine suspension consisted of 14,668 patients (9,211 females; 5,457 males) who had a mean age of 66 years, while the TKAs without injections or block consisted of 80,160 patients (49,699 females; 30,461 males) who had a mean age of 66 years. Analyses of LOS were performed using a linear model, controlling for age, sex, race, region, Charlson index, and operating time. Discharge status to home versus rehabilitation or short-term nursing facility was evaluated using logistic regression analysis controlling for the above covariates. The adjusted mean LOS for the injection cohort was significantly shorter at 2.58 days compared with 2.98 days in the no injection cohort. The unadjusted distribution of patients being discharged to home compared with short-term nursing facility or rehabilitation was higher in the injection cohort compared with the cohort who did not receive injections (73.2 vs. 66.6%). Logistic regression analysis demonstrated that there was a higher likelihood of being discharged to home with liposomal bupivacaine. Patients who underwent TKA with liposomal bupivacaine had a significantly shorter LOS and a higher likelihood of being discharged to home. These results suggest that liposomal bupivacaine may represent a promising addition to current pain management regimens. Furthermore, it may limit pain following surgery, which may allow patients to ambulate earlier and have improved outcomes.

Asunto(s)

RESUMEN

Transcutaneous electrical nerve stimulation (TENS) has been shown to decrease pain associated with knee osteoarthritis, which potentially leads to better function, improved quality of life, and postpones the need for surgical intervention. The purpose of this study was to perform a 1-year follow-up of a previous prospective group of patients with knee osteoarthritis, randomized to TENS or standard of care, who were asked to rate their changes in: (1) patient pain perception; (2) subjective medication use; (3) subjective functional abilities; (4) quality of life; (5) device use; and (6) conversion to TKA. A population of 70 patients were randomized to receive either a TENS device or a standard conservative therapy regimen. Patients were evaluated based on various subjective outcomes at minimum 1-year (mean, 19 months) follow-up. The TENS cohort had lower visual analog pain scores compared with the matching cohort. Subjective functional outcomes, as well as functional and activity scores, were also greater in the TENS cohort. Patients in TENS cohort showed significant improvements in their subjective and functional outcomes as compared with their initial status, while the control group did not show significant change. A majority of the TENS patients were able to reduce the amount of pain medications. Additionally, a large portion of the patients assigned to the TENS group continue to use the device, after completion of the trial. This study demonstrated the benefit of TENS for improving subjective outcomes in patients with pain due to knee osteoarthritis, compared with standard conservative treatments. The results of the study suggest that TENS is a safe and effective adjunct as part of the spectrum of current nonoperative treatment methods for knee osteoarthritis.

Asunto(s)

RESUMEN

When orthopedists consider which analgesia to use after total knee arthroplasty (TKA), the primary objective is to relieve pain with fewer adverse side effects. Over the last decade, substantial efforts have been made to improve pain control following TKA, but it is still very challenging to obtain optimal control. Current modalities in use, such as opioids, epidurals, and nerve blocks, provide substantial pain relief, but they are associated with substantial side effects and serious complications. Recently, bupivacaine, a commonly used nonopioid analgesic, has been formulated into an aqueous suspension of multivesicular liposomes that provide long-lasting analgesia, while avoiding significant adverse effects of opioids. The purpose of this review is to analyze the use of traditional postsurgical pain management and the potential contribution of a long-acting liposomal formulation of bupivacaine as part of the analgesic regimen in TKA, including its mode of action, injection technique, efficacy on pain, and health care costs.

Asunto(s)

RESUMEN

INTRODUCTION: Certain patients continue to suffer from knee stiffness following total knee arthroplasty (TKA) despite undergoing conventional therapies. Astym therapy to these patients may offer an effective, safe, nonoperative treatment. This study evaluates the effects of Astym therapy upon (1) range of motion and (2) subjective functional improvements in post-TKA patients who suffered from stiffness recalcitrant to other nonoperative interventions. METHODS: Twenty-three post-TKA patients (29 knees) who had recalcitrant knee stiffness were included in this study. Pre- and post-Astym improvements in range of motion and Knee Society scores were compared. We analyzed knees based on the presence of flexion deficit or contracture. Further stratification was made into knees that received Astym therapy before and after a 3-month period of standard rehabilitation. Differences in range of motion from pre- to post-Astym were evaluated by measuring (1) degree of flexion deficit or contracture and (2) total arc of passive motion. Improvements in subjective functional status were determined by evaluating Knee Society scores pre- and post-Astym therapy. A two-tailed Student t-test was used to compare weighted mean differences from pre- to post-Astym for the above parameters. RESULTS: The mean flexion deficit improved significantly (p < 0.001) in all patients after Astym therapy. The mean flexion contracture improved significantly in (p = 0.001) in 91% of patients after Astym therapy. Knees with flexion deficits or contractures both improved in total arc of motion when compared with pretherapy. Overall, patients who underwent treatment with Astym therapy reported significant mean improvements in both Knee Society objective (80 vs. 57 points; p < 0.0001) and functional scores (80 vs. 54 points; p = 0.0003) when compared with their pretherapy objective and functional scores. No harms were reported. CONCLUSION: Astym therapy is a novel, nonoperative treatment that may be an effective treatment option for post-TKA patients suffering from persistent knee stiffness. Further studies are needed to validate this intervention as a part of cost-effective, standard treatment after TKA.

Asunto(s)

RESUMEN

Despite technological advances in total knee arthroplasty (TKA), management of postoperative muscle weakness and pain continue to pose challenges for both patients and health care providers. Nonpharmacologic therapies, such as neuromodulation in the form of neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS), and other modalities, such as cryotherapy and prehabilitation, have been highlighted as possible adjuncts to standard-of-care pharmacologic management to treat postoperative pain and muscle weakness. The aim of this review was to discuss existing evidence for neuromodulation in the treatment of pain and muscular weakness following TKA, and to shed light on other noninvasive and potential future modalities. Our review of the literature demonstrated that NMES, prehabilitation, and some specialized exercises are beneficial for postoperative muscle weakness, and TENS, cooling therapies, and compression may help to alleviate post-TKA pain. However, there are no clear guidelines for the use of these modalities. Further studies should be aimed at developing guidelines or delineating indications for neuromodulation and other nonpharmacologic therapies in the management of post-TKA pain and muscle weakness.

Asunto(s)

RESUMEN

Polyethylene (PE) wear and osteolysis are common causes for late revisions of knee arthroplasties. Several implant and surgical factors have been implicated in contributing to the development of wear, such as type of bearing surface used, inaccurate articular geometry, and poor knee kinematics. In addition, patient-related factors, such as younger age and higher activity levels, may also contribute to wear. Our purpose was to evaluate and compare the effect of these variables on wear rates following knee arthroplasty. Recently, technological advancements have been aimed at reducing the incidence of wear by improving the PE manufacturing process, creating implants that minimize contact stresses, and refining our surgical techniques. Furthermore, the development of newer highly cross-linked PEs (HXLPEs) and the introduction of additives, such as vitamin E, to the PEs may improve overall implant survivorship. As a result, with the advent of newer implant and PE designs, wear is no longer the most common cause of early failure, though it remains an important factor in limiting long-term implant survivorship. However, there are a few clinical studies evaluating the long-term outcomes of newer HXLPEs and implant designs, with further evaluations necessary to determine the best implant-PE combination for improved knee arthroplasty survivorship.

Asunto(s)