Standard Outpatient Physiotherapy Regime Mockford et al 1111 Table 1. Preoperative Patient Characteristics in the Oxford Knee Score (OKS) , Bartlett patellar Each Group score (BPS) , and the Short-Form (SF-12) Group A Group B general health questionnaire were completed. (n = 71) (n = 72) Range of motion was measured using a goniometer.Age, y (mean) 69.4 70.9 As soon as possible after surgery, general medicalSex (women) 46 42 health permitting, all patients were mobilized fullyDiagnosis weight bearing with the use of either a walking Osteoarthritis 66 71 Rheumatoid arthritis 5 1 frame or crutches. Inpatient physiotherapy com-OKS 49 48 menced on day 1 and continued daily untilBPS 10.3 10.6 discharge. On days 1 and 2, the inpatient programSF-12 PCS 27.3 28SF-12 MCS 47 46.6 consisted of ankle exercises, static quadriceps andPostoperative length of stay 4.2 4.4 hamstring exercises, straight leg raising and knee flexion exercises, and walking practice. From day 3 PCS indicates physical component summary; MCS, mental until discharge, the physiotherapy was carried out incomponent summary. the gym and consisted of heel slides, quadriceps bar and hamstring pulley exercises, gait reeducation,using the LCS rotating platform prosthesis (DePuy, and stair practice. Continuous passive motion wasLeeds, UK). The local ethics committee granted not used. All patients were given a home exerciseethical approval. regime to follow on discharge. A letter was also sent One hundred and fifty patients undergoing to the patients general practitioner on day ofprimary TKA were recruited. Subjects were ran- discharge requesting them not to organize out-domized using a computer-generated randomiza- patient physiotherapy.tion program into 2 groups. Both the surgeon andinpatient physiotherapy team were blinded to the Statistical Analysisstudy grouping. To detect a clinically significant Analysis was carried out on an intention-to-treatdifference of 10° (estimating a within-group SD of basis. No adjustment needed to be made for any16° at 90% power and at a 5% significance level), baseline differences. Statistical analysis was per-a sample size of 54 patients in each arm of the formed using the independent samples T test andstudy was required. Recruitment of patients took the 1-sample T test using the SPSS version 11place on the day of admission to hospital. software package (SPSS, Inc, Chicago, Ill).Sufficient numbers were entered into the trial toallow for dropouts. Seven patients were lost to follow-up or died and Resultstherefore excluded from the study. This left 71patients in group A and 72 in group B. Group A The baseline characteristics of the 2 groups werereceived a standard outpatient physiotherapy similar (Table 1). No significant differences wereregime, whereas group B did not. Measurements noted between the 2 groups.of knee range of motion were taken preoperatively, The mean number of outpatient physiotherapyat 3-month and 1-year reviews after surgery, and sessions attended in group A was 7.3 (range, 0-9). Table 2. Measurements of Knee Motion and Analysis of Mean Differences of Each ParameterParameter Group Preoperative 1y Mean difference P valueActive extension A 3.7° 1.5° 2.2° .98 B 3.5° 1.3° 2.2°Passive extension A 3.6° 1.3° 2.3° .78 B 3.3° 1.2° 2.1°Active flexion A 97.8° 107.9° 10.1° .18 B 100.4° 106.6° 6.2°Passive flexion A 101.9° 109.9° 8° .48 B 103.5° 109.3° 5.8°Active ROM A 94° 106.3° 12.3° .23 B 96.8° 105.2° 8.4°Passive ROM A 98.3° 108.6° 10.3° .48 B 100.2° 108.1° 7.9° ROM indicates range of motion.
1112 The Journal of Arthroplasty Vol. 23 No. 8 December 2008 Table 3. Validated Outcome Scores Table 5. Walking Distance Before and (Mean Differences) Before and After Surgery in Each Group After Surgery in Each Group Group A Group B Group A Group B P value Preoperative 1y Preoperative 1yOKS 23 23.5 .77 Unlimited 1 28 1 30BPS 15.7 14.4 .22 N1000 m 3 20 2 20SF-12 PCS 11.7 11 .67 500-1000 m 8 15 12 9SF-12 MCS 3.3 3.4 .97 b500 m 53 6 52 10 Housebound 6 2 5 3Forty-three patients attended for all 9 plannedsessions. One patient in group B attended potential for this, it is necessary to evaluate commonphysiotherapy, requested by his GP. He received factors that may influence the amount of knee9 sessions. motion achieved after TKA. Postoperative rehabili- The mean absolute values for each range of tation, of which physiotherapy plays a large part, ismotion parameter are outlined in Table 2. The considered an important factor.difference between the 2 means was then calculated The range of motion at 1 year is felt to be anand compared. No significant differences were noted appropriate end point with no improvement in thebetween the 2 groups. range of knee motion thereafter [16-20]. An improvement was also noted in all validated Our study concurs with those authors whooutcome measures as expected. No significant differ- suggest that the most important factor in influencingences were noted between the 2 groups (Table 3). the range of motion after TKA is the preoperative One-way analysis of variance revealed no statis- value [7,16,21,22]. Regarded by most as the mosttical difference in any of the parameters between important parameter, active flexion was not sig-that preoperatively and at 1 year in groups receiving nificantly improved by 1 year after a course ofno outpatient physiotherapy, 1 to 8 sessions, or all 9 outpatient physiotherapy.sessions of physiotherapy. It was, however, noted that in group A the There was no difference noted between the 2 range of motion was improved at 3 monthsgroups in the type of walking aid used (Table 4) or compared to the nonphysiotherapy group B butwalking distance attained at 1 year (Table 5). not significantly. Like other physiotherapy mod- Four complications were noted in each group. In alities such as continuous passive motion [23,24]group A, 1 proximal deep vein thrombosis, 1 and muscle strengthening exercises , wepulmonary embolism, 1 supracondylar fracture, and could conclude that physiotherapy allows a faster1 superficial wound infection were seen, and in group return to a functional range of motion butB 1 proximal deep vein thrombosis, 1 superficial ultimately no benefit at 1 year or beyond.wound infection, 1 deep infection, and 1 hematoma Furthermore, when considering the individualrequiring drainage. None were directly attributable to groups, patients tended to migrate toward athe outpatient physiotherapy intervention. middle range, that is, those with poor preopera- tive active flexion gained flexion after TKA whereas those with good preoperative active Discussion flexion lost flexion. Contrary to other studies [1,3,4,16,17,25,26], we found an overall improve- The restoration of a functional range of knee ment in extension and flexion, active and passive,motion is important in TKA. To maximize the compared to that preoperatively in both groups. The physiotherapy group had a mean improve- ment of 3.9° over the no-physiotherapy group.Table 4. Walking Aid Use Before and After Surgery This was not statistically different and did not in Each Group elevate the number of patients into a higher functional range of motion. Kettlekamp et al  Group A Group B felt 93° of active flexion was necessary for Preoperative 1y Preoperative 1y everyday function. Six patients (13%) in groupNo support 30 54 33 51 A and 9 patients (12%) in group B did not1 stick 37 15 33 18 achieve this goal postoperatively.2 sticks 1 0 2 1Crutches or walker 3 2 4 2 The ability to passively flex the limb to beyond 93° is advantageous, and if 105° is manageable then
Standard Outpatient Physiotherapy Regime Mockford et al 1113elevation to a higher functional status is achieved 6. Schurman DJ, Matityahu A, Goodman SB, et al.allowing patients to get up comfortably from the Prediction of postoperative knee flexion in Insall-seated position. Seventy-three percent of patients in Burstein II total knee arthroplasty. Clin Orthop 1998;group A and 75% of patients in group B achieved 353:175. 7. Thompson NW. Factors influencing range of motion105° of passive flexion. following total knee replacement. MPhil Thesis, Our results were in agreement with the results of Queens University Belfast, 2003.a similar study by Rajan et al . Although 8. Figgie III HE, Goldberg VM, Heiple KG, et al. Theadjustment was required to account for baseline influence of tibial-patellofemoral location on functiondifferences between the groups preoperatively, they of the knee in patients with the posterior stabilizedfound no statistical difference between the 2 groups condylar knee prosthesis. J Bone Joint Surg 1986;at any of the review times of 3 months, 6 months, or 68A:1035.1 year. 9. Ryu J, Saito S, Yamamoto K, et al. Factors Outpatient physiotherapy did not improve the influencing the postoperative range of motion inability to walk further nor did it decrease the total knee arthroplasty. Bull Hosp Joint Dis 1993;53:necessity for walking aids. 35. 10. Ranawat CS, Luessenhop CP, Rodriguez JA. The The economic gains of not having to undergo press-fit condylar modular total knee system four-to-outpatient physiotherapy are considerable particu- six-year results with a posterior-cruciate–substitutinglarly in transport and staffing costs. design. J Bone Joint Surg 1997;79A:342. In conclusion, a standard routine course of out- 11. Ewald FC, Wright RJ, Poss R, et al. Kinematic totalpatient physiotherapy does not offer any benefits in knee arthroplasty. A 10- to 14-year prospective followthe long-term to patients undergoing TKA. It does, up review. J Arthroplasty 1999;14:473.however, produce a more rapid recovery in terms of 12. Callaghan JJ, Squire MW, Goetz DD, et al. Cementedknee flexion up to 3 months. It is difficult to say rotating-platform total knee replacement. A nine towhether the more rapid recovery made patients twelve-year follow-up study. J Bone Joint Surg 2000;better functionally in their activities of daily living. 82A:705.Obviously, the patient groups are within the age 13. Laubenthal KN, Smidt GL, Kettelkamp DB. A quanti- tative analysis of knee motion during activities of dailylimits of retirement and no conclusions could be living. Phys Ther 1972;52:34.drawn with regard to speed of return to work and 14. Dawson J, Fitzpatrick R, Murray D, et al. Ques-the duration of sickness payments offset against the tionnaire on the perceptions of patients about totalcost of attending physiotherapy. After 3 months, knee replacement. J Bone Joint Surg Br 1998;80:patients receiving or not receiving physiotherapy 63.improve similarly. 15. Feller JA, Bartlett RJ, Lang DM. Patellar resurfacing Outpatient physiotherapy does not improve the versus retention in total knee arthroplasty. J Bone Jfunctional range of motion for activities of daily Surg Br 1996;78:226.living at 1 year after TKA. 16. Lizaur A, Marco L, Cebrian R. Preoperative factors influencing the range if movement after total knee arthroplasty for severe osteoarthritis. J Bone Joint Surg 1997;79B:626. References 17. Rorabeck CH, Bourne RB, Nott L. The cemented kinematic-II and the noncemented porous coated 1. Ritter MA, Stringer EA. Predictive range of motion anatomic prosthesis for the total knee replacement. after total knee replacement. Clin Orthop 1979;143: J Bone Joint Surg 1988;70A:483. 115. 18. Insall JN, Hood RW, Flawn LB, et al. The total 2. Mullen JO. Range of motion following total knee condylar knee prosthesis in gonarthrosis—a five to arthroplasty in ankylosed joints. Clin Orthop 1983; nine year follow up of the first one-hundred 179:200. consecutive replacements. J Bone Joint Surg 1983; 3. Parsley BS, Engh GA, Dwyer KA. Preoperative 65A:619. flexion. Does it influence postoperative flexion after 19. Shoji H, Solomonow M, Yoshino S, et al. Factors posterior cruciate–retaining total knee arthroplasty? affecting postoperative flexion in total knee arthro- Clin Orthop 1992;275:204. plasty. Orthopaedics 1990;13:643. 4. Anouchi YS, McShane M, Kelly Jr F, et al. Range of 20. Malkani AL, Rand JA, Bryan RS, et al. Total knee motion in total knee replacement. Clin Orthop 1996; arthroplasty with the kinematic condylar prosthesis: a 331:87. ten-year follow up study. J Bone Joint Surg 1995; 5. Schurman DJ, Parker JN, Ornstein D. Total condylar 75A:402. knee replacement: a study of factors influencing range 21. Menke W, Schmitz B, Salm S. Range of motion after of motion as late as two years after arthroplasty. total condylar knee arthroplasty. Arch Orthop Trauma J Bone Joint Surg 1985;67A:1005. Surg 1992;111:280.
1114 The Journal of Arthroplasty Vol. 23 No. 8 December 200822. Ritter MA, Harty LD, Davis KE, et al. Predicting range people with total knee endoprosthesis. Scand J Med of motion after total knee arthroplasty. J Bone Joint Sci Sports 1992;2:234. Surg 2003;85A:1278. 26. Harvey IA, Barry K, Kirby SPJ, et al. Factors affecting23. Ritter MA, Gandolf VS, Holston KS. Continuous the range of movement of total knee arthroplasty. passive motion versus physical therapy in total knee J Bone Joint Surg 1993;75B:950. arthroplasty. Clin Orthop 1989;244:239. 27. Kettelkamp DB, Johnson RJ, Smidt GL, et al. An24. Lau SK, Chiu KY. Use of continuous passive motion electrogoniometric study of knee motion in normal after total knee arthroplasty. J Arthroplasty 2001;16: gait. J Bone Joint Surg 1970;52A:775. 336. 28. Rajan RA, Pack Y, Jackson H, et al. No need for25. Perhonen M, Komi PV, Hakkinen K, et al. Strength outpatient physiotherapy following total knee arthro- training and neuromuscular function in elderly plasty. Acta Orthop Scand 2004;75:71.