Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy

Gait Mechanics are Influenced by Quadriceps Strength, Age, and Sex after Total Knee Arthroplasty

Although most patients are satisfied with outcomes after total knee arthroplasty (TKA), many retain preoperative altered gait mechanics. Identifying patient characteristics associated with gait mechanics will improve rehabilitation strategies and enhance our understanding of movement disorders. Therefore, the purpose of this study was to identify which patient characteristics are related to gait mechanics in the surgical limb during walking post-TKA. Patient characteristics included age, body mass, sex, quadriceps strength, self-reported function, and knee pain. General linear regression was used to compare patient characteristics associated with gait mechanics, after controlling for gait speed, functional capacity and time from surgery. We tested 191 patients cross-sectionally at 6–24 months after primary, unilateral TKA. Quadriceps weakness in the surgical limb was associated with less peak vertical ground reaction force (PvGRF) (β = .245, p = .044), knee extension moment (β = .283, p = .049), and knee extension excursion (β = .298, p = .038). Older age (β = .168, p = .050) was associated with less PvGRF. Quadriceps strength in the nonsurgical limb (β = −.357, p = .021) was associated with greater knee extension excursion in the surgical limb. Females with TKA (β = −.276, p = .007) had less knee flexion excursion compared to males. Faster gait speed was also associated with greater PvGRF (β = .585, p \u3c .001), knee extensor moment (β = .481, p \u3c .001), and knee flexion excursion (β = .318, p \u3c .001). Statement of Clinical Significance: This study showed quadriceps weakness, slower gait speed, older age and being female were related to altered gait mechanics post-TKA. These findings will help clinicians better educate patients and develop targeted interventions for improving care in patients post-TKA

Prospective Telehealth Analysis of Functional Performance, Frailty, Quality of Life, and Mental Health after COVID-19 hospitalization

Background COVID-19 is a global pandemic with poorly understood long-term consequences. Determining the trajectory of recovery following COVID-19 hospitalization is critical for prioritizing care, allocating resources, facilitating prognosis, and informing rehabilitation. The purpose of this study was to prospectively evaluate recovery following COVID-19 hospitalization. Methods Participants age 18 years or older who were hospitalized for ≥24 h due to COVID-19 completed phone/video call virtual assessments (including the 10-time chair rise test) and survey forms at three time points (2–6, 12, and 18 weeks) after hospital discharge. Univariate logistic and linear regression models assessed the associations of the outcomes with primary predictors (categorical age, sex, race/ethnicity group, and categorical pre-hospitalization frailty) at baseline; the same were used to assess differences in change from week 2–6 (continuous outcomes) or outcome persistence/worsening (categorical) at last contact. Results One hundred nine adults (age 53.0 [standard deviation 13.1]; 53% female) participated including 43 (39%) age 60 or greater; 59% identified as an ethnic and/or racial minority. Over 18 weeks, the mean time to complete the 10-time chair rise test decreased (i.e., improved) by 6.0 s (95% CI: 4.1, 7.9 s; p \u3c 0.001); this change did not differ by pre-hospital frailty, race/ethnicity group, or sex, but those age ≥ 60 had greater improvement. At weeks 2–6, 67% of participants reported a worse Clinical Frailty Scale category compared to their pre-hospitalization level, whereas 42% reported a worse frailty score at 18 weeks. Participants who did not return to pre-hospitalization levels were more likely to be female, younger, and report a pre-hospitalization category of ‘very fit’ or ‘well’. Conclusions We found that functional performance improved from weeks 2–6 to 18 weeks of follow-up; that incident clinical frailty developed in some individuals following COVID-19; and that age, sex, race/ethnicity, and pre-hospitalization frailty status may impact recovery from COVID-19. Notably, individuals age 60 and older were more likely than those under age 45 years to return to their pre-hospitalization status and to make greater improvements in functional performance. The results of the present study provide insight into the trajectory of recovery among a representative cohort of individuals hospitalized due to COVID-19. Background Coronavirus disease (COVID)-19 is a global pandemic with poorly understood long-term consequences. Recent data suggest that even mild cases of COVID-19 can result in significant long-term morbidity [1]. Determining the trajectory of recovery in patients following COVID-19 hospitalization is critical for prioritizing care, allocating resources, facilitating prognosis, and informing rehabilitation

Modelling Patient Behaviour Using IoT Sensor Data: a Case Study to Evaluate Techniques for Modelling Domestic Behaviour in Recovery from Total Hip Replacement Surgery

The UK health service sees around 160,000 total hip or knee replacements every year and this number is expected to rise with an ageing population. Expectations of surgical outcomes are changing alongside demographic trends, whilst aftercare may be fractured as a result of resource limitations. Conventional assessments of health outcomes must evolve to keep up with these changing trends. Health outcomes may be assessed largely by self-report using Patient Reported Outcome Measures (PROMs), such as the Oxford Hip or Oxford Knee Score, in the months up to and following surgery. Though widely used, many PROMs have methodological limitations and there is debate about how to interpret results and definitions of clinically meaningful change. With the development of a home-monitoring system, there is opportunity to characterise the relationship between PROMs and behaviour in a natural setting and to develop methods of passive monitoring of outcome and recovery after surgery. In this paper, we discuss the motivation and technology used in long-term continuous observation of movement, sleep and domestic routine for healthcare applications, such as the HEmiSPHERE project for hip and knee replacement patients. In this case study, we evaluate trends evident in data of two patients, collected over a 3-month observation period post-surgery, by comparison with scores from PROMs for sleep and movement quality, and by comparison with a third control home. We find that accelerometer and indoor localisation data correctly highlight long-term trends in sleep and movement quality and can be used to predict sleep and wake times and measure sleep and wake routine variance over time, whilst indoor localisation provides context for the domestic routine and mobility of the patient. Finally, we discuss a visual method of sharing findings with healthcare professionals

Rationale, design and protocol of a longitudinal study assessing the effect of total knee arthroplasty on habitual physical activity and sedentary behavior in adults with osteoarthritis

Background: Physical activity levels are decreased and sedentary behaviour levels are increased in patients with knee osteoarthritis (OA). However, previous studies have shown that following total knee arthroplasty (TKA), objectively measured physical activity levels do not change compared to before the surgery. Very few studies have objectively assessed sedentary behaviour following TKA. This study aims to assess patterns of objective habitual physical activity and sedentary behaviour in patients with knee OA and to determine whether these change following TKA. Methods: Patients diagnosed with knee osteoarthritis and scheduled for unilateral primary total knee arthroplasty will be recruited from the Orthopaedic Division at the Charlotte Maxeke Johannesburg Academic Hospital. Eligible participants will have assessments completed one week before the scheduled arthroplasty, six weeks, and six months post-operatively. The primary outcomes are habitual physical activity and sedentary behaviour which will be measured using accelerometry (Actigraph GTX3+ and activPal monitors) at the specific time points. The secondary outcomes will be improvements in osteoarthritis-specific quality of life measures using the following questionnaires: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), Knee Society Clinical Rating System (KSS), UCLA activity index; subjective pain scores, and self reported sleep quality.Discussion: The present study will contribute to the field of musculoskeletal health by providing a rich detailed description of the patterns of accumulation of physical activity and sedentary behaviour in patients with knee OA. These data will contribute to existing knowledge using an objective measurement for the assessment of functional ability after total knee arthroplasty. Although studies have used accelerometry to measure physical activity in knee OA patients, the data provided thus far have not delved into the detailed patterns of how and when physical activity is accumulated before and after TKA. Accurate assessment of physical activity is important for physical activity interventions that target special populations

Delayed Recovery of Skeletal Muscle Mass following Hindlimb Immobilization in mTOR Heterozygous Mice

The present study addressed the hypothesis that reducing mTOR, as seen in mTOR heterozygous (+/−) mice, would exaggerate the changes in protein synthesis and degradation observed during hindlimb immobilization as well as impair normal muscle regrowth during the recovery period. Atrophy was produced by unilateral hindlimb immobilization and data compared to the contralateral gastrocnemius. In wild-type (WT) mice, the gradual loss of muscle mass plateaued by day 7. This response was associated with a reduction in basal protein synthesis and development of leucine resistance. Proteasome activity was consistently elevated, but atrogin-1 and MuRF1 mRNAs were only transiently increased returning to basal values by day 7. When assessed 7 days after immobilization, the decreased muscle mass and protein synthesis and increased proteasome activity did not differ between WT and mTOR+/− mice. Moreover, the muscle inflammatory cytokine response did not differ between groups. After 10 days of recovery, WT mice showed no decrement in muscle mass, and this accretion resulted from a sustained increase in protein synthesis and a normalization of proteasome activity. In contrast, mTOR+/− mice failed to fully replete muscle mass at this time, a defect caused by the lack of a compensatory increase in protein synthesis. The delayed muscle regrowth of the previously immobilized muscle in the mTOR+/− mice was associated with a decreased raptor•4EBP1 and increased raptor•Deptor binding. Slowed regrowth was also associated with a sustained inflammatory response (e.g., increased TNFα and CD45 mRNA) during the recovery period and a failure of IGF-I to increase as in WT mice. These data suggest mTOR is relatively more important in regulating the accretion of muscle mass during recovery than the loss of muscle during the atrophy phase, and that protein synthesis is more sensitive than degradation to the reduction in mTOR during muscle regrowth

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Assessing function in patients undergoing joint replacement: a study protocol for a cohort study

BACKGROUND: Joint replacement is an effective intervention for people with advanced arthritis, although there is an important minority of patients who do not improve post-operatively. There is a need for robust evidence on outcomes after surgery, but there are a number of measures that assess function after joint replacement, many of which lack any clear theoretical basis. The World Health Organisation has introduced the International Classification of Functioning, Disability and Health (ICF), which divides function into three separate domains: Impairment, activity limitations and participation restrictions. The aim of this study is to compare the properties and responsiveness of a selection of commonly used outcome tools that assess function, examine how well they relate to the ICF concepts, and to explore the changes in the measures over time. METHODS/DESIGN: Two hundred and sixty three patients listed for lower limb joint replacement at an elective orthopaedic centre have been recruited into this study. Participants attend the hospital for a research appointment prior to surgery and then at 3-months and 1-year after surgery. At each assessment time, function is assessed using a range of measures. Self-report function is assessed using the WOMAC, Aberdeen Impairment, Activity Limitation and Participation Restriction Measure, SF-12 and Measure Yourself Medical Outcome Profile 2. Clinician-administered measures of function include the American Knee Society Score for knee patients and the Harris Hip Score for hip patients. Performance tests include the timed 20-metre walk, timed get up and go, sit-to-stand-to-sit, step tests and single stance balance test. During the performance tests, participants wear an inertial sensor and data from motion analysis are collected. Statistical analysis will include exploring the relationship between measures describing the same ICF concepts, assessing responsiveness, and studying changes in measures over time. DISCUSSION: There are a range of tools that can be used to assess function before and after joint replacement, with little information about how these various measures compare in their properties and responsiveness. This study aims to provide this data on a selection of commonly used assessments of function, and explore how they relate to the ICF domains

Measuring movement symmetry using tibial-mounted accelerometers for people recovering from total knee arthroplasty

Background: The purpose of this investigation was to examine movement symmetry changes over the first 26 weeks following unilateral total knee arthroplasty in community environments using skin-mounted tibial accelerometers. Comparisons to healthy participants of similar age were also made. Methods: Patients (N = 24) with unilateral knee osteoarthritis (mean (SD), 65.2 (9.2) years) scheduled to undergo total knee arthroplasty and a control group (N = 19 healthy people; mean (SD), 61.3 (9.2) years) were recruited. The total knee arthroplasty group participated in a standardized course of physical rehabilitation. Tibial acceleration data were recorded during a Stair Climb Test and 6-Minute Walk Test. Tibial acceleration data were reduced to initial peak acceleration for each step. An inter-limb absolute symmetry index of tibial initial peak acceleration values was calculated. Findings: The total knee arthroplasty group had greater between limb asymmetry for tibial initial peak acceleration and initial peak acceleration absolute symmetry index values five weeks after total knee arthroplasty, during the Stair Climb Test and the 6-Minute Walk Test. Interpretation: Tibial accelerometry is a potential tool for measuring movement symmetry following unilateral total knee arthroplasty in clinical and community environments. Accelerometer-based symmetry outcomes follow patterns similar to published measures of limb loading recorded in laboratory settings