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2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.

ABSTRACT: BACKGROUND:Concerns about the cost and convenience of postsurgical physical therapy (PT) have sparked interest in unsupervised, home-based rehabilitation. However, the effectiveness of unsupervised home exercise after primary TKA has not been previously evaluated. QUESTIONS/PURPOSES:(1) Can unsupervised home exercise after surgery provide noninferior recovery of passive knee flexion compared with formal outpatient PT? (2) Does a web-based platform for home-based exercise provide an advantage compared with a printed PT manual? METHODS:We conducted a randomized, noninferiority trial involving 290 patients (20% of the 1464 eligible patients who could be contacted) who underwent primary TKA from March 2016 to April 2018. We included patients > 18 years old who were undergoing primary, unilateral TKA and provided written consent. We excluded patients with preoperative knee flexion < 90°, patients considering surgical intervention in a hip or the contralateral knee, patients discharged to an extended care facility, and revision or conversion TKA. We randomized patients to one of three groups: outpatient PT, unsupervised home exercise using a web-based platform (web PT), or unsupervised home exercise using a printed paper manual (paper PT). We also implemented a "delayed recovery intervention" within the home exercise program, in which patients were obliged to begin outpatient PT if knee flexion was < 70° at 2 weeks or < 90° at 4 weeks. The primary outcome was change in knee flexion from preoperative baseline after 4 to 6 weeks and 6 months. Secondary outcomes included Knee Injury and Osteoarthritis Outcome Score (KOOS), time back to activities of daily living, and time off narcotics. All analyses were intention to treat, and the noninferiority margin was 5% with maximum flexion as the outcome of interest for this parameter. RESULTS:Adjusted differences in change in passive flexion for web PT +3° (95% confidence interval [CI], -1.2° to 6.4°) and paper PT +5° (95% CI, 0.99°-8.6°) were not inferior to outpatient PT based on a predefined 5° margin. Change in knee flexion from baseline was 0° for outpatient PT, -2° for web PT, and -1° for paper PT after 4 to 6 weeks and 8°, 8°, and 12° for the three groups, respectively, after 6 months. Additionally, there was no difference in the change in KOOS from baseline at 4 to 6 weeks or 6 months postoperatively as well as time back to work, driving, and walking without an assistive device. CONCLUSIONS:Unsupervised home exercise is an effective rehabilitation strategy after primary TKA and was noninferior to formal outpatient PT in selected patients. It is worthwhile to reconsider the current practice of automatically designating patients for outpatient PT after primary TKA, because appropriately selected patients with adequate clinical support can achieve similar results at home. LEVEL OF EVIDENCE:Level I, therapeutic study.

SUBMITTER: Fleischman AN

PROVIDER: S-EPMC6345292 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.

Fleischman Andrew N AN Crizer Meredith P MP Tarabichi Majd M Smith Shelby S Rothman Richard H RH Lonner Jess H JH Chen Antonia F AF

Clinical orthopaedics and related research 20190101 1

<h4>Background</h4>Concerns about the cost and convenience of postsurgical physical therapy (PT) have sparked interest in unsupervised, home-based rehabilitation. However, the effectiveness of unsupervised home exercise after primary TKA has not been previously evaluated.<h4>Questions/purposes</h4>(1) Can unsupervised home exercise after surgery provide noninferior recovery of passive knee flexion compared with formal outpatient PT? (2) Does a web-based platform for home-based exercise provide a ...[more]

PMID: 30794229

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Project description:BackgroundIn primary TKA, prophylaxis with low-dose vancomycin through intraosseous regional administration (IORA) achieves tissue concentrations six to 10 times higher than systemic administration and was shown to provide more effective prophylaxis in an animal model. However, in revision TKA, the presence of a tibial implant may compromise IORA injection, and tourniquet deflation during a prolonged procedure may lower tissue concentrations.Questions/purposes(1) Does low-dose IORA reliably provide equal or higher tissue concentrations of vancomycin compared with systemic IV administration in revision TKA? (2) Are tissue concentrations of vancomycin after IORA maintained for the duration of the revision TKA despite a period of tourniquet deflation? (3) Is there any difference in early postoperative (< 6 weeks) complications between IORA and systemic IV administration in revision TKA?MethodsTwenty patients undergoing aseptic revision TKA were randomized to two groups. The IV group received 1 g systemic IV prophylactic vancomycin. The IORA group received 500 mg vancomycin as a bolus injection into a tibial intraosseous cannula below an inflated thigh tourniquet before skin incision. In all patients receiving IORA, intraosseous tibial injection was technically possible despite the presence of a tibial implant. Mean procedure length was 3.5 hours in both groups. Mean initial tourniquet inflation was 1.5 hours with a second inflation for a mean of 35 minutes during cementation. During the procedure, subcutaneous fat and bone samples were taken at regular intervals. Tissue vancomycin concentrations were measured using high-performance liquid chromatography.ResultsOverall geometric mean tissue concentration of vancomycin in fat samples was 3.7 μg/g (95% confidence interval [CI], 2.6-5.2) in the IV group versus 49.3 μg/g in the IORA group (95% CI, 33.2-73.4; ratio between means 13.5; 95% CI, 8.2-22.0; p < 0.001); mean tissue concentrations in femoral bone were 6.4 μg/g (95% CI, 4.5-9.2) in the IV group versus 77.1 μg/g (95% CI, 42.4-140) in the IORA group (ratio between means 12.0; 95% CI, 6.2-23.2; p < 0.001). Vancomycin concentrations in the final subcutaneous fat sample taken before closure were 5.3 times higher in the IORA group versus the IV group (mean ± SD, 18.2 ± 11.6 μg/g IORA versus 3.6 ± 2.5 μg/g; p < 0.001). The intraarticular concentration of vancomycin on postoperative Day 1 drain samples was not different between the two groups with the numbers available (mean 4.6 μg/L in the IV group versus 6.6 μg/g in the IORA group; mean difference 2.0 μg/g; 95% CI, 6.2-23.2; p = 0.08).ConclusionsIORA administration of vancomycin in patients undergoing revision TKA resulted in tissue concentrations of vancomycin five to 20 times higher than systemic IV administration despite the lower dose. High tissue concentrations were maintained throughout the procedure despite a period of tourniquet deflation. These preliminary results justify prospective cohort studies, which might focus on broader safety endpoints in more diverse patient populations. We believe that these studies should evaluate patients undergoing revision TKA in particular, because the risk of infection is greater than in patients undergoing primary TKA.Level of evidenceLevel I, therapeutic study.

Project description:BACKGROUND:Many patients undergo both THA and spinal arthrodesis, and those patients may not fare as well as those who undergo one procedure but not the other. The mechanisms of how spinal arthrodesis affects patient function after THA remain unclear. QUESTIONS/PURPOSES:The aims of our study were to (1) determine how patient-reported outcome measures (PROMs), including the Oxford hip score as well as dislocations and complications compare after THA between patients with and without spinal arthrodesis; (2) characterize sagittal pelvic changes in these patients that occur when moving between different functional positions and test for differences between patients with and without spinal arthrodesis; and (3) assess whether differences in sagittal pelvic dynamics are associated with PROMs, complications, and dislocations after THA. METHODS:In this case-control study, we identified 42 patients (60 hips) who had undergone both THA and spinal arthrodesis between 2002 and 2016 and who were available for followup at a minimum of 12 months (mean, 6 ± 5 years) after the later of the two procedures. These cases were case-control-matched for age, gender, and body mass index with 42 patients (60 hips) who underwent only THA and had no known spinal pathology. All patients completed PROMs, including the Oxford hip score, and underwent four radiographs of the pelvis and spinopelvic complex in three positions (supine, standing, and deep-seated). Cup orientation and various spinopelvic parameters, including pelvic tilt and pelvic-femoral angle, were measured. The difference in pelvic tilt between standing and seated allowed for patient classification based on spinopelvic mobility into normal (± 10°-30°), stiff (< ± 10°) or hypermobile (> ± 30°) groups. RESULTS:Compared with the THA-only group, the THA-spinal arthrodesis group had inferior PROMs (Oxford hip score, 33 ± 10 versus 43 ± 6; p < 0.001) and more surgery-related complications (such as dislocation, loosening, periprosthetic fracture or infection, psoas irritation) (12 versus 3; p = 0.013), especially dislocation (5 versus 0; p = 0.023). We detected no difference in change of pelvic tilt between supine and standing positions between the groups. When standing, patients undergoing THA-spinal arthrodesis had greater pelvic tilt (25° ± 11° versus 17° ± 8°; p < 0.001) and the hip was more extended (193° ± 22° versus 185° ± 30°; p = 0.012). We found that patients undergoing THA-spinal arthrodesis were more likely to have spinopelvic hypermobility (12 of 42 versus three of 42; odds ratio, 5.2; p = 0.02) with anterior tilting of the pelvis. Of all biomechanical parameters, only spinopelvic hypermobility was associated with inferior PROMs (Oxford hip score, 35 ± 9 versus 40 ± 7 in normal mobility; p = 0.049) and was also present in dislocating hips that underwent revision despite acceptable cup orientation. CONCLUSIONS:In patients with spinal arthrodesis who have undergone THA, spinopelvic hypermobility is associated with inferior outcomes, including hip instability. Spinopelvic hypermobility should be routinely assessed because these patients may have a narrow zone of optimum cup orientation that would require new technology to define and assist the surgeon in obtaining it.Level of Evidence Level III, therapeutic study.

Dataset Information

2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.

Publications

2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.

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