Use of continuous passive motion after total knee arthroplasty

Sixty primary total knee arthroplasties in 43 Chinese patients were included into a prospective study. Twenty-six patients who had unilateral knee arthroplasty were randomized to receive continuous passive motion (CPM) or immobilization in the first week. The 2 groups of patients were comparable in demographic data and preoperative knee range of motion (ROM). In 17 patients who had 1-stage sequential bilateral arthroplasties, one side had CPM and the other side was immobilized. The active knee ROM was assessed regularly until 1 year after the operation. For all patients, the early active knee ROM in the CPM group was significantly better than the immobilization group. There was no difference after 7 days, however. For patients who had 1-stage bilateral total knee arthroplasties, the active knee ROM was significantly better on the CPM side until day 28. After 4 weeks, there was no difference between the CPM group and the immobilization group. Immobilization after total knee arthroplasty does not preclude good ROM.     

全膝关节置换术后主动和被动锻炼促进关节功能恢复的前瞻性研究

目的 探讨全膝关节置换(TKA)术后持续被动活动和主动功能锻炼对患者关节功能康复效果的影响. 方法采用前瞻性研究方法,选取2007年2月至2008年6月行TKA的80例患者为研究对象,所有患者按入院序号应用随机数字表法分为持续被动活动组(CPM组)和主动功能锻炼组(AP组),每组40例.CPM组术后早期应用CPM机行康复治疗,AP组则在专业康复医师指导下进行主动功能锻炼.记录患者术后第3、6、9天时的VAS评分,术后第3、6、9天、出院及随访时的关节活动度,患者住院天数.采用美国膝关节外科学会的评分系统(KSS)对患者术前、术后3、6个月随访时的患膝关节功能进行评分. 结果术后第3天,CPM组、AP组的平均VAS评分分别为2.37、3.02分,差异有统计学意义(t=-2.52,P=0.03).术后第6、9天两组患者平均VAS评分差异均无统计学意义(P>0.05).术后3、6、9 d及出院时两组患者的关节活动度差异均无统计学意义(P>0.05).56例患者(CPM组30例,AP组26例)获得随访.术后3个月,CPM组、AP组患者的关节活动度为别为105.50°、112.96°,差异有统计学意义(P=0.04),但术后6个月时两组差异无统计学意义(P>0.05).术后3、6个月两组患者KSS评分差异均无统计学意义(P>0.05). 结论 TKA术后功能恢复应强调主动功能锻炼而非被动锻炼.不推荐常规应用CPM,但对痛觉过敏及无法进行主动功能锻炼的患者,仍应考虑CPM辅助治疗,以促进关节功能的恢复.     

Synovectomy and continuous passive motion (CPM) in hemophiliac patients

Synovectomy of the knee is a procedure that has been used traditionally for the management of arthropathies due to intraarticular bleeding diatheses. Although open synovectomy controls recurrent bleeding problems, the success of this procedure has been limited frequently by disabling stiffness of the joint. In an attempt to improve on the results of open synovectomy, arthroscopic synovectomy was combined with continuous passive motion (CPM) in a prospective surgical and rehabilitation program. Five male patients aged 10 to 35 years, with chronic and/or recurrent hemarthroses due to hemophilia, underwent arthroscopic synovectomy of the knee. CPM was begun in the recovery room and continued for 5-7 days. Each patient had mildly restricted range of motion (ROM) immediately postoperatively as compared with preoperative measurements. Both active and passive ROM improved rapidly with CPM and physical therapy. By 3-6 months postoperatively, all patients except one had achieved an active ROM greater than the preoperative range, and all showed a significant reduction in documented bleeding episodes. The combination of arthroscopic techniques, which result in minimal extraarticular trauma, and immediate mobilization using CPM has been successful in maximizing the benefits and minimizing the complications of synovectomy in the patient with hemorrhagic arthropathy.     

全膝关节置换术后主动和被动锻炼促进关节功能恢复的前瞻性研究

目的 探讨全膝关节置换(TKA)术后持续被动活动和主动功能锻炼对患者关节功能康复效果的影响. 方法采用前瞻性研究方法,选取2007年2月至2008年6月行TKA的80例患者为研究对象,所有患者按入院序号应用随机数字表法分为持续被动活动组(CPM组)和主动功能锻炼组(AP组),每组40例.CPM组术后早期应用CPM机行康复治疗,AP组则在专业康复医师指导下进行主动功能锻炼.记录患者术后第3、6、9天时的VAS评分,术后第3、6、9天、出院及随访时的关节活动度,患者住院天数.采用美国膝关节外科学会的评分系统(KSS)对患者术前、术后3、6个月随访时的患膝关节功能进行评分. 结果术后第3天,CPM组、AP组的平均VAS评分分别为2.37、3.02分,差异有统计学意义(t=-2.52,P=0.03).术后第6、9天两组患者平均VAS评分差异均无统计学意义(P>0.05).术后3、6、9 d及出院时两组患者的关节活动度差异均无统计学意义(P>0.05).56例患者(CPM组30例,AP组26例)获得随访.术后3个月,CPM组、AP组患者的关节活动度为别为105.50°、112.96°,差异有统计学意义(P=0.04),但术后6个月时两组差异无统计学意义(P>0.05).术后3、6个月两组患者KSS评分差异均无统计学意义(P>0.05). 结论 TKA术后功能恢复应强调主动功能锻炼而非被动锻炼.不推荐常规应用CPM,但对痛觉过敏及无法进行主动功能锻炼的患者,仍应考虑CPM辅助治疗,以促进关节功能的恢复.     

A Comparison of Patient-Reported and Measured Range of Motion in a Cohort of Total Knee Arthroplasty Patients

Range of motion (ROM) is an important component of the assessment of total knee arthroplasty (TKA) outcome. We compared patient-reported versus clinically observed ROM in a prospective cohort. Clinically observed ROM was measured using a goniometer by a trained research assistant. Self-reported ROM was estimated using a set of lateral knee photographs depicting varying levels of flexion and extension. All measures were taken pre-operatively, three, and six months postoperatively. We found statistically significant associations between self-reported ROM and clinically observed ROM for flexion and extension (all P < 0.001). We dichotomized flexion at 90° and found that self-report had a specificity of 94% and sensitivity of 65%. We conclude that patient-reported ROM may be a useful outcome measure for TKA.     

高龄骨关节炎患者膝关节置换术后功能与变量因素相关性的病例对照研究

目的:探讨多个变量因素与术后膝关节功能HSS评分的相关性,实现对患者进行综合有效的预后判断。方法:回顾2008年3月至2010年8月应用膝关节置换术治疗72例HoldenⅣ级膝关节炎患者作为研究组,男30例,女42例;年龄60～86岁,平均(71.9±6.2)岁。关节镜下清理术治疗的22例HoldenⅣ级膝关节炎患者作为对照组,男10例,女12例;平均年龄(70.5±5.9)岁。观测术前及术后1、2周关节活动度和HSS评分,分析患者年龄、身高、体重、BMI、肌力等影响因素。评估方法主要采用HSS评分方法。结果:研究组HSS评分、ROM均提高。全膝关节置换术后2周HSS评分与术前膝关节活动度、术前HSS评分、术前膝关节疼痛、术后早期CPM应用呈正相关。全膝关节置换术后2周HSS评分与患者年龄、身高、体重、BMI、肌力等因素无显著相关。结论:患者术前膝关节活动度、HSS评分、术前疼痛、围手术期并发症以及术后CPM应用初始角度均可影响膝关节置换术疗效。     

The Efficacy of Continuous Passive Motion After Total Knee Arthroplasty: A Comparison of Three Protocols

We conducted a randomized, controlled trial to determine the efficacy of CPM following total knee arthroplasty (TKA). Postoperative outcomes of interest were: swelling, drop in hemoglobin, self-reported pain scores, range of motion, and hospital length of stay. A total of 160 subjects were randomized into one of three treatment groups: CPM device on and moving from the immediate post-operative period, CPM device on and stationary at 90 degree flexion for the first night and then moving throughout the rest of their stay, and no CPM (N = 55, 51, and 54, respectfully). Subjects were followed during the first and second postoperative day until their first follow-up appointment approximately 3–4 weeks post-operatively. Cost of CPM was further evaluated. CPM provided no benefit to patients recovering from TKA.     

Relationship of Body Core Temperature and Warm-up to Knee Range of Motion

This study examined the effects of submaximal, treadmill exercise-induced body core temperature (BCT) increase on selected knee range of motion (ROM). Twenty males, 18-35 years old, were tested (randomized crossover) for ROM, BCT, and heart rate (HR), followed by either Treatment I (20 minutes of rest) or Treatment II (20 minutes of submaximal running). The two treatments were subsequently followed by a two-minute passive stretch. Range of motion was assessed before and after passive stretch treatment intervention. Treatment means differed for BCT and HR (p < 0.001) but not for ROM after exercise intervention. It was concluded that 20 minutes of exercise increased BCT (>1 degrees C) but had no effect on knee ROM. J Orthop Sports Phys Ther 1991;13(3):126-131.     

抗凝并早期被动活动预防膝关节置换后深静脉血栓

目的：寻找人工膝关节置换术后下肢深静脉血栓形成（Deep Venous Thrombosis,DVT）的最佳预防方案,评价围手术期抗凝并早期持续被动活动（Continuous Passive Motion,CPM）对人工膝关节置换术后深静脉血栓形成的预防作用。方法：2002年1月～2005年12月对接受人工膝关节置换术者280例（均为单侧关节置换）根据围手术期处理方法的不同,采用分层随机化的方法前瞻性地分成空白对照组（对照组,n=70）、单纯抗凝组（抗凝组,n=70）、单纯早期被动活动组（CPM组,n=70）和抗凝＋CPM锻炼治疗组（观察组,n=70）。手术后第4天观察各组患者下肢的肿胀情况,并行术侧下肢彩色多普勒血管检查,诊断DVT。统计各组中DVT的发生率,采用SPSS11．0统计分析软件进行统计学分析。结果：抗凝组术后DVT发生率25．7％,CPM组30．0％,观察组12．9％,对照组45．7％,经统计学检验,观察组术后DVT发生率明显低于其它各组（P〈0．05）。结论：围手术期抗凝并早期被动活动对人工膝关节置换术后深静脉血栓形成具有明显的预防作用。     

Impact of Perioperative Pain Control on Knee Range of Motion and Development of Arthrofibrosis Following Primary Total Knee Arthroplasty

BackgroundInadequate pain control following total knee arthroplasty (TKA) has been postulated to negatively impact knee range of motion (ROM). We sought to determine the association between perioperative pain levels and knee ROM at 3-month follow-up or need for manipulation under anesthesia (MUA).MethodsWe retrospectively reviewed 2243 primary TKAs performed from 2002 to 2019 at a single academic center using an institutional total joint registry. Mean age was 68, mean body mass index was 32.8, and 59% were female. Knee ROM was measured preoperatively and 3 months postoperatively. Change in knee ROM, rates of soft tissue contracture, and MUA were assessed in relation to in-hospital 10-point pain visual analog scale (VAS) measurements.ResultsOverall, 44% had improved ROM at 3-month follow-up, 29% had no change in ROM, and 27% had worsened ROM. There was no significant difference in mean VAS scores of patients with improved, unchanged, or worsened ROM postoperatively (3.0 vs 2.8 vs 3.0; P = .068). There was no significant difference in mean VAS scores of patients who developed a soft tissue contracture or required MUA vs those who did not develop these complications (2.7 vs 2.9; P = .24). Similarly, no significant relationship with these outcomes was identified when maximum and discharge VAS scores were analyzed.ConclusionComparable ROM and rates of MUA based on in-hospital pain levels were observed in this large series of primary TKA patients. While significant early pain may limit participation in ROM exercises initially, this does not appear to have a marked impact on ROM-related complications for most patients.Level of EvidenceIII, Therapeutic.     

Effect of adjunctive range-of-motion therapy after primary total knee arthroplasty on the use of health services after hospital discharge.

INTRODUCTION: There is controversy as to whether continuous passive motion (CPM) after total knee arthroplasty (TKA), which is the standard treatment, confers significant benefit with respect to outcome. The primary purpose of this study was to determine if CPM or slider-board (SB) therapy, used as adjuncts to standardized exercises (SEs) during the acute-care hospital stay, resulted in a reduced total length of hospitalization and post-discharge rehabilitation in patients who underwent primary TKA. METHODS: We carried out a randomized, clinical trial on 120 patients who received a TKA at the University of Alberta Hospital, Edmonton, a tertiary care institution. The study horizon began at the point of discharge from the hospital and continued up to 6 months after operation. Postoperatively, patients (40 in each group) received CPM and SEs, SB therapy and SEs or SEs alone while in the tertiary Health service use was compared using transfer institution length of stay(LOS), post-discharge rehabilitation, readmission and complication rates and their associated costs. RESULTS: There were no differences in health service use or costs among the 3 groups over the 6-month study. The rates of postoperative complications and readmissions also were similar among the groups. Increased health service use associated with knee flexion that was less than 60 degrees at discharge, but similar proportions of patients with poor knee range of movement (ROM) at discharge were found in each group. CONCLUSIONS: This finding suggests that adjunctive ROM therapy, as used in this study, does not reduce health service use. Further research is required to determine if adjunctive ROM therapy after discharge from the surgical hospital decreases health service utilization in those patients who have poor knee ROM at the time of discharge.     

术前活动度对人工全膝关节置换术后功能影响的观察

目的回顾性分析患者手术前的活动度对人工全膝关节置换(TKA)术后功能的影响。方法随访2000年1月—2003年12月在我科行TKA的患者65例(97膝),年龄64．8±9．9岁(35～85岁)。其中骨性关节炎55例(81膝),类风湿关节炎10例(16膝)。单膝置换33例,双膝同时置换32例。所有患者按术前膝关节活动度数(ROM)分成两组,≤90°(5°～90°)49膝,>90°(95°～140°)48膝。对两组患者进行疗效(最大屈膝度、活动度、KSS评分及功能评分)对比。所有患者均采用Scorpio后稳定型骨水泥固定的假体,均为初期置换,全部手术由同一组医师完成。术后3 d在同一康复师指导下行患肢CPM及主动功能锻炼至出院。结果平均随访时间29个月(10～44个月)。所有膝关节的活动度从术前的平均84．2°(5°～140°)提高到术后的平均101．6°(40°～140°) (P=0．000);而最大屈膝度数术前的平均103．5°(25°～140°)与术后的平均101．6°(40°～140°)无显著差异(P=0．439);KSS膝关节评分从术前平均19．5分(-24～62分)提高到术后平均78．8分(50～95分)(P=0．000)。所有患者的总满意度为93．8％(61／65)。两个分组比较,ROM≤90°的膝关节ROM及最大屈膝度术后均较术前有提高,而ROM>90°的膝关节平均最大屈膝度术后反而下降。没有翻修及深部感染。结论(1)在影响TKA术后膝关节功能的多种因素中,手术技术是关键因素。(2)在其他因素相同的情况下,术前膝关节的活动度对TKA术后的功能也有很大的影响,术前活动度大的膝关节比那些术前活动度小的膝关节术后能获得更好的功能。     

下肢骨关节术后持续被动活动(CPM)的几个问题

作者观察了50例下肢骨关节术后使用CPM疗效,发现随访3个月以上的32例中8例膝关节未达到正常伸屈角度,19例仍有不同程度的肌肉废用性萎缩。认为使用CPM的同时切莫忽视关节的主动运动,目前使用的CPM康复器有待改进。     

骨洗方联合持续被动活动治疗膝关节镜下前交叉韧带重建术后关节僵硬

目的观察骨洗方联合持续被动活动（CPM）治疗膝关节前交叉韧带（ACL）重建术后关节僵硬的疗效。方法对我院2009年1月至2010年3月24例（24膝）膝关节镜下ACL重建术后关节僵硬患者,随机分为两组（A组、B组）,每组12例,A组给予中药骨洗方（由薄荷、桂枝、半枫荷、两面针、红花、宽筋藤等组成）熏洗联合CPM训练,B组仅进行CPM训练,定期随访,以Lysholm膝关节功能评估系统（0-100分）和膝关节活动度（ROM）分别评估膝关节功能。结果 24例患者均获得随访,A组随访时间6-12个月,平均随访10个月,B组随访时间7-12个月,平均10.5个月。A组ROM由治疗前78.6°±16.2°（62-95°）,提高到治疗后125.5°±12.1°（112-135°）,差别有统计学意义（t=8.035,P〈0.001）。B组由治疗前80.2°±13.7°（65-91°）提高到治疗后115.4°±10.1°（102-131°）,差别有统计学意义（t=7.164,P〈0.001）。A、B组治疗前ROM无统计学差异（t=0.261,P〉0.05）,治疗后ROM有统计学差异（t=2.220,P〈0.05）。A组Lysholm评分由治疗前74.3±5.8,提高到治疗后86.7±6.5,差别有统计学意义（t=4.931,P〈0.001）。B组Lysholm评分由治疗前72.7±6.3,提高到治疗后81.5±5.5,差别有统计学意义（t=3.645,P〈0.001）。A、B组治疗前Lysholm评分无统计学差异（t=0.647,P〉0.05）,治疗后Lysholm评分有统计学差异（t=2.116,P〈0.05）。两组无一例患者出现皮肤过敏等并发症。结论中药骨洗方熏洗联合CPM训练对膝关节镜下ACL重建术后关节僵硬患者的膝关节活动功能恢复有明显的促进作用,且效果优于单纯行CPM训练。     

The influence of continuous passive motion on outcome in total knee arthroplasty

All primary condylar total knee replacement arthroplasties (TKAs) performed from 1977 to 1984 at the authors' institution were divided into two groups based on the use of continuous passive motion (CPM) in the immediate postoperative period. The control group consisted of 73 patients who were treated with 95 TKAs without postoperative CPM. The average age was 65.4 years. The study group consisted of 38 patients who had 51 TKAs in which CPM was used postoperatively. The mean patient age was 62.8 years. The most common diagnoses in both groups were osteoarthritis and rheumatoid arthritis. Range of motion (ROM) was recorded preoperatively, at discharge, at three months, one year, two years, and at the last follow-up visit. There were no statistically significant differences in the ROM between the two groups at any of these time periods. At two years, the mean flexion and extension in the study group were 99 degrees and -4 degrees, respectively, compared to 103 degrees and -5 degrees in the control group. The average hospital stay was 11.2 days in the study group, whereas it was 15.1 days in control group. In the control group, there was one superficial infection, no deep infections, and four pulmonary emboli compared with three superficial infections, two deep infections, and no pulmonary emboli in the study group. There was no difference in the transfusion requirements between the two groups. CPM is advocated by the authors to help achieve discharge ROM earlier, but the protocol has been changed to begin CPM on the second postoperative day to allow the wound to stabilize.     

Factors Affecting Range of Motion After Revision Total Knee Arthroplasty

BackgroundRange of motion (ROM) after revision total knee arthroplasty (RTKA) is an important clinical outcome, as decreased ROM can lead to patient dissatisfaction and diminished mobility. This study sought to determine the effect of type of revision, implant constraint level, and reason for revision has on RTKA ROM.MethodsA retrospective review of 832 RTKA cases from 2011 to 2019 was conducted at a single, urban academic institution. Patients who underwent aseptic RTKA and had preoperative and 1-year postoperative ROM in their chart were included. The ΔROM was calculated by subtracting the preoperative ROM from the 1-year postoperative ROM. ROM was compared between tibial polyethylene liner-only revisions (liner) and all other revision types (component) and based on reason for revision. Subanalysis was performed within the liner and component revision cohorts to determine the effect of reason for revision and implant constraint level on ROM.ResultsIn total, 290 patients qualified. Forty-two patients had liner revisions (14.5%) and 248 had component revisions (85.5%). The ΔROM for component revision cases was significantly higher than liner exchange only (10° ± 24° vs.1° ± 19°; P = .03). ΔROM was not significant when comparing the level of implant constraint nor was it when separating and comparing by type of revision. Component revisions due to instability were found to significantly decrease ΔROM.ConclusionComponent revision cases have significantly improved ΔROM when compared with liner-only revision. Constraint level is not significantly associated with changes in ROM in either liner or component revisions. Component revisions due to instability significantly reduce ΔROM.     

Continuous passive motion after total knee arthroplasty

Sixty-two patients undergoing primary total knee arthroplasty were studied prospectively. There were 42 patients in whom continuous passive motion (CPM) was used after surgery and 20 controls. The two groups were comparable with respect to age, diagnosis, sex, weight, and preoperative deformity and motion. The mean length of time required for CPM patients to achieve 90 degrees of flexion (9.1 days) was shorter than that for the control group (13.8 days). At the time of discharge from the hospital, however, there was no significant difference between the groups in amount of either flexion or extension. All patients had venograms performed after arthroplasty; the incidence of positive studies indicating thrombophlebitis was 45% in CPM patients and 75% in controls. These data demonstrate that CPM after knee arthroplasty enables patients to recover motion more quickly and affords some protection against deep vein thrombosis.     

Postoperative Range of Motion Does Not Correlate with Patient Reported Outcome Scores in Asians after Total Knee Arthroplasty

Activities in Asian cultures require greater knee flexion. However, this study hypothesized that post-operative range of motion (ROM) does not correlate with patient reported outcome scores at 2 years. 292 TKAs were evaluated at a public hospital in Singapore from January 2006 to May 2009. The relationship between ROM and outcome scores was examined using a multiple linear regression model with Generalized Estimating Equation (GEE) allowing adjustment for confounders and repeated TKAs within a patient. Analysis did not yield statistically significant results when patients' post-op ROM was correlated with outcome scores at 2 years. Lack of post op ROM does not translate into poorer outcome scores and dissatisfaction. Doctors can now counsel patients who are concerned about a lack of ROM after TKA.     

Heterotopic Ossification Negatively Influences Range of Motion After Revision Total Knee Arthroplasty

BackgroundThe incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) varies and is of unclear clinical significance. This study aimed to identify the incidence of HO in patients undergoing revision TKA for either stiffness or aseptic loosening/instability and determine if the presence of HO is associated with inferior absolute range of motion (ROM) and ROM gains.MethodsEighty-seven patients were prospectively enrolled and separated into 2 cohorts to evaluate ROM after revision TKA (2017-2019). Group 1 (N = 40) patients were revised for stiffness, while group 2 (N = 47) patients were revised for either aseptic loosening or instability. Goniometer-measured ROM values were obtained preoperatively and at 6 weeks, 6 months, and 1 year postoperatively. Statistical analysis included a Fisher’s exact test to assess for an association between preoperative HO and final ROM at 1 year after revision TKA.ResultsHO was identified on preoperative radiographs in 17 patients (20%). There was a significantly higher rate of preoperative HO in patients revised for stiffness compared to patients revised for instability or loosening (30% vs 11%; P = .03). Five cases of HO qualitatively identified as most clinically severe were associated with lower ROM at each time point compared to the remainder of HO cases in this study cohort (P < .02).ConclusionThe presence of HO is greater in patients undergoing revision TKA for stiffness. Additionally, HO severity appears to have a major effect on preoperative and postoperative ROM trajectory. This information should help guide patient expectations and highlight the need for a comprehensive, standardized classification system for HO.