The Journal of Arthroplasty Vol. 23 No. 8 2008

Does a Standard Outpatient Physiotherapy RegimeImprove the Range of Knee Motion After Primary

Total Knee Arthroplasty?

Brian James Mockford, MPhil, FRCS (Orth), Neville W. Thompson, MPhil, FRCS (Orth),Patricia Humphreys, BSc (Hons), and David E. Beverland, MD

Abstract: The aim of this study was to investigate whether a standard course ofoutpatient physiotherapy improves the range of knee motion after primary totalknee arthroplasty. One hundred and fifty patients were randomly assigned into oneof 2 groups. One group received outpatient physiotherapy for 6 weeks (group A).Another received no outpatient physiotherapy (group B). Range of knee motionwas measured preoperatively and at 1-year review. Validated knee scores and anSF-12 health questionnaire were also recorded. Although patients in group Aachieved a greater range of knee motion than those in group B, this was notstatistically significant. No difference either was noted in any of the outcomemeasures used. In conclusion, outpatient physiotherapy does not improve the rangeof knee motion after primary total knee arthroplasty. Key words: total kneearthroplasty, physiotherapy.© 2008 Elsevier Inc. All rights reserved.

In recent years, increasingly better functional resultsand greater patient satisfaction are being noted inpatients undergoing total knee arthroplasty (TKA).Range of motion remains a rather unpredictableentity with postoperative range of motion notalways meeting patient demands. After the primegoal of reducing pain, range of motion is probablyseen as the next most important outcome measureafter TKA and has therefore been the subject of anumber of studies [1-6].Variables including age, sex, primary diagnosis,

preoperative motion, implant design, surgical tech-

From the Musgrave Park Hospital, United Kingdom.Submitted March 8, 2006; accepted August 25, 2007.Benefits or support was received from the Belfast Arthroplasty

Research Trust.Reprint requests: Brian James Mockford, MPhil, FRCS (Orth),

45 Waringfield Avenue, Moira, Co. Armagh, BT67 0FA NorthernIreland, UK.

© 2008 Elsevier Inc. All rights reserved.0883-5403/08/2308-0003$34.00/0doi:10.1016/j.arth.2007.08.023

1110

nique, and rehabilitation have been studied todetermine their influence on postoperative kneeflexion. Many are retrospective and include datafrom a number of different surgeons, surgicaltechniques, and prostheses [7].

Most clinical studies have a final range of motionthat averages between 100° and 110° of flexionwhich is adequate for most activities of daily living[8-13]; however, many patients undergoing TKAare, however, becoming increasingly active andexpect to achieve a greater degree of movement.The aim of this study was to determine whether astandard course of postoperative outpatient phy-siotherapy improved the range of knee motion 1year after primary TKA.

Materials and Methods

All patients attending for primary TKA under thecare of one surgeon were targeted for entry into thisprospective study. All patients underwent TKA

Table 1. Preoperative Patient Characteristics inEach Group

Group A(n = 71)

Group B(n = 72)

Age, y (mean) 69.4 70.9Sex (women) 46 42DiagnosisOsteoarthritis 66 71Rheumatoid arthritis 5 1OKS 49 48BPS 10.3 10.6SF-12 PCS 27.3 28SF-12 MCS 47 46.6Postoperative length of stay 4.2 4.4

PCS indicates physical component summary; MCS, mentalcomponent summary.

Standard Outpatient Physiotherapy Regime � Mockford et al 1111

using the LCS rotating platform prosthesis (DePuy,Leeds, UK). The local ethics committee grantedethical approval.One hundred and fifty patients undergoing

primary TKA were recruited. Subjects were ran-domized using a computer-generated randomiza-tion program into 2 groups. Both the surgeon andinpatient physiotherapy team were blinded to thestudy grouping. To detect a clinically significantdifference of 10° (estimating a within-group SD of16° at 90% power and at a 5% significance level),a sample size of 54 patients in each arm of thestudy was required. Recruitment of patients tookplace on the day of admission to hospital.Sufficient numbers were entered into the trial toallow for dropouts.Seven patients were lost to follow-up or died and

therefore excluded from the study. This left 71patients in group A and 72 in group B. Group Areceived a standard outpatient physiotherapyregime, whereas group B did not. Measurementsof knee range of motion were taken preoperatively,at 3-month and 1-year reviews after surgery, and

Table 2. Measurements of Knee Motion and Ana

Parameter Group Preoperative

Active extension A 3.7°B 3.5°

Passive extension A 3.6°B 3.3°

Active flexion A 97.8°B 100.4°

Passive flexion A 101.9°B 103.5°

Active ROM A 94°B 96.8°

Passive ROM A 98.3°B 100.2°

ROM indicates range of motion.

the Oxford Knee Score (OKS) [14], Bartlett patellarscore (BPS) [15], and the Short-Form (SF-12)general health questionnaire were completed.Range of motion was measured using a goniometer.

As soon as possible after surgery, general medicalhealth permitting, all patients were mobilized fullyweight bearing with the use of either a walkingframe or crutches. Inpatient physiotherapy com-menced on day 1 and continued daily untildischarge. On days 1 and 2, the inpatient programconsisted of ankle exercises, static quadriceps andhamstring exercises, straight leg raising and kneeflexion exercises, and walking practice. From day 3until discharge, the physiotherapy was carried out inthe gym and consisted of heel slides, quadriceps barand hamstring pulley exercises, gait reeducation,and stair practice. Continuous passive motion wasnot used. All patients were given a home exerciseregime to follow on discharge. A letter was also sentto the patient's general practitioner on day ofdischarge requesting them not to organize out-patient physiotherapy.

Statistical Analysis

Analysis was carried out on an intention-to-treatbasis. No adjustment needed to be made for anybaseline differences. Statistical analysis was per-formed using the independent samples T test andthe 1-sample T test using the SPSS version 11software package (SPSS, Inc, Chicago, Ill).

Results

The baseline characteristics of the 2 groups weresimilar (Table 1). No significant differences werenoted between the 2 groups.

The mean number of outpatient physiotherapysessions attended in group A was 7.3 (range, 0-9).

lysis of Mean Differences of Each Parameter

1 y Mean difference P value

1.5° 2.2° .981.3° 2.2°1.3° 2.3° .781.2° 2.1°

107.9° 10.1° .18106.6° 6.2°109.9° 8° .48109.3° 5.8°106.3° 12.3° .23105.2° 8.4°108.6° 10.3° .48108.1° 7.9°

Table 3. Validated Outcome Scores(Mean Differences) Before andAfter Surgery in Each Group

Group A Group B P value

OKS 23 23.5 .77BPS 15.7 14.4 .22SF-12 PCS 11.7 11 .67SF-12 MCS 3.3 3.4 .97

Table 5. Walking Distance Before andAfter Surgery in Each Group

Group A Group B

Preoperative 1 y Preoperative 1 y

nlimited 1 28 1 301000 m 3 20 2 2000-1000 m 8 15 12 9500 m 53 6 52 10ousebound 6 2 5 3

1112 The Journal of Arthroplasty Vol. 23 No. 8 December 2008

Forty-three patients attended for all 9 plannedsessions. One patient in group B attendedphysiotherapy, requested by his GP. He received9 sessions.The mean absolute values for each range of

motion parameter are outlined in Table 2. Thedifference between the 2 means was then calculatedand compared. No significant differences were notedbetween the 2 groups.An improvement was also noted in all validated

outcome measures as expected. No significant differ-ences were noted between the 2 groups (Table 3).One-way analysis of variance revealed no statis-

tical difference in any of the parameters betweenthat preoperatively and at 1 year in groups receivingno outpatient physiotherapy, 1 to 8 sessions, or all 9sessions of physiotherapy.There was no difference noted between the 2

groups in the type of walking aid used (Table 4) orwalking distance attained at 1 year (Table 5).Four complications were noted in each group. In

group A, 1 proximal deep vein thrombosis, 1pulmonary embolism, 1 supracondylar fracture, and1 superficial wound infectionwere seen, and in groupB 1 proximal deep vein thrombosis, 1 superficialwound infection, 1 deep infection, and 1 hematomarequiring drainage. Nonewere directly attributable tothe outpatient physiotherapy intervention.

Discussion

The restoration of a functional range of kneemotion is important in TKA. To maximize the

Table 4. Walking Aid Use Before and After Surgeryin Each Group

Group A Group B

Preoperative 1 y Preoperative 1 y

No support 30 54 33 511 stick 37 15 33 182 sticks 1 0 2 1Crutches or walker 3 2 4 2

UN5bH

potential for this, it is necessary to evaluate commonfactors that may influence the amount of kneemotion achieved after TKA. Postoperative rehabili-tation, of which physiotherapy plays a large part, isconsidered an important factor.

The range of motion at 1 year is felt to be anappropriate end point with no improvement in therange of knee motion thereafter [16-20].

Our study concurs with those authors whosuggest that the most important factor in influencingthe range of motion after TKA is the preoperativevalue [7,16,21,22]. Regarded by most as the mostimportant parameter, active flexion was not sig-nificantly improved by 1 year after a course ofoutpatient physiotherapy.

It was, however, noted that in group A therange of motion was improved at 3 monthscompared to the nonphysiotherapy group B butnot significantly. Like other physiotherapy mod-alities such as continuous passive motion [23,24]and muscle strengthening exercises [25], wecould conclude that physiotherapy allows a fasterreturn to a functional range of motion butultimately no benefit at 1 year or beyond.Furthermore, when considering the individualgroups, patients tended to migrate toward amiddle range, that is, those with poor preopera-tive active flexion gained flexion after TKAwhereas those with good preoperative activeflexion lost flexion. Contrary to other studies[1,3,4,16,17,25,26], we found an overall improve-ment in extension and flexion, active and passive,compared to that preoperatively in both groups.The physiotherapy group had a mean improve-ment of 3.9° over the no-physiotherapy group.This was not statistically different and did notelevate the number of patients into a higherfunctional range of motion. Kettlekamp et al [27]felt 93° of active flexion was necessary foreveryday function. Six patients (13%) in groupA and 9 patients (12%) in group B did notachieve this goal postoperatively.

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 1113

elevation to a higher functional status is achievedallowing patients to get up comfortably from theseated position. Seventy-three percent of patients ingroup A and 75% of patients in group B achieved105° of passive flexion.Our results were in agreement with the results of

a similar study by Rajan et al [28]. Althoughadjustment was required to account for baselinedifferences between the groups preoperatively, theyfound no statistical difference between the 2 groupsat any of the review times of 3 months, 6 months, or1 year.Outpatient physiotherapy did not improve the

ability to walk further nor did it decrease thenecessity for walking aids.The economic gains of not having to undergo

outpatient physiotherapy are considerable particu-larly in transport and staffing costs.In conclusion, a standard routine course of out-

patient physiotherapy does not offer any benefits inthe long-term to patients undergoing TKA. It does,however, produce a more rapid recovery in terms ofknee flexion up to 3 months. It is difficult to saywhether the more rapid recovery made patientsbetter functionally in their activities of daily living.Obviously, the patient groups are within the agelimits of retirement and no conclusions could bedrawn with regard to speed of return to work andthe duration of sickness payments offset against thecost of attending physiotherapy. After 3 months,patients receiving or not receiving physiotherapyimprove similarly.Outpatient physiotherapy does not improve the

functional range of motion for activities of dailyliving at 1 year after TKA.

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