Question: In patients having primary total knee arthroplasty, does a standard course of postoperative outpatient physiotherapy improve knee range of motion?
Design: Randomized (allocation concealed), blinded (surgeon and inpatient physiotherapy team) controlled trial with 1-year follow-up.
Setting: A hospital in Northern Ireland.
Patients: 150 patients scheduled for primary total knee arthroplasty by 1 surgeon were recruited. 143 patients (95%) (mean age, 70 y; 62% women) completed the study.
Intervention: Patients were allocated to receive 9 standard outpatient physiotherapy sessions over 6 weeks (n = 71) or no physiotherapy (n = 72). Total knee arthroplasty was done with use of the LCS (low contact stress) rotating platform prosthesis (DePuy, Leeds, United Kingdom), and all patients received inpatient physiotherapy until discharge, followed by a home exercise regimen.
Main outcome measures: The primary outcome was knee range of motion. Patients were also assessed with use of the Oxford knee score, the Bartlett patellar score, and the Short Form-12 (SF-12) general health questionnaire.
Main results: Analysis was by intention to treat. The study had 90% power to detect a 10° difference between groups in knee range of motion. There was no significant difference between groups in mean knee range of motion at 1 year (Table). Groups did not significantly differ for the other measured validated outcome scores (Table).
Conclusion: In patients having primary total knee arthroplasty, a standard course of postoperative outpatient physiotherapy did not significantly improve knee range of motion as compared with that measured in patients who had no physiotherapy.
A recent meta-analysis concluded that postoperative physiotherapy is beneficial in the short term1 and a nonrandomized comparison showed that therapy combined with progressive strengthening exercises can provide improved function2, but no consensus exists regarding the long-term benefit of physiotherapy after total knee arthroplasty. Because of cost, insurance coverage, patient transportation, accessibility, and availability of qualified rehabilitation specialists, defining the benefits of physiotherapy is essential.
The trial by Mockford et al. has several potential limitations. First, while the trial had an adequate sample size, the outcome measures were limited to range of motion and a few functional scores. Although range of motion is a useful end point, patients and physicians are also interested in the speed of recovery. Second, no information was provided on comorbid conditions or patient expectations after surgery, both of which can have a substantial effect on outcome after total knee arthroplasty3,4. Third, the definition and description of "standard physiotherapy" were lacking, including the duration and content of each session (although details of the physiotherapy sessions can be found in another article1). Furthermore, only 43 of 71 patients attended all 9 physiotherapy sessions, and the authors do not report exactly how many sessions the other 28 intervention patients received (only the range is given). While all patients received detailed instructions about home exercises, no information is given as to the compliance of patients with the home-exercise program in either group. Therefore, it is not known whether patients in the intervention group actually received more physiotherapy than the patients in the control group did.
In conclusion, this study investigates but does not yet answer the question of whether or not to include an outpatient physiotherapy program to aid postoperative rehabilitation.
Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ.2007;335:812.335812
2007
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Petterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstab A, Newcomb W, Snyder-Mackler L. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum.2009;61:174-83.61174
2009
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Franklin PD, Li W, Ayers DC. Functional outcome after total knee replacement varies with patient attributes. Clin Orthop Relat Res.2008;466:2597-604.4662597
2008
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Noble PC, Conditt MA, Cook KF, Mathis KB. Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res.2006;452:35-43.45235
2006
[CrossRef]