Question:
In patients having total knee arthroplasty for osteoarthritis, does initiation of rehabilitation within twenty-four hours after surgery confer greater benefit than waiting forty-eight to seventy-two hours?
Design:
Randomized (unclear allocation concealment), blinded (outcome assessor), controlled trial with follow-up to hospital discharge.
Setting:
A university hospital in Almeria, Spain.
Patients:
Three hundred and six patients who were fifty to seventy-five years of age and undergoing total knee arthroplasty because of unilateral osteoarthritis. Exclusion criteria were cardiac, renal, or hepatic events in the previous year; requirement for total knee prosthesis because of rheumatoid arthritis or cancer; or severe cognitive deficit or physical ailments that might limit treatment or require implantation of a special knee prosthesis. Outcome data were available for 273 patients (89%) (mean age, sixty-six years, 77% women).
Intervention:
Patients were allocated to begin rehabilitation treatment within twenty-four hours (n = 153) or within forty-eight to seventy-two hours (n = 153) after surgery. Rehabilitation treatment occurred every day until hospital discharge and was always received from the same therapist. The forty-five minute sessions included mobilization with knee range of motion from 0° to 40°, isometric exercises for quadriceps and hamstring muscles, ankle and leg flexion, breathing exercises, posture instruction, transferring from bed to chair, walking (with increasing distances), management of walking aids, and adaptation of daily life activities. The rehabilitation treatment schedule introduced exercise elements gradually and covered all elements by day four.
Main outcome measures:
The primary outcomes were knee motion, muscle strength (measured with use of a six-point test ranging from 0 [no activity] to 5 [normal muscle response]), and pain (measured with use of a visual analog scale that ranged from 0 [no pain] to 10 [worst imaginable pain]). Secondary outcomes were autonomy (measured with use of the Barthel index, which scored degrees of dependence in performing ten activities of daily living ranging from ≤20 [totally dependent] to 100 [independent]) and gait and balance (measured with use of the twenty-two-item Tinetti test, with scores ranging from 0 [abnormal] to 2 [normal]).
Main results:
Patients who received rehabilitation treatment within twenty-four hours spent fewer days in the hospital than did patients in the delayed rehabilitation group (mean 6.7 vs. 8.5 days, p < 0.001). Patients in the early rehabilitation group had better results than the delayed group in knee motion, muscle strength, and pain (Table). More patients in the early rehabilitation group achieved normal balance and normal gait (Table). The groups did not differ in assessment of autonomy, which improved from baseline in both groups.
Conclusion:
Patients who began rehabilitation treatment within twenty-four hours after total knee arthroplasty rather than delaying rehabilitation to within forty-eight to seventy-two hours after surgery had a superior range of knee motion, muscle strength, and pain improvement by the time of hospital discharge.
Source of funding: No external funding.
For correspondence: Ms. A.M. Castro-Sánchez, Carretera de Sacramento s/n., Departamento de Enfermería y Fisioterapia, Universidad de Almería, Almería, Spain. E-mail address: adelaid@ual.es
For a glossary of terms for evidence-based orthopaedics, go to jbjs.org/ebo_glossary.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
The study by Labraca and colleagues is important given the current pressures to reduce health-care costs, such as hospital length of stay, and to improve function and reduce pain.
The trial was conducted in Spain and the racial makeup of the target population was not provided. This is important given that certain racial groups have worse outcomes than others1. The authors also did not report several factors that can adversely affect outcomes after total knee arthroplasty, including lower preoperative mental health and other psychological factors2 such as self-ratings of general and mental well-being3. While comorbid conditions such as hypertension and diabetes were included, others were not, nor was any comorbidity index (e.g., Charlson or Elixhauser) used. The authors did not describe which implants were used in this study nor how many surgeons’ patients were included; device use and surgeon technique can lead to post-surgical complications and even implant failure4.
Despite these concerns, the authors showed that early intensive rehabilitation (within twenty-four hours after surgery) was the better method for rehabilitating patients after total knee arthroplasty. While the study did not include an economic analysis, it stands to reason that fewer days in the hospital should lead to cost savings.