SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
article
Range
of
motion
predictability
after
total
knee
arthroplasty
with
medial
pivot
prosthesis
夽
Lúcio
Honório
de
Carvalho
Júnior
a,b,c,∗,
Bruno
Presses
Teixeira
a,
Cláudio
Otávio
da
Silva
Bernardes
a,
Luiz
Fernando
Machado
Soares
a,
Matheus
Braga
Jacques
Gonc¸alves
a,
Eduardo
Frois
Temponi
aaHospitalMadreTeresa,BeloHorizonte,MG,Brazil
bUniversidadeFederaldeMinasGerais,FaculdadedeMedicina,DepartamentodoAparelhoLocomotor,BeloHorizonte,MG,Brazil
cPontifíciaUniversidadeCatólicadeMinasGerais,DepartamentodeMedicina,BeloHorizonte,MG,Brazil
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Articlehistory: Received15April2016 Accepted13June2016 Availableonline9March2017
Keywords:
Articularmovementrange Kneearthroplasty Prosthesisdesign
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b
s
t
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c
t
Objective:To assesswhether therethe finalrange ofmotion(ROM) resultsachievedby patientsundergoingtotalkneearthroplasty(TKA)withprosthesisusingMedialPivotdesign arepredictable.
Methods:BetweenJanuaryandAugustof2014,155patientswithprimaryosteoarthritisof kneewhounderwentTKAusingtheprosthesisADVANCE®MedialPivotwereprospectively assessed. AllROMmeasuresweremadeandrecordedbefore,during,andaftersurgery. Allpatientswereclinicallyassessedpreoperativelyandpostoperatively(15,45days,three months,sixmonths,oneyear,andannuallythereafteraftersurgery);theirfunctionalstatus wasassessedusingtheWOMACquestionnaire.
Results:Significantdifferences(p<0.001)wereobservedbetweenthemeansandmediansof ROMinthepreoperativewhencomparedwiththoseduringtheperioperative;the perioper-ativevalues,whencomparedwiththoseaftersixmonthspostoperative,werealsodifferent (p<0.001).NosignificantdifferenceswerefoundbetweenthemeansandmediansROM betweentheintraoperativeperiodandatthe45-dayassessment(ns)andbetweenthemeans andmediansROMbetweenthepreoperativeperiodandatthesix-monthevaluation(ns). Conclusion: ThefinalROMachievedbypatientsthatunderwentTKAwithmedialpivot pros-thesiscanbepredicted.TheperioperativeROMcorrelateswiththatat45daysaftersurgery. ThefinalROMiscorrelatedwiththatofthepre-operativeperiod.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedatHospitalMadreTeresa,BeloHorizonte,MG,Brazil.
∗ Correspondingauthor.
E-mails:dufrois@hotmail.com,luciohcj@gmail.com(L.H.CarvalhoJúnior). http://dx.doi.org/10.1016/j.rboe.2017.03.001
Previsibilidade
da
amplitude
de
movimento
após
artroplastia
total
do
joelho
com
prótese
medial
pivot
Palavras-chave:
Amplitudedemovimento articular
Artroplastiadojoelho Desenhodeprótese
r
e
s
u
m
o
Objetivo:Avaliarseháprevisibilidadedaamplitudedemovimentosalcanc¸adaporpacientes submetidosaartroplastiatotaldojoelhocomprótesequeusadesenhomedialpivot. Métodos: Entrejaneiro eagostode2014foifeitaavaliac¸ãoprospectivade155pacientes comosteoartroseprimáriadojoelhosubmetidosaartroplastiatotaldojoelhocomouso dapróteseAdvance® MedialPivot.Todasasmedidasdaamplitudedemovimentosforam feitasantes,duranteeapósacirurgia.Todosospacientesforamavaliadosclinicamente nopré-epós-operatório(15,45dias,trêsmeses,seismeses,umanoedepoisanualmente apósacirurgia)paraaanálisedeseuestadofuncional.OquestionárioWesternOntarioand McMasterUniversitiesOsteoarthritisIndex(Womac)foiusado.
Resultados: Diferenc¸assignificativas(p<0,001)foramrelatadasentreasmédiasemedianas daamplitudedemovimentosnopré-operatórioemcomparac¸ãocomasmedidasobtidas noperíodointraoperatório.Asmedidasdopré-operatóriotambémsemostraramdiferentes quandocomparadascomaquelasapósseismesesdepós-operatório(p<0,001).Nãoforam encontradasdiferenc¸assignificativasentreasmédiasemedianasdaamplitudede movi-mentonacomparac¸ãodointraoperatórioeasmedidasfeitasaos45dias(ns)eentreas médiasemedianasdasmedidaspré-operatóriaseaquelasobservadasaosseismeses(ns). Conclusão:Háprevisibilidadedaamplitudedemovimentosobtidaporpacientessubmetidos aartroplastiatotaldojoelhocomprótesemedialpivot.Aamplitudeaos45diasé semel-hanteàquelaobservadanasmedidasintraoperatórias.Aamplitudefinalestárelacionadaà amplitudepré-operatória.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Osteoarthrosisofthekneeisacommoncauseofpain, disabil-ity,anddecreasingqualityoflife,affecting41.1%ofcertain populationgroups,especiallywomenover70years.1–3Total
kneearthroplasty(TKA)isawell-establishedprocedure asso-ciated with good clinical outcomes, particularly regarding functionalimprovement.4–6
AlthoughdifferentresultsmayberelatedtoTKA,rangeof motion(ROM)recoveryisessentialforfunctionaloutcome.7,8
Severalfactorsmay influencethe post-TKAROM,including pre- and perioperative ROM, surgical technique, posterior cruciateligament(PCL)resection,prosthesisdesign,and post-operativerehabilitation.8–11 In somegroups and incertain
situations,evenROMlosshasbeendescribedafterTKA.9,11–14
Somestudiesalsodiscusstheimportanceoftheperioperative ROMasanindicatorofthefinalmovement;tothebestofthe authors’knowledge,therearenostudiesusingmedialpivot prostheses.12,13,15
Medial pivot prostheses were introduced in 1998 as a revolutionary concept in relation to the other prosthe-sesthenavailable.16 By sacrificingbothcruciate ligaments,
stability was based on the conformation of the condyle and medialplateau, making this region a spherically sta-ble center of rotation, and allowing greater movement in thelateral compartment.6,17,18Thisasymmetryattemptsto
ensurethereproductionofthecombinedmovementof rota-tion/translationnormallyobservedinhumanknees.16,18–20
Itisassumed thatahigher perioperativeROMcan pos-itively influence the ROM observed after TKA using the ADVANCE®Medial-Pivotprosthesis,whichcouldresultin bet-terfunctionalresults.Thisstudyaimedtoassesswhetheritis possibletopredictfinalROMachievedbypatientssubmitted toTKAwithamedial-pivotdesignprosthesis.
Material
and
methods
Allpatientsunderwentspinalanesthesiaassociatedwith femoral and sciatic nerve blocks, with the use of pneu-matictourniquet,anteriorlongitudinalcutaneousaccess,and medialparapatellararthrotomy.Inallcases,thefemoraland tibialcomponentswerecementedinonestage.Thepatellar componentwasnotused;however,peripatellarneurectomy wasperformedinallpatients.Theposteriorcruciateligament (PCL)wasresectedinallprocedures.
Thepatients were evaluated in the orthopedicclinic in thepostoperativeperiod.Thepreventionofthromboembolic eventswasperformedwithmechanicalandpharmacological prophylaxis.Prophylacticanticoagulationdrugswere admin-isteredtothethirdpostoperativedayatthehospital,andfor 12daysathome,totaling15days.Patientswereencouragedto walksoonafterrecoveryfromperipheralnerveblocks.Weight bearingwasallowedastoleratedwithacaneorwalkeronthe firstpostoperativeday,underthesupervisionofa physiother-apist.PassiveROMexerciseswereperformeddailyfromthe firstpostoperativedayonwards.Patientsunderwentatleast twohoursofdailyphysicaltherapy, consistingofisometric exercises,passiveROM,activeassistedROM,quadricepsand hamstringstrengthening,andgaittraining,whichincluded stairclimbing.Themeanhospitalstaywas54h.Allpatients werereferredtorehabilitationcentersforcontinuingthe reha-bilitationprogram.
Clinicalassessmentswereconductedat15,45,90,180,and 365daysaftersurgery,andannuallythereafter.AllROM mea-surementswererecordedbefore,during,andaftersurgery.All patientswereclinicallyevaluatedpreoperativelyand atthe 12-monthpostoperativeevaluationusingtheWesternOntario andMcMasterUniversitiesOsteoarthritisIndex(WOMAC).21
All ROM measurementswere obtainedin the supine posi-tion(Fig.1).Flexionmeasurementswereperformedwiththe hipat90◦ offlexion,passively,undermaximalgravitational
flexion and using a standard goniometer (Prestige Medical Goniometer,2013,Northridge,UnitedStates)asdescribedby
Leeetal.12,22 ThepreoperativeROMwasmeasured
immedi-atelybeforesurgery.Theperioperativemeasurementswere obtainedundermaximumpassivegravitationalflexionwith the hip at 90◦ offlexion, after the arthrotomy was closed
andthepneumatictourniquetwasdeflated(Video1.0).ROM was measured atthe 45-day and six-month postoperative assessments. To minimize variation among observers, all measurements were made by a single, previously trained observer.
Thestudy wasapprovedbythe EthicsCommitteeunder CAAE n◦ 38474114.2.0000.5127. All participants signed the
informedconsentpriortoenrollment.Nofinancialincentive toparticipatewasofferedtotheparticipants.
Statisticalanalysis
All datawere presented asmedians, means,and standard deviations.StatisticalanalysiswasperformedwithSPSS20® (IBMCorp.Releasedin2011.IBMSPSSStatisticsforWindows, version20.0,Armonk,NY:IBMCorp.).Thesignificancelevel wasset at0.05.Overtime, the datawastested fornormal distributionusingtheD’Agostino-Pearsontest,andwhen nec-essary,thedifferencebetweenthemeanswascalculatedusing
Fig.1–Assessmentofkneerangeofmotionduringthe processoftotalkneearthroplasty.(A)preoperative,(B) perioperative,(C)postoperative.
Student’st-testorWilcoxon’stestforthosedatainwhichthe normalityassumptionwasnotapplicable.
Results
TheROMthroughouttheanalyzedperiodisshowninTable1. Significantdifferences(p<0.001)werereportedbetweenthe mean and median preoperative ROM compared to those observed in the perioperative period. Disparity was found betweenROMmeasurementsinthepostoperativeperiod com-paredwiththosesixmonthspostoperatively.Therewereno significant differencesbetweenthe meanandmedian peri-operativeROMandthoseobtained45dayslater(ns).However, therewasameanlossof10◦whencomparedwiththe
Table1–Rangeofmotionduringtotalkneearthroplasty.
Extension Meanextension Flexion Meanflexion
Preoperative
General 0◦–20◦
−1 45◦–140◦ 111◦
Male 0◦–15◦ 3◦ 95◦–140◦ 115◦
Female 0◦–20◦ 1◦ 45◦–140◦ 111◦
Perioperative
General 0◦–5◦ 0.05◦ 86◦–125◦ 101◦
Male 0◦ 0◦ 101◦ 100◦
Female 0◦–5◦ 0.01◦ 86◦–120◦ 101◦
45dayspostoperatively
General 0◦–10◦ 1◦ 80◦–130◦ 102◦
Male 0◦ 0◦ 90◦–130◦ 104◦
Female 0◦–10◦ 1◦ 80◦–120◦ 102◦
Sixmonthspostoperatively
General 0◦–10◦ 1◦ 90◦–130◦ 111◦
Male 0◦–5◦ 0.3◦ 90◦–130◦ 113◦
Female 0◦–10◦ 1◦ 90◦–130◦ 110◦
aftersixmonths.Therewasnostatisticaldifferencebetween genders,although ashorterROM wasobserved duringthe perioperativeperiodinmen,whichdidnotimplyashorter ROMinthepostoperativeperiod.
TheWOMACindexrangedfrom21.87to80.24,withamean of49.63inthepreoperativeperiod.Inthepostoperative anal-ysis(12months),themeanWOMACscorewas73.71,ranging between53.12and88.54(p<0.0001).
Discussion
Themostimportantfinding ofthis studywas the relation-shipbetweentheperioperativeROMmeasurementsandthose obtainedat45dayspostoperatively.Thisfindingmay repre-sentthemarkerforthosepatientswhowould benefitfrom greaterattentionandcareduringtherehabilitationprocess.It canalsobeusedasagoaltobeachievedpostoperativelyorasa markerofnormalityinpatientsevolution.Norelationshipwas observedbetweentheperioperativemeasuresandtheROM achievedsixmonthsaftersurgery.Forthisperiod,the preop-erativemeasurementswereshowntobereliableandallowed thepredictionofthefinalROM.Itisimportanttonotethat thepostoperativeROMandthatat45daysaftersurgerywere significantlyshorterthan inthe preoperativeperiod,which reinforcestheimportanceofsurgicalaggression,pain,andthe healingprocessinROMrecovery.8,23,24
Several authors analyzed ROM after arthroplasty with the use of the medial-pivot design and found a relation-ship between preoperative ROM and that obtained after surgery.4,5,23,25–27 Shakespeare et al.28 compared 261 knees
undergoing arthroplasty with medial-pivot prosthesis with 913casesinwhich TKA withPCLsacrifice wasperformed. TheyfoundnodifferencebetweentheirROMsobtainedafter 12monthsoffollow-up.Karachaliosetal.25analyzed284TKA
withmedial-pivotdesignandfoundimprovedROM(101◦
pre-operativelyand117◦inthefinalevaluation).Andersonetal.23
described298primaryTKAinfivecenters.Flexionimproved from107◦preoperativelyto121◦ atthelastfollow-upexam.
Inthepresentstudy,maintenanceofpreoperativeROMwas
observed,althoughwithlowervaluesthanthoseobservedin otherstudies.Whenstratifyingbygender,asimilarROM pro-gression wasobserved, withhigherabsolutevaluesamong men,demonstratingnofinalrepercussiononthemeasured values.
Few studieshaveexamined the importanceof perioper-ative ROM.12,13,15 Leeetal.12observedthatthe finalflexion
measurement observed in patients with poor preoperative flexion (<85◦) could be provided by intraoperative
mea-surement (gravitational measurement), rather than by the preoperativevalue. Ritteretal.15 observedthat the
periop-erativeandpostoperativeflexionwererelated,andthatthe perioperative ROM was the best predictor ofpostoperative ROM. Kotani et al.10 found a positive correlation between
preoperativeROMandthoseobservedatthreemonthsand oneyearpostoperative,butnoclearcorrelationwasobserved two years aftersurgery. In the present study,the relation-ship between perioperative ROM and that observed at 45 postoperativedayswerenotrelatedtothemeasurements per-formedatsixmonths.ThefactthattheperioperativeROMwas measuredpassively,usinggravityandwithoutactivemuscle contraction,mayexplainthedifferencebetweenitsvaluesand the measurementsatsixmonthspostoperatively,inwhich rehabilitationandrecoveryofmusclestrengthcouldhave con-tributedtotheimprovementinROM.10,13,29
RecoveryafterTKAisassociatedwithdecreasedpainand consequent functional improvement. These achievements canbemeasuredwhenanalyzingtheWOMACquestionnaire. Pritchettetal.20assessedtheclinicalimpressionofpatients
afterTKA;76%ofthepatientspreferredpivotalmedial pros-thesescomparedtothose inwhichthe PCLwassacrificed, and 61% preferred those with medial-pivot design when comparedwithprostheses withmobileplatform.Anderson etal.23examined204kneeswith5.4yearsoffollow-upand
reported asignificantimprovementinfunctional outcomes comparedtothe preoperativeperiod.Baeetal.24compared
arthroplastieswith6.7yearsoffollow-up.Significant improve-mentswereobservedintheWOMAC(30.8preoperative;79.2 final),SF-12 (26.6preoperative; 47 final),and Oxford scores (44.4preoperative;22.6final).Inthepresentstudy,functional outcomeimprovementwasobservedafter12months,despite themaintenanceofthesamepreoperativeROM.
Thepresentstudyhadsomelimitations.Theevaluationof differentprosthesisdesignscoulddetermineiftheROMwould followthepatternobservedinthepresentstudy.Further stud-iesareneededtoassessthereproducibilityofROMmeasures and whether thereisfunctional and ROMimprovement in thecomparisonofprostheseswithmedial-pivotdesignwith theotherdesigns.Anotherlimitationofthepresentstudyis thefactthatROMwasmeasuredwithastandard goniome-ter,ratherthanwithradiographicmeasurements,whichmay haveresultedinlessreliablevalues.Thefactthatallthe eval-uationswereperformedwiththesameinstrumentandbythe sameresearcher,previouslyvalidatedinapilotstudy,reduces thesignificanceofthislimitation.22
Thisstudyisimportantforinformingorthopedicsurgeons tobe alertto the ROMduring TKA recovery. Patients with ROMlossaftersurgery(within45days)shouldbecounseled regardingtheirprogression.ThosewhorecoverROM,butat alowerthanexpectedrate,shouldbeconsideredforgreater attentionandcareintherehabilitationprocess,evenserving asanalertforpossiblemanipulationunderanesthesia.
Conclusion
Itispossibleto predictthe final range ofmotionobtained by patients submitted to total knee arthroplasty with medial-pivotprosthesis.Thepreoperativerangeofmotionis correlatedwiththefinalpostoperativerangeofmotion.The perioperativerangeofmotioniscorrelatedwiththatobserved 45daysaftersurgery.
Conflicts
of
interest
OnlyL.H.C. Jr has made paid presentations and actsas a
paidconsultantatMicroportOrthopedics.Theotherauthors declarenoconflictsofinterest.
Acknowledgements
Toallresearchersandresearchparticipants.
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