Total hip arthroplasty (THA) is usually performed using 1 of 3 surgical approaches: direct lateral (DLA), posterior (PA), or anterior (AA). AA is different from DLA and PA owing to limited ...intraoperative visibility of the femoral canal. This could affect stem positioning and therefore migration. We aimed to perform an exploratory radiostereometric analysis (RSA) study with 3 groups for surgical approach assessing stem migration up to 5 years postoperatively.
61 patients with unilateral osteoarthritis of the hip were included. 21 patients were allocated to the DLA, 20 to the PA, and 20 to the AA group. All patients received an uncemented, collarless, double-tapered, fully hydroxyapatite-coated Profemur Gladiator stem. Migration was measured with model-based RSA. Baseline RSA was on day 1 postoperatively. The follow-ups were at day 8, at 5 weeks, and at 3, 6, 12, 24, and 60 months after surgery. Generalized linear mixed models were used to analyze maximum total point motion (MTPM) migrations.
Group mean differences in MTPM were 0.4 mm (95% confidence interval CI -1.5 to 2.4) for DLA vs. PA, 1.1 mm (CI -1.0 to 3.3) for AA vs. DLA, and 1.6 mm (CI -0.8 to 3.9) for AA vs. PA, when adjusted for sex and age as covariates. 2 stems in the AA group had excessive early migration. For all stems the migrations occurred mainly within 5-week follow-up and then stabilized.
At 5-year follow-up, there were no statistically significant differences in stem migration associated with the 3 surgical approaches used in this study.
Total knee arthroplasty (TKA) alleviates pain, but muscle strength and function is reduced for a long period postoperatively.
To investigate whether maximal strength training (MST) is more effective ...in improving muscle strength than standard rehabilitation (SR) after TKA.
A randomized, controlled study.
Community physical therapy centers and University hospital research department.
Forty-one adults <75 years with primary, unilateral osteoarthritis of the knee scheduled for TKA.
Participants were randomized to supervised MST of the lower extremities 3 times/week for 8 weeks and physiotherapy session1/week (N.=21) or to SR, including physiotherapy sessions/telephone contact 1/week and writing home exercise logs (N.=20). Maximal strength in leg press and knee extension, 6-minute walk test, patient-reported functional outcome score and pain were assessed preoperatively, 7 days, 10 weeks and 12 months postoperatively.
The MST group exceeded preoperative levels of muscle strength in leg press and knee extension by 37% and 43%, respectively at 10 weeks' follow-up, and the increase was higher than in the SR group (P≤0.001). Strength differences persisted up to 12-months follow-up. At 12 months, both groups recovered to normative levels in the 6-Minute Walk Test, with no statistically significantly difference between the groups.
Participants undergoing MST experienced superior increases in leg press and knee extension muscle strength compared with those managed with SR from 7-day to 10-week follow-up. The difference in muscle strength was maintained at 12-month follow-up. No differences in functional performance were found at any time-point.
Exercises after TKA should be performed with high intensity and target the operated leg specifically.
This study investigates the impact of perioperative tourniquet on skeletal muscle cells during total knee arthroplasty (TKA) and its effects on the gene expression of apoptotic, inflammatory, and ...angiogenic pathways. The randomized controlled trial included 44 patients undergoing TKA. The patients were randomized to undergo surgery with (n = 23) or without (n = 21) tourniquet. The tourniquet was inflated before skin incision and deflated before wound closure in the tourniquet group. Biopsies from the lateral vastus muscle were obtained from both groups before wound closure and 8 weeks after surgery. The messenger ribonucleic acid (mRNA) expression and protein levels of angiopoietin‐like 4 (ANGPTL4), Hypoxia‐inducible Factor 1α, and Vascular Endothelial Growth Factor Alpha (VEGF‐A) in the biopsies were examined by reverse transcription‐quantitative polymerase chain reaction and tissue microarray, respectively. Differences in mean values (ΔCt for mRNA expression and staining positivity for protein expression) were compared with t‐tests. The apoptotic marker BID and the angiogenic marker VEGF‐A were significantly lower in the tourniquet group compared to the control group (p = 0.03, p = 0.047). However, there was a significant upregulation of VEGF‐A 8 weeks after surgery in the tourniquet group compared to perioperative biopsies (p = 0.002), indicating persistent changes. A significant upregulation in protein expression of the angiogenic marker ANGPTL4 was found perioperatively in the tourniquet group (p = 0.02). Our results demonstrate that the angiogenic gene expression is significantly altered by the tourniquet, the effects of which might contribute to postoperative interstitial edema, increased pain, and decreased muscle strength. These effects could lead to delayed rehabilitation and ultimately reduced patient satisfaction after TKA.
Background and purpose — Total hip arthroplasty (THA) patients have reduced muscle strength after rehabilitation. In a previous efficacy trial, 4 weeks’ early supervised maximal strength training ...(MST) increased muscle strength in unilateral THA patients <65 years. We have now evaluated muscle strength in an MST and in a conventional physiotherapy (CP) group after rehabilitation in regular clinical practice. Patients and methods — 60 primary THA patients were randomized to MST or CP between August 2015 and February 2016. The MST group trained at 85–90% of their maximal capacity in leg press and abduction of the operated leg (4 × 5 repetitions), 3 times a week at a municipal physiotherapy institute up to 3 months postoperatively. The CP group followed a training program designed by their respective physiotherapist, mainly exercises performed with low or no external loads. Patients were tested pre- 3, 6, and 12 months postoperatively. Primary outcomes were abduction and leg press strength at 3 months. Other parameters evaluated were pain, 6-min walk test, Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) Physical Function Short-form score. Results — 27 patients in each group completed the intervention. MST patients were substantially stronger in leg press and abduction than CP patients 3 (43 kg and 3 kg respectively) and 6 months (30 kg and 3 kg respectively) postoperatively (p ≤ 0.002). 1 year postoperatively, no intergroup differences were found. No other statistically significant intergroup differences were found. Interpretation — MST increases muscle strength more than CP in THA patients up to 6 months postoperatively, after 3 months’ rehabilitation in clinical practice. It was well tolerated by the THA patients and seems feasible to conduct within regular clinical practice.
Background and purpose - Minimizing the decrease in muscular strength after total hip arthroplasty (THA) might allow patients to recover faster. We evaluated muscular strength in patients who were ...operated on using 3 surgical approaches.
Patients and methods - In a prospective cohort study, 60 patients scheduled for primary THA were allocated to the direct lateral, posterior, or anterior approach. Leg press and abduction strength were evaluated 2 weeks or less preoperatively, 2 and 8 days postoperatively, and at 6-week and 3-month follow-up.
Results - Differences in maximal strength change were greatest after 2 and 8 days. The posterior and anterior approaches produced less decrease in muscular strength than the direct lateral approach. 6 weeks postoperatively, the posterior approach produced greater increase in muscular strength than the direct lateral approach, and resulted in a greater increase in abduction strength than the anterior approach. At 3-month follow-up, no statistically significant differences between the groups were found. The operated legs were 18% weaker in leg press and 15% weaker in abduction than the unoperated legs, and the results were similar between groups.
Interpretation - The posterior and anterior approaches appeared to have the least negative effect on abduction and leg press muscular strength in the first postoperative week; the posterior approach had the least negative effect, even up to 6 weeks postoperatively. THA patients have reduced muscle strength in the operated leg (compared to the unoperated leg) 3 months after surgery.
The aim of the study was to investigate the effect of maximal strength training on postural sway after total hip arthroplasty, performed before and after a battery of physical performance tests that ...resemble daily living activities.
This study is an exploratory study based on data from a 3-mo randomized controlled trial involving 54 total hip arthroplasty patients performing maximal strength training or conventional rehabilitation. At 3, 6, and 12 mos postoperatively, postural sway was evaluated in two gait tests; ie, one test before and one test after conducting a battery of physical performance tests.
At 3 mos postoperatively, postural sway in the test after was significantly higher for the conventional rehabilitation group than the maximal strength training group (P = 0.045); however, there was no between-group difference at the test before (P = 0.670). Postural sway was also significantly higher in the test after compared with the test before in the conventional rehabilitation group (P < 0.001). No difference was found between the test before and test after in the maximal strength training group (P = 0.713). At 6 and 12 mos postoperatively, there were no statistically significant within- or between-group differences in postural sway.
Increased muscular strength limits postural sway 3 mos postoperatively in total hip arthroplasty patients after a demanding battery of physical performance tests simulating daily living activities.
Husby VS, Helgerud J, Bjørgen S, Husby OS, Benum P, Hoff J. Early maximal strength training is an efficient treatment for patients operated with total hip arthroplasty.
To compare muscle strength, ...work efficiency, gait patterns, and quality of life in patients undergoing total hip arthroplasty (THA) randomly assigned to either maximal strength training or a conventional rehabilitation program.
A randomized controlled study.
Research laboratory, rehabilitation center, and physical therapy clinic.
Patients (N=24) with osteoarthritis as the main reason for THA were randomly assigned to perform maximal strength training (n=12) or conventional rehabilitation (n=12).
The maximal strength training group (STG) performed maximal strength training in leg press and abduction with the operated leg only 5 times a week for 4 weeks in addition to the conventional rehabilitation program. The conventional rehabilitation group (CRG) received supervised physical therapy 3 to 5 times a week for 4 weeks.
1-repetition maximum (1RM) leg press strength, 1RM abduction strength, rate of force development (RFD), work efficiency, gait patterns, and quality of life.
1RM increased in the bilateral leg press (P<.002) and in the operated leg separately (P<.002) in the STG compared with the CRG. 1RM abduction strength in the operated leg (P<.002) and the healthy leg (P<.002) increased in the STG compared with the CRG. RFD increased in the STG compared with the CRG (P(g)=.030), followed by a trend towards increased peak force in the STG (P(g)=.053) (P(g) = probability for differences between groups). Work efficiency tended to improve in the STG compared with the CRG (P=.065). No differences in gait patterns were revealed between the groups after the training intervention.
Early maximal strength training 1 week postoperatively is feasible and an efficient treatment to regain muscular strength for patients who have undergone THA, demonstrated by a significantly larger increase in muscular strength and a trend towards a better work efficiency in the STG compared with the CRG.
Purpose:
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients significantly increase muscle strength after maximal strength training (MST) initiated soon after surgery. Owing to ...severe postoperative pain, knee patients are anticipated to be more limited in performing heavy load exercises than hip patients. The aim of the present study was to describe pain and load progression during early MST in THA and TKA patients.
Methods:
Explorative study based on secondary analyses from two randomized controlled trials: 26 THA and 16 TKA patients had their training sessions logged. They trained at 85–90% of their maximal capacity in leg press, and abduction/knee-extension of the operated leg (4 × 5 repetitions) for 8–10 weeks, initiated early postoperatively.
Results:
Knee patients experienced significantly more pain than hip patients during the training sessions (p < 0.03), however, pain before and after training was not different (p > 0.09). All patients significantly increased leg press training load until the last intervention week (p < 0.01).
Conclusion:
This study demonstrates that TKA patients experience more pain than THA patients during training following a MST program but not more than moderate levels during or after training. Pain before and after training is not different. Both groups significantly increased load progression during the intervention. These findings indicate that both THA and TKA patients might perform MST with extensive load progression early after surgery without compromising pain. The studies were registered at ClinicalTrials.gov.
In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable ...complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department.
This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes.
The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning.
This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.
Muscle weakness due to trauma from the surgical approach is anticipated to affect the ability of the patient to undertake daily physical activity early after total hip arthroplasty (THA). The ...objective of this study was to compare daily physical activity on days 1 to 4 after discharge, in patients following THA performed by 1 of 3 surgical approaches.
A cohort study included 60 hip osteoarthritis patients, scheduled for THA, allocated to direct lateral approach, posterior approach, or anterior approach. Daily physical activity was measured by an accelerometer, with upright time per 24 hours as primary outcome and walking time, number of steps, and number of upright events per 24 hours as secondary outcomes.
There were no statistically significant group differences in any of the measures of daily physical activity (P > 0.290) or between days of follow-up (P > 0.155). Overall, the median participant had 3.50 hours (interquartile range, 2.85-4.81 hours) of upright time, and participants showed wide variation in all outcomes of daily physical activity.
There were no differences in daily physical activity between THA patients undergoing different surgical approaches. The surgical approach may not be a limiting factor for daily physical activity early after surgery in a fast-track treatment course.
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