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Home physiotherapy with vs. without supervision of physiotherapist for assessingmanipulation under anaesthesia after total knee arthroplasty

Home physiotherapy with vs. without supervision of physiotherapist for assessingmanipulation... Londhe et al. Arthroplasty (2021) 3:10 https://doi.org/10.1186/s42836-020-00063-3 Arthroplasty RESEARCH Open Access Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty 1* 2 3 4 Sanjay Bhalchandra Londhe , Ravi Vinod Shah , Amit Pankaj Doshi , Shubhankar Sanjay Londhe , 5 6 7 Kavita Subhedar , Krishnan Iyengar and Prashant Mukkannavar Abstract: The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. Methods: A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients’ age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. Results: In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). Conclusion: After total knee arthroplasty, frequent physiotherapist’s instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. Level of evidence: Therapeutic study, Level IIa. Keywords: Total knee arthroplasty, Manipulation under anaesthesia, Postoperative physiotherapy, Stiff knee * Correspondence: sanlondhe@yahoo.com Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra 400069, India Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Londhe et al. Arthroplasty (2021) 3:10 Page 2 of 5 Introduction end of the sixth postoperative week. The study was Total Knee Arthroplasty (TKA) is one of the most started with null hypothesis. Using a pocket goniom- successful operations in modern orthopaedics [1]. eter, ROM (angle of maximal flexion to extension) of TKA is highly effective in relieving pain and improv- the knee was measured by an independent observer ing functions, including activities of daily living [2–6]. (nurse practitioner). Preoperative data were recorded Huge advances have been made in the implant de- 1 week prior to TKA. signs, refinement of the surgical treatment of TKA and patient selection. Bourne et al.[7] and other au- TKA and physiotherapy thors showed that a sizable percentage of patients, All operations were done by the same surgical team. i.e., 19%. remain dissatisfied with their primary TKA Operation was performed under tourniquet control [8–13]. One of the common reasons in these 19% un- and through the standard parapatellar approach. We satisfied patients is development of knee stiffness after used a cemented posterior stabilized knee implant the TKA surgery. If untreated, knee stiffness may pro- (Freedom Total Knee system, Maxx Orthopedics Inc., gress over time and affects patients’ ability to perform PA, USA) in all patients. The physiotherapy was daily tasks [14]. Early gait analyses and biomechanical started immediately after TKA, i.e.,onthe very same studies showed that the knee should achieve at least day of the operation. The physiotherapy was in the 83° of flexion to ascend stairs, 90° to 100° of flexion form of muscle strengthening exercises, ROM exer- to descend stairs, 93° to 105° flexion to rise from a cises, closed chain exercises, and practice of stair chair, and more than 120° of flexion to squat or kneel climbing and gait training. The muscle strengthening [15–17]. Till now, there is no clear consensus on the exercises were in the form of ankle pump, static and definition of knee stiffness in the literature. Usually, a dynamic quadriceps muscle strengthening, and glutei stiff knee is confirmed when the knee flexed less than and hamstring muscle strengthening exercises. The 90° after TKA [18–20]. Some factors may be associ- ROM exercises comprised of passive, assisted active ated with knee stiffness, including a decreased pre- and active knee movements. Gait training included operative ROM, younger age, diabetes mellitus, socio- walking initially with walking aid like walker and economic status, and previous knee surgery, malposi- gradually progressing to walking stick. tioning of implant, inadequate resection, and over- Patients of group A were instructed to have physio- stuffing of the component [21–24]. therapy on their own at home. The physiotherapist did The objective of this retrospective cohort study was to not visit them at home. The physiotherapist just gave compare home physiotherapy with and without supervi- them instructions at the time of discharge from the hos- sion of physiotherapist for assessing MUA after TKA. pital. We provided information booklets to show how We also reported the efficacy of postoperative home the physiotherapy exercises were performed. physiotherapy under supervision of physiotherapist. Patients of group B received postoperative physiother- apy at home with physiotherapist visiting their home for Patients and methods 6 weeks. The physiotherapist visited the patients at home The institutional review boards of the participating hos- initially 6 days a week (excluding Sunday) for the first 2 pitals approved the study. Informed consent was ob- weeks, 3 days a week for the next 2 weeks, and then once tained from each patient. a week for the final 2 weeks. The same physiotherapy A total of 900 patients (involving 810 females and team conducted the home physiotherapy. The informa- 90 males) were included in this study and divided tion conveyed by the physiotherapist included ROM, into two groups. Group A consisted of 300 patients walking with/without walking aid, ability to perform day who had undergone TKA between January 2011 and to day activities, and amount of knee pain the patient December 2013; group B included 600 patients who was experiencing. had undergone TKA between January 2014 and De- MUA was applied when the patients had failed to cember 2018. achieve 90° of ROM at the first follow-up visit (6 weeks Preoperatively, we recorded patients’ age, body mass after TKA). Under general anaesthesia, the patient index (BMI), ROM of the knee, diagnosis, degree of underwent MUA as a day care procedure and was put varus deformity, 100-mm visual analogue score (VAS) on standard post-TKA rehabilitation program. Postoper- for knee pain, and forgotten joint score (FJS)-12 ative data were recorded at each clinic visit. (Table 1). The duration of hospital stay, and hip- knee-ankle alignment were also recorded (Table 2). An independent observer who did not attend the Statistical analysis treatments assessed all the data. MUA was carried Data were expressed as mean ± standard deviation. Com- out when the knee flexion was less than 90° at the parisons between the groups were made by using Londhe et al. Arthroplasty (2021) 3:10 Page 3 of 5 Table 1 Comparison of preoperative characteristics of patients between Group A and Group B Parameters Group A Group B p value Number of patients (n) 300 600 – Mean Age (years) 69.1 ± 14.3 (58–82) 66.5 ± 15.7 (56–83) 0.5780 Mean BMI (kg/m ) 28.2 ± 4.7 27.6 ± 5.4 0.1016 Gender Females n = 269 (89.66%) n = 542 (90.33%) 0.7511 Males n = 31 (10.33%) n = 58 (9.66%) 0.7510 Mean Preoperative ROM 95.8 ± 18.1 95.4 ± 17.8 0.7521 Preoperative degree of deformity (varus) 8.5 ± 2.6 9.8 ± 3.1 0.1498 Preoperative clinical diagnosis OA n = 268 (89.33%) n = 533 (88.83%) 0.8213 RA n = 30 (10%) n = 62 (10.33%) 0.8776 Others n = 2 (0.67%) n = 5 (0.83%) 0.7967 Preoperative Associated co-morbidities: Cardiac 112 (37.33) 230 (38.33) 0.7709 Renal 53 (17.66) 137 (22.833) 0.0732 Hepatic 10 (3.33) 16 (2.833) 0.6594 Mean Preoperative FJS-12 11.90 ± 11.3 11.72 ± 12.1 0.8298 Mean Preoperative VAS score 7.4 ± 2.9 7.5 ± 1.5 0.3899 Student’s unpaired t-test. The null hypothesis was tested respectively (p < 0.0001). Postoperative hip-knee-ankle with chi-squared test and t-test. A p < 0.05 was consid- angle of the group A and B was 181.4° ± 0.5° and ered statistically significant. 182.5° ± 0.2°, respectively (p = 0.1302). The mean postop- erative FJS-12 scores of the group A and B were 24.5 ± Results 16.4 and 25.6 ± 17.4, respectively (p = 0.3625). The MUA The results were expressed as the mean ± standard devi- rates were 3% in group A and 0.2% in group B (p = ation. In group A, the mean age was 69.1 ± 14.3 years 0.0001) (Table 2). (range: 58 to 82 years). In group B, the mean age was The sample size was estimated to be 870 with ɑ error 66.5 ± 15.7 years (range: 56 to 83 years). Preoperatively, of 0.05, β error of 0.1, and power of 90. Considering the mean ROM of the knee in group A and B were dropouts, it was rounded to 900 patients who had 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p = 0.7521). undergone TKA. The MUA rate of group B (0.2%) was The mean varus of deformity in group A and group B less than that of group A (3%) (p = 0.0001). The MUA were 8.5° ± 2.6° and 9.8 ± 3.1°, respectively (p = 0.1498). rate of group B was also less than the MUA rates (4 to The mean FJS-12 scores of group A and B were 11.90 ± 6%) reported in large Western cohorts (p < 0.001; 95% 11.3 and 11.72 ± 12.1 (p = 0.8298). The mean hospital confidence interval − 0.002) (Table 3). stay for patients in group A and B was 4.4 ± 0.5 and 4.6 ± 0.4 days, respectively (Table 1). Discussion Six weeks after TKA, the mean ROM of the knee in Stiff knee after primary TKA is a very debilitating condi- group A and B was 109.7° ± 22.3° and 121° ± 21.5°, tion. If left untreated, it will affect patients’ daily Table 2 Comparison of postoperative characteristics of patients between Group A and Group B Parameters Group A Group B p value Mean hospital stay duration (days) 4.4 ± 0.5 4.6 ± 0.4 0.0734 Mean Postoperative VAS score at 6 weeks 4.5 ± 1.8 4.3 ± 1.4 0.0674 Mean Postoperative FJS-12 at 6 weeks 24.5 ± 16.4 25.6 ± 17.4 0.3625 Mean Postoperative Knee Alignment (HKA angle or FT angle) (degrees) 181.4 ± 0.5 182.5 ± 0.2 0.1302 Mean Postoperative ROM 109.7 ± 22.3 121.3 ± 21.5 < 0.0001 MUA Rate n = 9 (3%) n = 1 (0.1667%) 0.0001 Londhe et al. Arthroplasty (2021) 3:10 Page 4 of 5 Table 3 MUA rate of current study versus the rates of other Abbreviations TKA: Total Knee Arthroplasty; MUA: Manipulation Under Anaesthesia; large cohorts with p values ROM: Range of Motion; VAS: Visual Analogue Score; FJS-12: Forgotten Joint Author Country of study Patients (n) MUA rate p value Score-12 Werner USA 141016 4.3 < 0.001 Acknowledgements Bawa USA 3224 4.3 < 0.001 We acknowledge the help provided by Mr. Vishal Jagadale, a statistician. Issa USA 3128 4.9 < 0.001 Authors’ contributions Pamilo Finland 624 5.9 < 0.001 All authors have contributed significantly to the preparation of manuscript. The authors read and approved the final manuscript. Wied Denmark 259 5.8 < 0.001 Current study India 600 0.167 Funding No funding was obtained. Availability of data and materials activities, such as climbing up and down the stairs, rising Not Applicable. from a chair, or tying shoelaces that routinely requires Ethics approval and consent to participate the knee to flex more than 90° [17, 25–27]. Asian popu- Local ethics committee approval was obtained before the study. Also all lation even requires more than 120° to perform certain patients gave their consent. activities, such as squatting and sitting cross-legged. Consent for publication We found that physiotherapy at home with physio- We hereby give our consent for publication. therapist visiting decreased the MUA rate, compared with no visiting. Our results were also lower than those Competing interests The authors declare that they have no competing interests. of the previous large cohort studies. We believe the con- stant feedback mechanism between the physiotherapists Author details and patients is helpful in reducing the incidence of stiff Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra 400069, India. Orthopaedic Surgeon, knee, thereby decreasing the MUA rate. 3 4 Hinduja Healthcare, Khar, India. Meril Life Sciences, Mumbai, India. Dr Many treatment options are available for managing Vishwanath Karad MIT World Peace University, Pune, India. Criticare Hospital, 6 7 the stiff knee. Initially, the patients are subjected to ag- Mumbai, India. Alpha speciality Clinic, Mumbai, India. SDM College of Physiotherapy, Sattur, Dharwad, Karnataka, India. gressive physiotherapy. If the physiotherapy fails to help the patient achieve an acceptable ROM, MUA is indi- Received: 30 April 2020 Accepted: 14 December 2020 cated. Even though the MUA helps in achieving satisfac- tory ROM after the procedure, the occurrence of stiff References knee should be prevented in the first place. Werner 1. Riley LH Jr. Total knee arthroplasty. Clin Orthop Relat Res. 1985;192:34–9. et al.[28] showed that MUA applied within 6 months 2. Genêt F, Schnitzler A, Lapeyre E, et al. Change of impairment, disability and after TKA increased the risk of early revision of TKA. patient satisfaction after total knee arthroplasty in secondary care practice. Ann Readapt Med Phys. 2008;51:671–6 676–82. English, French. Some factors may be associated with the development 3. Mainard D, Guillemin F, Cuny C, et al. Quality of life assessment one year of stiff knee after TKA. Werner et al.[28] found age < after total hip or knee arthroplasty. Rev Chir Orthop Reparatrice Appar Mot. 65 years, female gender, and smoking were associated 2000;86:464–73 French. 4. Heck DA, Robinson RL, Partridge CM, Lubitz RM, Freund DA. Patient with a high MUA rate. Issa et al.[29] showed that white outcomes after knee replacement. Clin Orthop Relat Res. 1998;356:93–110. race, preoperative diabetes, high cholesterol levels, pre- 5. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion operative ROM < 100°, and osteonecrosis of the knee of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected were associated with an increased MUA rate. patients. BMJ Open. 2012;2:e000435. The study had several limitations. First, this study was 6. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total not a prospective, blinded, or randomized study. Patient knee arthroplasty. J Bone Joint Surg Am. 2005;87:1719–24. 7. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient characteristics, such as age, BMI, ROM, varus deformity, satisfaction after total knee arthroplasty: who is satisfied and who is not? knee pain, and FJS-12 may not reflect the actual statis- Clin Orthop Relat Res. 2010;468:57–63. tical differences. The cost of both types of physiother- 8. Anderson JG, Wixson RL, Tsai D, Stulberg SD, Chang RW. Functional outcome and patient satisfaction in total knee patients over the age of 75. apies was not assessed, which might affect patients’ J Arthroplast. 1996;11:831–40. selection of treatments. 9. Chesworth BM, Mahomed NN, Bourne RB, Davis AM. Willingness to go through surgery again validated the WOMAC clinically important difference from THR/TKR surgery. J Clin Epidemiol. 2008;61:907–18. Conclusion 10. Dunbar MJ, Robertsson O, Ryd L, Lidgren L. Appropriate questionnaires for After TKA, frequent physiotherapist’s instruction helps knee arthroplasty, results of a survey of 360patients from the Swedish knee the patients improve knee exercises and therefore de- Arthroplasty registry. J Bone Joint Surg Br. 2001;83:339–44. 11. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, Katz B, Bombardier crease the risk of revision surgery. The home physiother- C, Heck D, Freund D. Health-related quality of life after knee replacement. apy under supervision of physiotherapist also decreases Results of the knee replacement patient outcomes research team study. the MUA rate. J Bone Joint Surg Am. 1998;80:163–73. Londhe et al. Arthroplasty (2021) 3:10 Page 5 of 5 12. Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall award: patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res. 2006;452:35–43. 13. Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand. 2000;71:262–7. 14. Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, Beard DJ. Knee replacement. Lancet. 2012;379:1331–40. 15. Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg. 2004;12:164–71. 16. Kettelkamp DB, Leaverton PE, Misol S. Gait characteristics of the rheumatoid knee. Arch Surg. 1972;104:30–4. 17. Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther. 1972;52:34–43. 18. Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am. 2004; 86:1479–84. 19. Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr, Ruh EL, Clohisy JC, Hamilton WG, Della Valle CJ, Barrack RL. High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res. 2014;472: 133–7. 20. Pivec R, Issa K, Kester M, Harwin SF, Mont MA. Long-term outcomes of MUA for stiffness in primary TKA. J Knee Surg. 2013;26:405–10. 21. Parvizi J, Tarity TD, Steinbeck MJ, Politi RG, Joshi A, Purtill JJ, Sharkey PF. Management of stiffness following total knee arthroplasty. J Bone Joint Surg Am. 2006;88(Suppl 4):175–81. 22. Ries MD, Badalamente M. Arthrofibrosis after total knee arthroplasty. Clin Orthop Relat Res. 2000;380:177–83. 23. Ritter MA, Stringer EA. Predictive range of motion after total knee replacement. Clin Orthop Relat Res. 1979;143:115–9. 24. Robertson F, Geddes J, Ridley D, McLeod G, Cheng K. Patients with type 2 diabetes mellitus have a worse functional outcome post knee arthroplasty: a matched cohort study. Knee. 2012;19:286–9. 25. Seyler TM, Marker DR, Bhave A, Plate JF, Marulanda GA, Bonutti PM, Delanois RE, Mont MA. Functional problems and arthrofibrosis following total knee arthroplasty. J Bone Joint Surg Am. 2007;89(Suppl 3):59–69. 26. Vince KG. The stiff total knee arthroplasty: causes and cures. J Bone Joint Surg Br. 2012;94:103–11. 27. Nelson CL, Kim J, Lotke PA. Stiffness after total knee arthroplasty. J Bone Joint Surg Am. 2005;87(Suppl 1):264–70. 28. Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplast. 2015;30(9 Suppl):72–5. 29. Issa K, Rifai A, Boylan MR, Pourtaheri S, McInerney VK, Mont MA. Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty? Clin Orthop Relat Res. 2015;473(1):143–7. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png "Arthroplasty" Springer Journals

Home physiotherapy with vs. without supervision of physiotherapist for assessingmanipulation under anaesthesia after total knee arthroplasty

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Londhe et al. Arthroplasty (2021) 3:10 https://doi.org/10.1186/s42836-020-00063-3 Arthroplasty RESEARCH Open Access Home physiotherapy with vs. without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty 1* 2 3 4 Sanjay Bhalchandra Londhe , Ravi Vinod Shah , Amit Pankaj Doshi , Shubhankar Sanjay Londhe , 5 6 7 Kavita Subhedar , Krishnan Iyengar and Prashant Mukkannavar Abstract: The aim of this retrospective cohort study was to compare home physiotherapy with or without supervision of physiotherapist for assessing manipulation under anaesthesia after total knee arthroplasty. Methods: A total of 900 patients (including 810 females and 90 males) who had undergone total knee arthroplasty were divided into group A (n = 300) and group B (n = 600). Patients in group A had home physiotherapy on their own after discharge from hospital. The physiotherapist did not visit them at home. Patients in group B received home physiotherapy under supervision of physiotherapist for 6 weeks after discharge from hospital. Patients’ age, range of motion of the knee, and forgotten joint score-12 were assessed. A p < 0.05 was considered statistically significant. Results: In group A, the mean age was 69.1 ± 14.3 years (range: 58 to 82 years); in group B, the mean age was 66.5 ± 15.7 years (range: 56 to 83 years) (p > 0.05). Preoperatively, the mean range of motion of the knee in group A and B was 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p > 0.05). The mean forgotten joint score-12 of group A and B were 11.90 ± 11.3 and 11.72 ± 12.1 (p > 0.05), respectively. Six weeks after total knee arthroplasty, the mean ROM of the knee in group A and B was 109.7° ± 22.3° and 121° ± 21.5°, respectively (p < 0.05). The mean postoperative forgotten joint score-12 of the group A and B was 24.5 ± 16.4 and 25.6 ± 17.4, respectively (p > 0.05). The rate of manipulation under anaesthesia was 3% in group A and 0.2% in group B (p < 0.05). Conclusion: After total knee arthroplasty, frequent physiotherapist’s instruction helps the patients improve knee exercises and therefore decrease the risk of revision surgery. The home physiotherapy under supervision of physiotherapist lowers the rate of manipulation under anaesthesia. Level of evidence: Therapeutic study, Level IIa. Keywords: Total knee arthroplasty, Manipulation under anaesthesia, Postoperative physiotherapy, Stiff knee * Correspondence: sanlondhe@yahoo.com Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra 400069, India Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Londhe et al. Arthroplasty (2021) 3:10 Page 2 of 5 Introduction end of the sixth postoperative week. The study was Total Knee Arthroplasty (TKA) is one of the most started with null hypothesis. Using a pocket goniom- successful operations in modern orthopaedics [1]. eter, ROM (angle of maximal flexion to extension) of TKA is highly effective in relieving pain and improv- the knee was measured by an independent observer ing functions, including activities of daily living [2–6]. (nurse practitioner). Preoperative data were recorded Huge advances have been made in the implant de- 1 week prior to TKA. signs, refinement of the surgical treatment of TKA and patient selection. Bourne et al.[7] and other au- TKA and physiotherapy thors showed that a sizable percentage of patients, All operations were done by the same surgical team. i.e., 19%. remain dissatisfied with their primary TKA Operation was performed under tourniquet control [8–13]. One of the common reasons in these 19% un- and through the standard parapatellar approach. We satisfied patients is development of knee stiffness after used a cemented posterior stabilized knee implant the TKA surgery. If untreated, knee stiffness may pro- (Freedom Total Knee system, Maxx Orthopedics Inc., gress over time and affects patients’ ability to perform PA, USA) in all patients. The physiotherapy was daily tasks [14]. Early gait analyses and biomechanical started immediately after TKA, i.e.,onthe very same studies showed that the knee should achieve at least day of the operation. The physiotherapy was in the 83° of flexion to ascend stairs, 90° to 100° of flexion form of muscle strengthening exercises, ROM exer- to descend stairs, 93° to 105° flexion to rise from a cises, closed chain exercises, and practice of stair chair, and more than 120° of flexion to squat or kneel climbing and gait training. The muscle strengthening [15–17]. Till now, there is no clear consensus on the exercises were in the form of ankle pump, static and definition of knee stiffness in the literature. Usually, a dynamic quadriceps muscle strengthening, and glutei stiff knee is confirmed when the knee flexed less than and hamstring muscle strengthening exercises. The 90° after TKA [18–20]. Some factors may be associ- ROM exercises comprised of passive, assisted active ated with knee stiffness, including a decreased pre- and active knee movements. Gait training included operative ROM, younger age, diabetes mellitus, socio- walking initially with walking aid like walker and economic status, and previous knee surgery, malposi- gradually progressing to walking stick. tioning of implant, inadequate resection, and over- Patients of group A were instructed to have physio- stuffing of the component [21–24]. therapy on their own at home. The physiotherapist did The objective of this retrospective cohort study was to not visit them at home. The physiotherapist just gave compare home physiotherapy with and without supervi- them instructions at the time of discharge from the hos- sion of physiotherapist for assessing MUA after TKA. pital. We provided information booklets to show how We also reported the efficacy of postoperative home the physiotherapy exercises were performed. physiotherapy under supervision of physiotherapist. Patients of group B received postoperative physiother- apy at home with physiotherapist visiting their home for Patients and methods 6 weeks. The physiotherapist visited the patients at home The institutional review boards of the participating hos- initially 6 days a week (excluding Sunday) for the first 2 pitals approved the study. Informed consent was ob- weeks, 3 days a week for the next 2 weeks, and then once tained from each patient. a week for the final 2 weeks. The same physiotherapy A total of 900 patients (involving 810 females and team conducted the home physiotherapy. The informa- 90 males) were included in this study and divided tion conveyed by the physiotherapist included ROM, into two groups. Group A consisted of 300 patients walking with/without walking aid, ability to perform day who had undergone TKA between January 2011 and to day activities, and amount of knee pain the patient December 2013; group B included 600 patients who was experiencing. had undergone TKA between January 2014 and De- MUA was applied when the patients had failed to cember 2018. achieve 90° of ROM at the first follow-up visit (6 weeks Preoperatively, we recorded patients’ age, body mass after TKA). Under general anaesthesia, the patient index (BMI), ROM of the knee, diagnosis, degree of underwent MUA as a day care procedure and was put varus deformity, 100-mm visual analogue score (VAS) on standard post-TKA rehabilitation program. Postoper- for knee pain, and forgotten joint score (FJS)-12 ative data were recorded at each clinic visit. (Table 1). The duration of hospital stay, and hip- knee-ankle alignment were also recorded (Table 2). An independent observer who did not attend the Statistical analysis treatments assessed all the data. MUA was carried Data were expressed as mean ± standard deviation. Com- out when the knee flexion was less than 90° at the parisons between the groups were made by using Londhe et al. Arthroplasty (2021) 3:10 Page 3 of 5 Table 1 Comparison of preoperative characteristics of patients between Group A and Group B Parameters Group A Group B p value Number of patients (n) 300 600 – Mean Age (years) 69.1 ± 14.3 (58–82) 66.5 ± 15.7 (56–83) 0.5780 Mean BMI (kg/m ) 28.2 ± 4.7 27.6 ± 5.4 0.1016 Gender Females n = 269 (89.66%) n = 542 (90.33%) 0.7511 Males n = 31 (10.33%) n = 58 (9.66%) 0.7510 Mean Preoperative ROM 95.8 ± 18.1 95.4 ± 17.8 0.7521 Preoperative degree of deformity (varus) 8.5 ± 2.6 9.8 ± 3.1 0.1498 Preoperative clinical diagnosis OA n = 268 (89.33%) n = 533 (88.83%) 0.8213 RA n = 30 (10%) n = 62 (10.33%) 0.8776 Others n = 2 (0.67%) n = 5 (0.83%) 0.7967 Preoperative Associated co-morbidities: Cardiac 112 (37.33) 230 (38.33) 0.7709 Renal 53 (17.66) 137 (22.833) 0.0732 Hepatic 10 (3.33) 16 (2.833) 0.6594 Mean Preoperative FJS-12 11.90 ± 11.3 11.72 ± 12.1 0.8298 Mean Preoperative VAS score 7.4 ± 2.9 7.5 ± 1.5 0.3899 Student’s unpaired t-test. The null hypothesis was tested respectively (p < 0.0001). Postoperative hip-knee-ankle with chi-squared test and t-test. A p < 0.05 was consid- angle of the group A and B was 181.4° ± 0.5° and ered statistically significant. 182.5° ± 0.2°, respectively (p = 0.1302). The mean postop- erative FJS-12 scores of the group A and B were 24.5 ± Results 16.4 and 25.6 ± 17.4, respectively (p = 0.3625). The MUA The results were expressed as the mean ± standard devi- rates were 3% in group A and 0.2% in group B (p = ation. In group A, the mean age was 69.1 ± 14.3 years 0.0001) (Table 2). (range: 58 to 82 years). In group B, the mean age was The sample size was estimated to be 870 with ɑ error 66.5 ± 15.7 years (range: 56 to 83 years). Preoperatively, of 0.05, β error of 0.1, and power of 90. Considering the mean ROM of the knee in group A and B were dropouts, it was rounded to 900 patients who had 95.8° ± 18.1° and 95.4° ± 17.8°, respectively (p = 0.7521). undergone TKA. The MUA rate of group B (0.2%) was The mean varus of deformity in group A and group B less than that of group A (3%) (p = 0.0001). The MUA were 8.5° ± 2.6° and 9.8 ± 3.1°, respectively (p = 0.1498). rate of group B was also less than the MUA rates (4 to The mean FJS-12 scores of group A and B were 11.90 ± 6%) reported in large Western cohorts (p < 0.001; 95% 11.3 and 11.72 ± 12.1 (p = 0.8298). The mean hospital confidence interval − 0.002) (Table 3). stay for patients in group A and B was 4.4 ± 0.5 and 4.6 ± 0.4 days, respectively (Table 1). Discussion Six weeks after TKA, the mean ROM of the knee in Stiff knee after primary TKA is a very debilitating condi- group A and B was 109.7° ± 22.3° and 121° ± 21.5°, tion. If left untreated, it will affect patients’ daily Table 2 Comparison of postoperative characteristics of patients between Group A and Group B Parameters Group A Group B p value Mean hospital stay duration (days) 4.4 ± 0.5 4.6 ± 0.4 0.0734 Mean Postoperative VAS score at 6 weeks 4.5 ± 1.8 4.3 ± 1.4 0.0674 Mean Postoperative FJS-12 at 6 weeks 24.5 ± 16.4 25.6 ± 17.4 0.3625 Mean Postoperative Knee Alignment (HKA angle or FT angle) (degrees) 181.4 ± 0.5 182.5 ± 0.2 0.1302 Mean Postoperative ROM 109.7 ± 22.3 121.3 ± 21.5 < 0.0001 MUA Rate n = 9 (3%) n = 1 (0.1667%) 0.0001 Londhe et al. Arthroplasty (2021) 3:10 Page 4 of 5 Table 3 MUA rate of current study versus the rates of other Abbreviations TKA: Total Knee Arthroplasty; MUA: Manipulation Under Anaesthesia; large cohorts with p values ROM: Range of Motion; VAS: Visual Analogue Score; FJS-12: Forgotten Joint Author Country of study Patients (n) MUA rate p value Score-12 Werner USA 141016 4.3 < 0.001 Acknowledgements Bawa USA 3224 4.3 < 0.001 We acknowledge the help provided by Mr. Vishal Jagadale, a statistician. Issa USA 3128 4.9 < 0.001 Authors’ contributions Pamilo Finland 624 5.9 < 0.001 All authors have contributed significantly to the preparation of manuscript. The authors read and approved the final manuscript. Wied Denmark 259 5.8 < 0.001 Current study India 600 0.167 Funding No funding was obtained. Availability of data and materials activities, such as climbing up and down the stairs, rising Not Applicable. from a chair, or tying shoelaces that routinely requires Ethics approval and consent to participate the knee to flex more than 90° [17, 25–27]. Asian popu- Local ethics committee approval was obtained before the study. Also all lation even requires more than 120° to perform certain patients gave their consent. activities, such as squatting and sitting cross-legged. Consent for publication We found that physiotherapy at home with physio- We hereby give our consent for publication. therapist visiting decreased the MUA rate, compared with no visiting. Our results were also lower than those Competing interests The authors declare that they have no competing interests. of the previous large cohort studies. We believe the con- stant feedback mechanism between the physiotherapists Author details and patients is helpful in reducing the incidence of stiff Orthopaedic surgeon, Criticare Hospital, Plot No 516, Besides SBI, Teli Gali, Andheri East, Mumbai, Maharashtra 400069, India. Orthopaedic Surgeon, knee, thereby decreasing the MUA rate. 3 4 Hinduja Healthcare, Khar, India. Meril Life Sciences, Mumbai, India. Dr Many treatment options are available for managing Vishwanath Karad MIT World Peace University, Pune, India. Criticare Hospital, 6 7 the stiff knee. Initially, the patients are subjected to ag- Mumbai, India. Alpha speciality Clinic, Mumbai, India. SDM College of Physiotherapy, Sattur, Dharwad, Karnataka, India. gressive physiotherapy. If the physiotherapy fails to help the patient achieve an acceptable ROM, MUA is indi- Received: 30 April 2020 Accepted: 14 December 2020 cated. 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