Satisfactory adherence to the Dutch physical therapy guideline for patients with a total knee arthroplasty. A survey study involving 103 specialised physical therapists.

OBJECTIVE: To explore and gain more insight into the usual preoperative and postoperative physical therapy (PT) treatment of patients with a total knee arthroplasty (TKA) among Dutch physical therapists experienced with TKA rehabilitation. Secondly, to evaluate physical therapists' adherence to guideline recommendations for postoperative rehabilitation. METHODS: In this cross-sectional study, physical therapists working in primary care within a designated Dutch hospital's catchment area were surveyed online. The survey queried PT treatment approaches before surgery, during hospitalisation, and after surgery. All data were analysed descriptively. When both education and all recommended exercise modalities were used postoperatively, therapists were considered fully adherent with the Dutch clinical practice guideline. RESULTS: One hundred and three therapists participated, representing a response rate of 58%. Postoperative PT treatment was applied by all therapists, of which 65 (63.1%) were fully adherent to the guideline. Partial adherence was mainly due to not using the aerobic exercise modality. Furthermore, beyond the modalities recommended in the guideline, a range of PT interventions were used. Preoperative treatment was applied by 73 therapists (70.9%). These 73 indicated that only a median of 20% (IQR 10%-40%) of their patients received preoperative PT. CONCLUSIONS: This study revealed satisfactory adherence to guideline recommendations on postoperative management of patients with a TKA among experienced physical therapists. Aerobic exercises were utilised less often or with inappropriate intensity. Correct adherence to guideline recommendations on aerobic exercise training can result in more physically active individuals and important general health benefits.

Direct active rehabilitation after reverse total shoulder arthroplasty: an international multicentre prospective cohort safety study with 1-year follow up.

OBJECTIVES: To gain insight in the safety of direct active rehabilitation without immobilisation in patients undergoing reverse total shoulder arthroplasty without subscapularis reattachment, measured by the occurrence of complications until 1-year follow up. Next, to explore improvement in shoulder function and in patient-reported outcome measures. DESIGN: An international multicentre prospective cohort safety study. SETTING: Patients indicated for reverse total shoulder arthroplasty, visiting the orthopaedics outpatient clinic at two hospitals in the Netherlands and one hospital in Curaçao between January 2019 and July 2021, were selected. PARTICIPANTS: 100 patients (68% female, mean age 74±7.0 years) undergoing unilateral primary shoulder replacement were included if: ≥50 years, diagnosed with shoulder osteoarthritis, rotator cuff arthropathy or avascular necrosis, and selected for reverse total shoulder arthroplasty. A sling was used for only 1 day, followed by a progressive active rehabilitation for ≥12 weeks with no precautions. MAIN OUTCOME MEASURES: Complications, range of motion and patient-reported outcome measures (Oxford Shoulder Score, Pain Numeric Rating Scale and EuroQol-5D for quality of life). Patients were evaluated preoperatively and 6 weeks, 3 months and 1 year postoperatively. RESULTS: In total, 17 complications were registered (17.0%) including five (5.0%) categorised as potentially related to the rehabilitation strategy: one dislocation, one acromion fracture and three cases with persistent pain. Anteflexion, abduction and external rotation, pain scores and the Oxford Shoulder Score all improved significantly (p<0.05) at all time points compared with preoperative. Quality of life improved significantly from 3 months onwards. These secondary outcomes improved further until 1 year postoperatively. CONCLUSION: Direct active rehabilitation after reverse total shoulder arthroplasty seems to be safe and effective. Potentially, this approach will lead to less dependent patients and faster recovery. Larger studies, preferably including a control group, should corroborate our results. TRIAL REGISTRATION NUMBER: NL7656.

Submaximal cardiopulmonary exercise testing to assess preoperative aerobic capacity in patients with knee osteoarthritis scheduled for total knee arthroplasty: a feasibility study.

OBJECTIVE: To investigate the feasibility of submaximal cardiopulmonary exercise testing (CPET) in patients with knee osteoarthritis (OA) scheduled for primary total knee arthroplasty (TKA) surgery. Secondly, to assess their preoperative aerobic capacity. METHODS: In this observational, single-center study, participants performed a submaximal CPET 3-6 weeks before surgery. To examine their experiences, participants completed a questionnaire and one week later they were contacted by telephone. CPET was deemed feasible when five feasibility criteria were met. Aerobic capacity was evaluated by determining the oxygen uptake (VO2) at the ventilatory anaerobic threshold (VAT) and oxygen uptake efficiency slope (OUES). OUES values were compared with two sets of normative values. RESULTS: All feasibility criteria were met as 14 representative participants were recruited (recruitment rate: 60.9%), and all participants were able to perform the test and reached the VAT. No adverse events occurred, and all participants were positive toward submaximal CPET. The median VO2 at the VAT was 12.8 mL/kg/min (IQR 11.3-13.6). The median OUES/kg was 23.1 (IQR 20.2-28.9), 106.4% and 109.4% of predicted. CONCLUSION: Submaximal CPET using cycle ergometry seems feasible in patients with knee OA scheduled for TKA surgery to evaluate preoperative aerobic capacity.

Fast track rehabilitation after reversed total shoulder arthroplasty: a protocol for an international multicentre prospective cohort study.

INTRODUCTION: The use of reversed total shoulder arthroplasty (rTSA) has increased because of an increasing number of indications for this procedure and by ageing of the population. Usual postoperative care consists of immobilisation of the shoulder for a period of 2-6 weeks to allow healing of the subscapularis tendon and protection of the joint. However, new literature proved that reattachment of the subscapularis tendon is unnecessary. Therefore we hypothesised that immobilisation of the shoulder is not necessary and patients can start safely with mobilisation on the first postoperative day. We expect this fast track protocol to be safe and result in better short-term and long-term functional outcomes. METHODS AND ANALYSIS: In our prospective cohort, we will include at least 75 patients aged 50 years and older indicated for rTSA, with acute fracture treatment as an exclusion criterion. Patients will be selected and operated in three hospitals: two in the Netherlands and one in Curacao.Patients will visit the outpatient clinic preoperative, at 6 weeks, 3 months and 1 year postoperative. The data that will be collected includes baseline characteristics, reason for surgery, complications and adverse events, patient reported outcomes (Oxford Shoulder Score, EuroQol-5D and Numeric Rating Scale for pain) and range of motion of the shoulder.All patients will be instructed to use a sling only for 1 day and to follow a progressive physiotherapy schedule for 12 weeks. The primary outcome is the occurrence of complications and adverse events. ETHICS AND DISSEMINATION: The Medical Ethics Committee from the VUmc and Curacao reviewed this study protocol and granted exemption from ethical approval (METC VUmc 2019.111, METC Curacao 2019-02). Study results will be presented at (inter)national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL7656).

It is safe to use minimal restrictions following posterior approach total hip arthroplasty: results from a large cohort study.

BACKGROUND: To prevent early postoperative dislocation following a total hip arthroplasty (THA) procedure, patients must adhere to restrictions. Restrictive protocols are common if THA surgery is performed using the posterior approach, but scientific evidence form larger studies that supports these restrictions are scarce. In this large cohort study we compare the <90-days dislocation rate between patients receiving posterior approach THA managed with minimal versus extensive restrictions. METHODS: Prospective cohort (n = 1049) of consecutive elective primary hip replacement surgery procedures (September 2014-July 2017) managed with minimal postoperative restrictions. Hospital charts were prospectively reviewed for patient demographics, risk factors and any hip dislocation. Control (n = 1102) consecutive primary elective THAs (January 2011-August 2014) managed with a traditional restrictive protocol. A posterior surgical approach was used in all procedures. RESULTS: Minimal restrictions group: 17 dislocations <90 days (1.6%); Restricted group: 28 (2.5%), chi-square p = 0.1. Testing the hypothesis of inferiority by a minimum of 1% increase in ⩽90 days dislocation risk: p = 0.14 (test for difference) and p < 0.001 (non-inferiority test), allowing us to discard the null hypothesis (absolute increase in risk of ⩾1% with minimal restrictions). The proportion of surgeries performed with a femoral head size ⩾32 mm was higher in the minimal restrictions group. CONCLUSIONS: Patients can be managed safely with minimal restrictions following posterior approach THA if combined with frequent use of larger femoral heads.

Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature.

OBJECTIVE: A systematic literature review and meta-analysis on the effectiveness of lifestyle restrictions and precautions to prevent dislocation after total hip arthroplasty. DATA SOURCES: MEDLINE and the Cochrane Library were searched in February 2015, with additional hand searching of systematic reviews and reference lists. REVIEW METHODS: This review was conducted in accordance with the PRISMA statement for reporting systematic reviews and meta-analysis. PubMed and the Cochrane Library were searched from their start date through to February 2015. Randomized controlled trials and comparative case series in English, Dutch or German language were included. Only primary total hip arthroplasty procedures managed with different postoperative restrictions and precautions protocols were included. Primary outcome was the total hip arthroplasty dislocation rate, secondary outcomes were patient functioning, return to activities of daily living and patient satisfaction. RESULTS: A total of 119 eligible articles were identified, six were included: three randomized controlled trials, one retrospective matched cohort study, one retrospective and one prospective cohort study, describing 1122 procedures (restrictions group: n = 528; no restrictions group: n = 594). Both the standard posterior and anterolateral surgical approaches were included. There were eight dislocations (1.5%) in the restricted group, vs. six dislocations (1.0%) in the unrestricted group. Patients in the unrestricted group resumed activities significantly faster and were more satisfied with their pace of recovery. CONCLUSION: A more liberal lifestyle restrictions and precautions protocol will not lead to worse dislocation rates after total hip arthroplasty, but will lead to earlier and better resumption of activities and higher patient satisfaction. These results appear to hold up for various surgical approaches.