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Predicting 1-year flexion results in Predicting 1-year flexion results in Total Knee Replacement patientsTotal Knee Replacement patients
Negus JJ Negus JJ MSc MSc 1,21,2
Parker DA Parker DA FRACSFRACS11
Coolican MRJ Coolican MRJ FRACSFRACS11
Galea A Galea A MRCSMRCS11
Ogut M Ogut M 22
11 Sydney Orthopaedic Research Institute Sydney Orthopaedic Research Institute22 University of Sydney University of Sydney
Australian Orthopaedic AssociationAustralian Orthopaedic Association7070thth Annual Scientific Meeting Annual Scientific Meeting
Adelaide, 2010Adelaide, 2010
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DeclarationsDeclarations
No conflicts of interest to declareNo conflicts of interest to declare
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IntroductionIntroduction
A knee with poor flexion can be clinically restrictive.A knee with poor flexion can be clinically restrictive. ≤≤90˚ often a clinical cut-off90˚ often a clinical cut-off
It is unclear whether a knee with poor flexion at It is unclear whether a knee with poor flexion at
6-weeks will benefit from a manipulation6-weeks will benefit from a manipulation
Postoperative flexion has been shown to correlate Postoperative flexion has been shown to correlate to preoperative flexion, but not as a quantitative to preoperative flexion, but not as a quantitative predictor.*predictor.*
* Anouchi * Anouchi et al et al `96, Lingard `96, Lingard et al et al ‘04, Ritter ‘04, Ritter et al et al ’03’03
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Aims of StudyAims of Study
1.1. To identify the value of early postoperative To identify the value of early postoperative flexion measurements as predictors of 1-year flexion measurements as predictors of 1-year flexion.flexion.
2.2. To identify which knees might benefit from To identify which knees might benefit from manipulation in the early postoperative phase.manipulation in the early postoperative phase.
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MethodsMethods Prospective series of Prospective series of 104 knees in 100 patients104 knees in 100 patients
2 specialist knee surgeons2 specialist knee surgeons Age, BMI, Surgeon (implant)Age, BMI, Surgeon (implant) ROM measured ROM measured
Pre-op, intra-op, day 2, day 6, 6 weeks, 1 yearPre-op, intra-op, day 2, day 6, 6 weeks, 1 year Functional scores (WOMAC, Oxford)Functional scores (WOMAC, Oxford)
Pre-operativePre-operative 1 year1 year
Discharge 6 days postoperativelyDischarge 6 days postoperatively Most commonly to inpatient rehabilitationMost commonly to inpatient rehabilitation
Physiotherapy and rehabilitation not standardisedPhysiotherapy and rehabilitation not standardised
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Patients and MethodsPatients and Methods
Knee flexion measured with a goniometerKnee flexion measured with a goniometer Reproducible technique *Reproducible technique *
Spinal or general anaestheticSpinal or general anaesthetic
Medial parapatellar approachMedial parapatellar approach
Fixed bearing prosthesis; patella Fixed bearing prosthesis; patella resurfacedresurfaced
Peri-articular soft tissue infiltration of local Peri-articular soft tissue infiltration of local anaestheticanaesthetic
Closure with knee flexed between 60 – Closure with knee flexed between 60 – 90˚90˚
* Edwards * Edwards et al et al ‘04‘04
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DemographicsDemographics
Group Male Female
Number 104 33 67
Pre-op flexion
113 (50-135)
Age 70 (52-86) 71 (47-94)
BMI 28.9 28.9
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RESULTSRESULTS
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Arc of motionArc of motion
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Correlations with flexion at 1 yearCorrelations with flexion at 1 year
Significant correlations between –Significant correlations between – Preoperative flexion Preoperative flexion & 1 year flexion & 1 year flexion p= p=
0.0040.004 Week 6 flexion Week 6 flexion & 1 year flexion& 1 year flexion p=<0.001p=<0.001
Preoperative flexion Week 6 flexion
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Predictive equation at 6 Predictive equation at 6 weeksweeks
6/52 Flexion Multiply by
<100˚ 1.27
100-109˚ 1.122
110-119˚ 1.068
≥120˚ 1.035
Mean accuracy of 0.22˚ (0.04˚ if 6 week flexion is >100˚)
If 6 week flexion >100˚ 4 knees overestimated by >10˚Only 1 had 1 year flexion <110˚
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Clinical courseClinical course
• ≤≤90˚ at 6 weeks90˚ at 6 weeks
• Only 15% of these still had ≤90˚ at 1-yearOnly 15% of these still had ≤90˚ at 1-year
• ≤ ≤90˚ at 1 year90˚ at 1 year
• 75% had ≥110˚preoperative flexion75% had ≥110˚preoperative flexion
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Pre-op ≤90˚ vs. >90˚Pre-op ≤90˚ vs. >90˚
*
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6 week ≤90˚ vs. >90˚6 week ≤90˚ vs. >90˚
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Statistical modelStatistical model
A regression analysis model taking into account all A regression analysis model taking into account all variablesvariables
It explains 54% of the variance in the results *It explains 54% of the variance in the results *
Mean predictive accuracy 1.0˚ Mean predictive accuracy 1.0˚ (SD 8.0, CI 1.9)(SD 8.0, CI 1.9)
Only 8 predictions were overestimated by >10˚ Only 8 predictions were overestimated by >10˚
* * Anouchi Anouchi et al et al 19961996
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EquationEquation
1 year flexion 1 year flexion = =
-29753306 -29753306
+ ( 137000000 + ( 137000000 * * BMI BMI -0.5 -0.5 ) )
+ ( 6.18 + ( 6.18 * * Pre-op flexion Pre-op flexion 3 3 ) )
+ ( 2983 * + ( 2983 * 6 week flexion 6 week flexion 2 2 ))
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ConclusionsConclusions
1.1. 54% of the variance of final flexion accounted for 54% of the variance of final flexion accounted for byby
Preoperative flexion, 6 week flexion and BMI.Preoperative flexion, 6 week flexion and BMI. No effect of age, gender, surgeon and flexion at other time pointsNo effect of age, gender, surgeon and flexion at other time points
1.1. Flexion at 6 weeks can guide our predictions of Flexion at 6 weeks can guide our predictions of final flexion.final flexion.
1.1. A statistical model is needed to predict poor A statistical model is needed to predict poor flexion results.flexion results.
2.2. This study suggests caution before manipulating This study suggests caution before manipulating knees, based on a single postoperative flexion knees, based on a single postoperative flexion measurement alone.measurement alone.
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DiscussionDiscussion
The ability to predict which knees are likely to The ability to predict which knees are likely to end up with a poor result would benefit end up with a poor result would benefit surgeons and patients.surgeons and patients.
Further work before the model can be used as Further work before the model can be used as a clinical tool.a clinical tool.
Retrospective data analysis of extensive database.Retrospective data analysis of extensive database. Regression analysis for all variables.Regression analysis for all variables. Refine predictive equation.Refine predictive equation.
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Thank YouThank You
Many thanks to Dr Corey Scholes 1 PhD for his help with the statistical analysis
1 – Sydney Orthopaedic research Institute
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BibliographyBibliography
Anouchi YS Anouchi YS et alet al. Range of motion in total knee . Range of motion in total knee replacement. COOR 1996;331:87-92replacement. COOR 1996;331:87-92
Ritter MA Ritter MA et alet al. Predicting ROM after total knee . Predicting ROM after total knee arthroplasty. JBJS Am 2003;85:1278-1285arthroplasty. JBJS Am 2003;85:1278-1285
Edwards JZ Edwards JZ et alet al. Measuring flexion in knee . Measuring flexion in knee arthroplasty patients. J Arthroplasty;19:3:369-372arthroplasty patients. J Arthroplasty;19:3:369-372
Lingard EA Lingard EA et alet al. Predicting the outcome of total knee . Predicting the outcome of total knee arthroplasty. JBJS Am. 2004;86:2179-2186arthroplasty. JBJS Am. 2004;86:2179-2186