The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm recommends intra-articular (IA) hyaluronic acid (HA) for management of knee osteoarthritis (OA) as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs (NSAIDs). This recommendation is based upon accumulating evidence that IA HA provides a significant benefit in knee OA. There is good evidence that IA HA injections reduce pain and increase function in knee OA, and the benefits are long-lasting as compared with IA corticosteroids. Evidence from real-life studies of repeat courses of IA HA demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of IA HA on knee OA may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (ii) the re-establishment of joint homeostasis through induction of endogenous HA production, which continues long after the exogenous injection has left the joint. The magnitude of the clinical effect may be different for different HA products, but this has not been proven so far and requires further investigation. IA HA injections are generally considered to be safe, although a slightly higher number of cases of local reactions and post-injection non-septic arthritis has been reported with high molecular weight cross-linked HAs. The use of IA HA in knee OA patients with mild-moderate disease, and for more severe patients wishing to delay TKR surgery, is recommended by the ESCEO task force. Further investigation into the OA patient types most likely to benefit from IA HA is warranted. Viscosupplementation with IA HA is a safe and effective component of the multi-modal management of knee OA.

Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys.

Biofeedback following total knee arthroplasty (TKA) seems to be a feasible approach to improve rehabilitation, outcomes, mobility and reduce pain. This systematic review gives the practicing orthopedic surgeon a summary of what is available and how biofeedback affects clinical outcomes. We reviewed the current literature regarding methods, devices and effects of biofeedback in patients who underwent total knee arthroplasty. Embase, Pubmed, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to May 2018 for the following keywords: Biofeedback OR Feedback AND Total Knee Arthroplasty OR TKA. Data were extracted according to a predefined setting (see Protocol for systematic review on PROSPEO). Devices used for biofeedback were recorded. Demographics, training methods and effects were also collected. The search resulted in 380 potentially eligible studies from which 11 met all inclusion criteria including 7 randomized controlled trials (RCTs), 3 cohort studies, and 1 cross-sectional study. A total of 416 patients with unilateral TKA were included, with an average of 37.8 patients per study. In patients with TKA, significant improvements in activity scores or pain were reported by 9 of 11 studies. Only two of the studies reported no significant influence of the feedback on the chosen outcome parameters. Devices for biofeedback varied between studies and included the use of a goniometer, force plate, balance board, treadmill, and/or electromyography (EMG). The most common type of feedback was visual followed by audio, with one study mentioning that the audio mode was preferred by the patients as it was easier to handle. Overall, 5 out of 6 different methods demonstrated a potential value for improving mobility and decreasing pain. This review suggests that biofeedback in early postoperative rehabilitation after TKA is effective in improving gait symmetry, reducing pain and increasing activity level. It should be noted that the great variety of devices used for feedback limits comparisons between studies. IIa.

Training with biofeedback devices improves clinical outcome compared to usual care in patients with unilateral TKA: a systematic review

BACKGROUND Total knee arthroplasty (TKA) remains the surgical gold standard treatment for patients suffering from end-stage osteoarthritis (OA) of the knee. However, due to the high demand and scarce medical resources, the waiting time for surgery is astoundingly lengthy. Controversies are shown in numerous studies, on whether physical functionality and mental status decline or remain stable over the waiting period. This study aims to evaluate the progression in patients suffering from end-stage OA while on the waiting list for TKA. METHODS One hundred and twenty-seven patients suffering from end-stage OA who were on the TKA waiting list were prospectively recruited from our orthopaedics specialist clinic. They were assessed once a year for 2 years or until surgery. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), SF-36 self-rated questionnaire and 15D health-related quality of life (HRQoL) questionnaire were used as outcome measurements for functionality and disability assessment. RESULTS Patients on the waiting list for TKA showed a progressive increase in pain and disability level within the first year (P = .035). Those patients waiting for more than 2 years showed worsening HRQoL (P < .05) as time progressed. However, no significant difference was observed between the first and second years. CONCLUSIONS A decline in functionality and increase in disability were shown in follow-up assessments conducted every year. However, a plateau effect is observed with end-stage disease. This emphasizes that more active conservative management programmes should be introduced and implemented while patients are enlisted on the TKA waiting list. Moreover, timely surgical intervention can improve patients' overall function. TRIAL REGISTRATION This study involved human participants and reports health-related outcomes concerning the HRQoL in patients with end-stage OA of the knee. Thus, it was registered, retrospectively, as a clinical trial under the U.S. National Library of Medicine ClinicalTrials.gov (https://clinicaltrials.gov/) on March 4, 2018.

Progression of health-related quality of life of patients waiting for total knee arthroplasty

Background Impact of total knee arthroplasty (TKA) on proprioception remains to be determined. The aim of this systematic review is to analyze factors influencing proprioception in patients with knee osteoarthritis (OA) undergoing TKA. Methods A systematic literature search was conducted on 3 medical electronic databases: PubMed, PeDRO, and Cochrane Collaboration. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used. Risk of bias analysis and best evidence synthesis were performed. Three main aspects were investigated: the presence of preoperative, surgical, and postoperative factors influencing proprioception in OA patients undergoing TKA. Results Search identified 1601 records. After screening, 19 papers were used for the analysis of 676 patients. Proprioception generally improved but often remained impaired after surgery. Strong evidence was found for no influence of prosthesis design on proprioception. Moderate evidence was found for patellar resurfacing not affecting proprioception, varus deformity negatively influencing proprioception, and time elapsed from surgery positively influencing proprioception. Limited evidence was found for valgus deformity, OA grade, intact anterior cruciate ligament, and anteroposterior joint laxity negatively affecting knee proprioception, and for muscle strength and sensorimotor training not affecting proprioception. Finally, conflicting evidence was found for better postoperative proprioception vs preoperative level. Conclusion Proprioception in OA patients undergoing TKA improves but remains impaired after surgery. The best evidence synthesis demonstrated no influence of prosthetic design, while the role of the treatment remains unclear. This warrants for further research efforts to study proprioceptive impairment to better manage OA patients undergoing TKA.

Total Knee Arthroplasty in Patients With Knee Osteoarthritis: Effects on Proprioception. A Systematic Review and Best Evidence Synthesis

Background With the development of three-dimensional printing (3DP) technology, the patient-specific instrumentation (PSI) has been widely applied in total knee arthroplasty (TKA) The purpose of this study was to compare the gait parameters of patients with 3DP personalized guide-assisted and standard TKA Methods Retrospective analysis of the advanced knee OA cases in our hospital between June 2017 and June 2018 was conducted 30 cases received 3DP personalized guide-assisted TKA (group A), and 60 patients who underwent standard TKA during the same period were in group B and group C according to the computed tomography (CT) measurement results, each with 30 cases Hip–knee–ankle angle (HKA), patella transverse axis-femoral transepicondylar axis angle (PFA), and gait parameters were statistically analyzed The function was assessed by Hospital for Specific Surgery (HSS) and Knee Society Score (KSS) Results The mean follow-up period was 123 months in the three groups The knee max flexion angle at the swing phase of group A was larger than group B and group C ( ), there was no statistically significant difference in other gait parameters The mean PFA of group A was smaller than that of group B and group C ( ) While, the HKA, HSS, and KSS scores of three groups showed no significant difference Conclusion 3DP personalized guide technology could improve the gait parameters after surgery, specifically reflected in the knee max flexion angle at the swing phase It could also assist in the reconstruction of more accurate patellar tracking and rotational alignment in TKA, avoiding the occurrence of insufficient or excessive extorsion

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Gait Analysis after Total Knee Arthroplasty Assisted by 3D-Printed Personalized Guide.

Background Among the procedures for severe gonarthrosis, total knee arthroplasty (TKA) is considered a successful method patient satisfaction and functional improvement; however, TKA is commonly associated with incompletely recovered gait function. The aim of this study was to evaluate the influence of TKA and physiotherapy programmes on gait features and patient-reported functional status and the relationship between them, leading to broader knowledge of the origins of long-term gait disturbances. Methods Walking speed, step length and single support time were analysed by GAITRite system in 60 healthy controls and 21 TKA patients analysed at four time points: one day before and five days after surgery and before and after a three-week rehabilitation (12 and 15 weeks after surgery). Functional status was assessed using the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Results At all time points, the TKA subjects walked significantly slower than the controls, but walking speed continuously increased after surgery. Gait asymmetries were observed in single support time (before surgery) and step length (after surgery). Partial restoration of gait function was observed 12 weeks after surgery and completion of the rehabilitation programme. An indirect correlation between gait velocity and function WOMAC subscores was found. Conclusions Patients after TKA were characterised by significant improvements in self-reported functionality and progressive reduction of gait abnormalities, probably related to pain reduction. However, at 15 weeks after surgery, patients exhibited step length asymmetry, which could be considered as an effect of habits of three-point crutch gait in the early postoperative period.

Gait and functional status analysis before and after total knee arthroplasty

Background: Knee immobilization is a common intervention for patients with traumatic injuries. However, it usually leads to biomechanical/morphological disturbances of articular tissues. These changes may contribute to declining kinetic friction-related quality of arthrokinematics; however, this phenomenon has not been analyzed in vivo and remains unrecognized. Thus, the aim of the present study is to investigate the effect of immobilization and subsequent re-mobilization on the quality of arthrokinematics within the patellofemoral joint, analyzed by vibroarthrography (VAG). Methods: Thirty-four patients after 6-weeks of knee immobilization and 37 controls were analyzed. The (VAG) signals were collected during knee flexion/extension using an accelerometer. Patients were tested on the first and last day of the 2-week rehabilitation program. Results: Immobilized knees were characterized by significantly higher values of all VAG parameters when compared to controls (p < 0.001) on the first day. After 2 weeks, the participants in the rehabilitation program that had immobilized knees showed significant improvement in all measurements compared to the baseline condition, p < 0.05. However, patients did not return to normal VAG parameters compared to controls. Conclusion: Immobilization-related changes within the knee cause impairments of arthrokinematic function reflected in VAG signal patterns. The alterations in joint motion after 6 weeks of immobilization may be partially reversible; however, the 2-week physiotherapy program is not sufficient for full recovery.

Effects of Immobilization and Re-Mobilization on Knee Joint Arthrokinematic Motion Quality

Background Osteoarthritis is one of the most common dysfunctions of the musculoskeletal system and viscosup-plementation is becoming an increasingly popular treatment in OA. However, current knowledge regarding biomechanical changes in synovial joints reveals many discrepancies. Therefore, the aim of our study was to evaluate the effect of visco-supplementation on knee joint arthrokinematics as analyzed by vibroarthrography. Material and methods Seventeen individuals diagnosed with moderate knee osteoarthritis (VSC) were examined before and after a single injection of hyaluronate. A control group consisted of 30 asymptomatic individuals. During alter-nating extension/flexion of the knee joint, a 6-second vibroarthrographic signal was recorded using an accelerometer. The following parameters were calculated: variance (VMS), amplitude (R4), and spectral power density in the 50-250 Hz (P1) and 250-450 Hz (P2) bands. Results Statistical analysis showed significant differences (pl0.05) in the values of R4 and P2, which were higher in the VSC group than among the controls. After viscosupplementation, the values of R4, P1 and P2 in the VSC group de-creased to a level not significantly different from that seen among the controls. Conclusions 1. After a single intra-articular HA injection, joint motion-related vibrations were reduced, which was recorded as a decreased intensity of vibroacoustic emission. 2. This suggests that the use of viscosupplementation in pa-tients with moderate knee osteoarthritis may improve qualitative aspects of arthrokinematics.

Effects of Viscosupplementation on Knee Joint Arthrokinematics - Pilot Study.

ObjectiveTo evaluate the influence of viscosupplementation on osteoarthritic knee arthrokinematics analyzed by VAG. It is considered that intra-articular hyaluronic acid injection may improve the f...

Effects of Viscosupplementation on Quality of Knee Joint Arthrokinematic Motion Analyzed by Vibroarthrography

In patients with advanced degenerative changes of the hip joint, the joint endoprosthesoplasty is the only effective method of treatment. Technically correctly performed surgery and choosing the appropriate implant are prerequisites for optimal result of the treatment. The aim of the study was to evaluate whether and to which extent the endoprosthesoplasty of the hip joint affects parameters of the balance control process following the total hip alloplasty surgery. Group of 20 patients age 52 – 64 after implantation of ANTEGA cementless endoprosthesis with anatomical stem was included in the study. In all cases, the operation was performed utilising posterior access . Immediately after surgical operation , during early postoperative period all patients underwent rehabilitation according to the standards developed at “Opolskie Centrum Rehabilitacji” [Rehabilitation Center of Opole] in Korfantow. Tests were conducted on the day preceeding operation and in three months after operation. Unconstrained standing on a force-plate for 20 seconds was performed during the test. Data was recorded with frequency of 20 Hz. Obtained results suggest that maintenance of stable body posture is easier for patients after total endoprosthesoplasty of the hip joint.

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Grzegorz Skiba

Papers

Gait and functional status analysis before and after total knee arthroplasty

Effects of Immobilization and Re-Mobilization on Knee Joint Arthrokinematic Motion Quality

Effects of Viscosupplementation on Knee Joint Arthrokinematics - Pilot Study.

Effects of Viscosupplementation on Quality of Knee Joint Arthrokinematic Motion Analyzed by Vibroarthrography

Evaluation of some stabilography parameters in patients after total alloplastisiti hip join