Abstract
Objective
To investigate whether sex affects the trajectory of functional recovery after total
knee arthroplasty (TKA).
Design
Retrospective analysis from a historical database containing data from 3 prospective
clinical trials and a pilot study.
Setting
Clinical laboratory setting.
Participants
Recruitment across studies was restricted to patients who underwent an elective unilateral
TKA for the treatment of osteoarthritis and were between 50 and 85 years of age (N=301).
Interventions
Across all 4 studies, patients received a TKA and physical therapy intervention. Measures
of physical function and strength were assessed before TKA and 1, 3, and 6 months
after TKA.
Main Outcome Measures
Using a repeated-measures maximum likelihood model, statistical inference was made
to estimate the changes in outcomes from before surgery to 1, 3, and 6 months after
TKA that were stratified by sex. Muscle strength was assessed during maximal isometric
quadriceps and hamstrings contractions. Muscle activation was assessed in the quadriceps
muscle. Physical function outcomes included timed Up and Go (TUG) test, stair climbing
test, and 6-minute walk test (6MWT).
Results
Women demonstrated less decline in quadriceps strength than did men at 1, 3, and 6
months after TKA (P<.04), whereas women demonstrated less decline in hamstrings strength 1 month after
TKA (P<.0001). Women demonstrated a greater decline than did men on the TUG test (P=.001), stair climbing test (P=.004), and 6MWT (P=.001) 1 month after TKA. Sex differences in physical function did not persist at
3 and 6 months after TKA.
Conclusions
Sex affected early recovery of muscle and physical function in the first month after
TKA. Women demonstrated better preservation of quadriceps strength but a greater decline
on measures of physical function than did men.
Keywords
List of abbreviations:
6MWT (6-minute walk test), BMI (body mass index), OA (osteoarthritis), SEE (standard error of estimate), SCT (stair climbing test), TKA (total knee arthroplasty), TUG (timed Up and Go)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.Arthritis Rheum. 2008; 58: 26-35
- Sex differences in patients with different stages of knee osteoarthritis.Arch Phys Med Rehabil. 2014; 95: 2376-2381
- Estimating the burden of total knee replacement in the United States.J Bone Joint Surg Am. 2013; 95: 385-392
- Osteoarthritis in women: effects of estrogen, obesity and physical activity.Womens Health (Lond Engl). 2010; 6: 601-615
- Women with knee osteoarthritis have more pain and poorer function than men, but similar physical activity prior to total knee replacement.Biol Sex Differ. 2011; 2: 12
- The effect of patients' sex on physicians' recommendations for total knee arthroplasty.CMAJ. 2008; 178: 681-687
- A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis.Osteoarthritis Cartilage. 2005; 13: 769-781
- Epidemiology of osteoarthritis.Orthopedics. 2005; 28: s201-s205
- The risk of nursing home use in later life.Med Care. 1990; 28: 952-962
- Differentials in active life expectancy in the older population of the United States.J Gerontol B Psychol Sci Soc Sci. 1996; 51: S111-S120
- Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.J Bone Joint Surg Am. 2007; 89: 780-785
- Does total knee replacement restore normal knee function?.Clin Orthop Relat Res. 2005; 431: 157-165
- Predictors of moderate-severe functional limitation 2 and 5 years after revision total knee arthroplasty.J Arthroplasty. 2010; 25 (1091-5, 1095.e1-4)
- Influence of gender on age of treatment with TKA and functional outcome.Clin Orthop Relat Res. 2010; 468: 1759-1764
- The clinical effect of gender on outcome of total knee arthroplasty.J Arthroplasty. 2008; 23: 331-336
- Analysis of the outcome in male and female patients using a unisex total knee replacement system.J Bone Joint Surg Br. 2009; 91: 357-360
- Disease-specific gender differences among total knee arthroplasty candidates.J Bone Joint Surg Am. 2007; 89: 2327-2333
- Effect of gender and preoperative diagnosis on results of revision total knee arthroplasty.Clin Orthop Relat Res. 2008; 466: 2701-2705
- Early quadriceps strength loss after total knee arthroplasty: the contributions of muscle atrophy and failure of voluntary muscle activation.J Bone Joint Surg Am. 2005; 87: 1047-1053
- Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis.J Orthop Res. 2003; 21: 775-779
- Association of muscle strength with maximum walking speed in disabled older women.Am J Phys Med Rehabil. 1998; 77: 299-305
- Strength, power and related functional ability of healthy people aged 65-89 years.Age Ageing. 1994; 23: 371-377
- Muscle weakness and falls in older adults: a systematic review and meta-analysis.J Am Geriatr Soc. 2004; 52: 1121-1129
- The relationship of strength to function in the older adult.J Gerontol A Biol Sci Med Sci. 1995; 50 Spec No: 55-59
- Effects of detraining on knee extensor strength and functional mobility in a group of elderly women.J Orthop Sports Phys Ther. 1997; 26: 340-346
- Quadriceps muscle strength and dynamic stability in elderly persons.Gait Posture. 1999; 10: 10-20
- Quadriceps strength and the time course of functional recovery after total knee arthroplasty.J Orthop Sports Phys Ther. 2005; 35: 424-436
- The impact of gender, age, and preoperative pain severity on pain after TKA.Clin Orthop Relat Res. 2008; 466: 2717-2723
- Restoration of physical function in patients following total knee arthroplasty: an update on rehabilitation practices.Curr Opin Rheumatol. 2012; 24: 208-214
- Relationship between intensity of quadriceps muscle neuromuscular electrical stimulation and strength recovery after total knee arthroplasty.Phys Ther. 2012; 92: 1187-1196
- Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial.Phys Ther. 2012; 92: 210-226
- Minimally invasive total knee arthroplasty improves early knee strength but not functional performance: a randomized controlled trial.J Arthroplasty. 2012; 27: 1812-1819.e2
Bade M, Strussel T, Dennis D, et al. High-intensity versus low-intensity rehabilitation after total knee arthroplasty: a randomized controlled trial. Abstract presented at: American Physical Therapy Association Combined Sections Meeting; 2016 Feb 17–20; Anaheim, CA.
Loyd B, Bade M, Paxton R, et al. Poor quadriceps activation 72 hours after total knee replacement is related to poor functional performance at 1 month. Abstract presented at: American Physical Therapy Association Combined Sections Meeting; 2016 Feb 17–20; Anaheim, CA.
- Quadriceps and hamstrings muscle dysfunction after total knee arthroplasty.Clin Orthop Relat Res. 2010; 468: 2460-2468
- Minimally invasive total knee arthroplasty: surgical implications for recovery.J Knee Surg. 2013; 26: 195-201
- Muscle inactivation: assessment of interpolated twitch technique.J Appl Physiol (1985). 1996; 81: 2267-2273
- Comparison of interpolation and central activation ratios as measures of muscle inactivation.Muscle Nerve. 2001; 24: 925-934
- Early neuromuscular electrical stimulation to optimize quadriceps muscle function following total knee arthroplasty: a case report.J Orthop Sports Phys Ther. 2007; 37: 364-371
- Early high-intensity rehabilitation following total knee arthroplasty improves outcomes.J Orthop Sports Phys Ther. 2011; 41: 932-941
- Relative contributions of muscle activation and muscle size to plantarflexor torque during rehabilitation after immobilization.J Orthop Res. 2006; 24: 1729-1736
- Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty.BMC Musculoskelet Disord. 2005; 6: 3
- Interrater reliability and validity of the stair ascend/descend test in subjects with total knee arthroplasty.Arch Phys Med Rehabil. 2010; 91: 932-938
- The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.J Am Geriatr Soc. 1991; 39: 142-148
- Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty.Arch Phys Med Rehabil. 2002; 83: 70-80
- Verbeke G. Molenberghs G. Linear mixed models in practice: a SAS oriented approach. Springer, New York1997
- Risk factors for delayed inpatient functional recovery after total knee arthroplasty.Biomed Res Int. 2015; 2015: 167643
- The John Insall Award: gender-specific total knee replacement: prospectively collected clinical outcomes.Clin Orthop Relat Res. 2008; 466: 2612-2616
- Sex differences and impact of body mass index on the time course of knee range-of-motion, knee strength, and gait speed after total knee arthroplasty.Arthritis Care Res (Hoboken). 2015; 67: 1397-1405
- A prospective, longitudinal study of outcomes following total knee arthroplasty stratified by gender.J Arthroplasty. 2015; 30: 1372-1377
- A cross-sectional study of muscle strength and mass in 45- to 78-yr-old men and women.J Appl Physiol (1985). 1991; 71: 644-650
- Muscle disuse alters skeletal muscle contractile function at the molecular and cellular levels in older adult humans in a sex-specific manner.J Physiol. 2014; 592: 4555-4573
- Aging, muscle fiber type, and contractile function in sprint-trained athletes.J Appl Physiol (1985). 2006; 101: 906-917
- Reduced rate of knee extensor torque development in older adults with knee osteoarthritis is associated with intrinsic muscle contractile deficits.Exp Gerontol. 2015; 72: 16-21
- Asymmetry in quadriceps rate of force development as a functional outcome measure in TKA.Clin Orthop Relat Res. 2010; 468: 191-198
- Quadriceps rate of force development affects gait and function in people with knee osteoarthritis.Eur J Appl Physiol. 2014; 114: 273-284
- Age-related slowing of myosin actin cross-bridge kinetics is sex specific and predicts decrements in whole skeletal muscle performance in humans.J Appl Physiol (1985). 2013; 115: 1004-1014
- Knee joint biomechanics and neuromuscular control during gait before and after total knee arthroplasty are sex-specific.J Arthroplasty. 2015; 30: 118-125
- Gender differences in patient preferences may underlie differential utilization of elective surgery.Am J Med. 1997; 102: 524-530
- Differences between men and women in the rate of use of hip and knee arthroplasty.N Engl J Med. 2000; 342: 1016-1022
- Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences.Med Care. 2001; 39: 206-216
Comprehensive care for joint replacement payment model for acute care hospitals furnishing lower extremity joint replacement services. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 42 CR Part 510. 2015; 8(226). Available at: https://www.gpo.gov/fdsys/pkg/FR-2015-11-24/pdf/2015-29438.pdf. Accessed February 23, 2016.
Article info
Publication history
Published online: April 07, 2016
Footnotes
Supported in part by the Health Professional Research Preceptorship from the Rheumatology Research Foundation; Florence P. Kendall Doctoral Scholarship and the Promotion of Doctoral Studies I from the Foundation for Physical Therapy; the Fellowship for Geriatric Research from the Academy of Geriatric Physical Therapy; and by the National Institutes of Health (grant nos. R01AG033547 and R01HD065900).
Disclosures: none.
Identification
Copyright
Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
