Efficacy Of Dynamic Splinting Health And Social Care Essay

The procedure has proven to both reliable and durable. A successful total knee replacement allows patient to resume almost all activities of daily living with minimal difficulty. In most cases patients no longer require external aids or chronic medications. Finally total knee replacement helps patients to maintain their overall self esteem.

Total knee replacement is indicated when there is unremitting severe pain in the knee with or without deformity. The pain/ deformity may be due to osteoarthritis, Rheumatoid arthritis and various non specific arthritis. It relieves pain, provides mobility and correct deformity.

Total knee replacement is a surgical procedure in which injured or damaged parts of the knee joint are replaced with artificial parts. The procedure is performed by seperating the muscles and ligaments around the knee to expose the knee capsule. The knee capsule is opened, exposed the inside of the joint. The end of the femur and tibial are removed. The artificial parts are cemented into place. The knee will consist of metal shell at the end of the femur, a metal and plastic trough on the tibia and if needed a plastic button in the cap. In a way this could be more appropriately called a Knee resurfacing operation.

The common pathology for total knee replacement is knee flexion contracture.

DEFINITION:

Flexion contracture is defined as the shortening of the connective tissue thereby stiffening the joint. It is due to tightening of the posterior capsule combined with the tightening of biceps femoris and collateral ligaments.

Hence rehabilitation program should be undertaken soon after TKA to maintain joint range of motion.

In particular this study examined the value of dynamic splinting in increasing range of motion and reducing the flexion contracture. Dynamic splinting utilizes the biomechanical adaptation of keeping the joint at end-range to achieve a physiological change of molecular realignment to elongate the connective tissue. This protocol of low-load, prolonged-duration stretch with dynamic tension continually reduces the contracture.

ANATOMY OF KNEE JOINT:

The knee joint is the largest and most complex joint in the body. It is synovial modified hinge joint. It is formed by fusion and medial tibio- femoral and patella- femoral joint.

ARTICULAR SURFACES:

It is comprised the

Femoral condyles: distal end of femur

Tibial condyles : proximal end of tibia.

Patellar facetes : posterior surface of patella.

Femoral condyles:

The articular surfaces of femur are pulley shaped. The femoral condyles are convex in both planes. They are extended interiorly by the pulley shaped patellar surfaces. The neck of the pulley is represented anteriorly by the central groove on the patellar surface and posteriorly by the intercondylar notch.

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Tibial condyle:

The tibial surfaces are reciprocally curved and comprises two curved and concave parallel gutters which are separated by a blunt eminence running antero- posteriorly eminence lodges the two intercondylar tubercles.

Tibio-femoral joints:

The tibial condyles correspond to the femoral condyles while the inter condylar tibial tubercles come to within the femoral intercondylar notch, these surfaces constitute functionally the tibio-femoral joint.

Femero-patellar joints:

The facets of patella correspond to the patellar surface of the femur while the vertical ridge of the patella fits into the central groove of the femur.

LIGAMENTS OF KNEE JOINT:

Medial collateral ligament:

It is flattened band rhomboidal in outine. It is attached above to the medial epicondyle of femur, below to the medial margin and the adjoining medial surface of tibia.

Function:

restrain valgus rotation

Lateral collateral ligament:

Function:

restrain varus rotation and resist internal rotation

kneeanat

Anterior cruciate ligament:

It is attached below to the anterior part of the intercondylar area of tibia between the anterior ends of lateral and medial semilunar cartilages. Above it is attached to the posterior part of the medial surface of lateral femoral condyle.

Function:

To resist anterior displacement of the tibia on the femur when the knee is flexed

To resist varus or valgus rotation of the tibia, especially in the absence of the collateral ligaments

Resists internal rotation of the tibia.

Posterior cruciate ligament:

It is attached below to the posterior part of intercondylar area of tibia, posterior to the attachment of posterior end of medial semilunar cartilage. Above it is attached to the anterior part of lateral surface of the medial condyle of femur.

Function:

To allow femoral rollback in flexion

Resist posterior translation of the tibia relative to the femur

Controls external rotation of the tibia with increasing knee flexion.

Retention of the PCL in total knee replacement has been shown biomechanically to provide normal kinematic rollback of the femur on the tibia. This also is important for improving the lever arm of the quadriceps mechanism with flexion of the knee.

MUSCLES OF KNEE JOINT:

Quadriceps femoris

Popliteus

Semitendinosus

Semimembranous

Sartorius

Biceps femoris

Gastrocnemius

Plantaris

BURSAE AROUND THE KNEE JOINT:

Anteriorly:

The suprapatellar bursa

The prepatellar bursa

Superficial intrapatellar bursa

Deep infrapatellar bursa

Laterally:

A bursa between lateral collateral ligament and biceps tendon

A bursa between lateral collateral ligament and popliteus tendon

Popliteus bursa lies between the popliteus and lateral condyle of femur.

Medially:

The tibial inter tendinous bursa( pes anserine bursa)

A bursa between medial collateral ligament and semimembranous tendon

A bursa between semimembranous tendon and tibia.

Posteriorly:

A bursa between lateral head of gastrocnemius and capsule.

Semimembranous bursa(brodies bursa)

NERVE SUPPLY:

Femoral nerve

Sciatic nerve

Obturator nerve

BLOOD SUPPLY:

The arterial supply to knee joint, is from the branches of

Popliteal artery

Femoral artery

Tibial artery

TIBIO-FEMORAL ARTHROKINEMATICS:

Viewed in the sagittal plane, the femur’s articulating surface is convex while the tibia’s in concave. We can predict arthrokinematics based on the rules of concavity and convexity:

During Knee Extension

During Knee Flexion

Open Chain

Closed Chain

Open Chain

Closed Chain

Tibia Glides Anteriorly On Femur

Femur Glides Posteriorly On Tibia

Tibia Glides Posteriorly On Femur

Femur Glides Anteriorly On Tibia

from 20o knee flexion to full extension

from full knee extension to 20o flexion

Tibia rotates externally

Femur rotates internally on stable tibia

Tibia rotates internally

Femur rotates externally on stable tibia

THE “SCREW-HOME” MECHANISM:

Rotation between the tibia and femur occurs automatically between full extension (0o) and 20o of knee flexion. These figures illustrate the top of the right tibial plateau as we look down on it during knee motion.

top of tibial plateau

During Knee Extension, the tibia glides anteriorly on the femur.

During the last 20 degrees of knee extension, anterior tibial glide persists on the tibia’s medial condyle because its articular surface is longer in that dimension than the lateral condyle’s.

Prolonged anterior glide on the medial side produces external tibial rotation, the “screw-home” mechanism.

THE SCREW-HOME MECHANISM REVERSES DURING KNEE FLEXION

top of tibial plateau

When the knee begins to flex from a position of full extension, posterior tibial glide begins first on the longer medial condyle.

Between 0 deg. extension and 20 deg. of flexion, posterior glide on the medial side produces relative tibial internal rotation, a reversal of the screw-home mechanism.

TOTAL KNEE REPLACEMENT

Total knee replacement is indicated when there is unremitting severe pain in the knee with or without deformity. The pain/ deformity may e due to osteoarthritis, Rheumatoid arthritis and various non specific arthritis. It relieves pain, provides mobility and correct deformity.

E:New FolderNAGU PROJECTimAGESTotal-Knee-Replacement.jpg

The total knee replacement can be:

Unicompartmental arthroplasty: The Articular surface of femur and tibia, either the medial or lateral compartment of the knee are replaced by an implant. Eg: osteoathritis.

Bicomprtmental arthroplasty: In bicompartmental arthroplasty, the articular surface of tibia and femur of both medial and lateral compartments of the knee joints are replaced by an implant. The third compartment i.e.., the patellofemoral joint is however left intact.

Tricomprtmental arthroplasty: the articular surface of the lower femur, upper tibia and patella are replaced by prosthesis. Most commonly performed arthroplsty.

The prosthesis consists of a tibial component, a metal femoral component and a high molecular weight polyethylene button for articular surface of the patella.

TKA GOALS

Restore mechanical alignment [neutral tibiofemoral alignment =

4°-6° of anatomic valgus],

Horizontal joint line,

Soft tissue balance (ligament),

(Patella tracking (Q-angle)

INDICATION

Oteoarthritis

Rheumatoid arthritis

Hemophilic arthritis

Traumatic arthritis

Sero negative arthrides

Crystal deposition disease

Pigmented villonoular synovitis

Avascular necrosis

Bone dysplasias

Asymmetric arthrits

CONTRA INDICATION

Absolute contraindications

Recent or curren joint infection

Sepsis or systematic infection

Neuropathic arthropathy

Painful solid knee fusion

Relative contraindications

Severe osteoporosis

Debilated poor health

Non functioning extensor mechanism

Painless, well functioning arthrodesis

Significant peripheral vascular diseases

TKA Complications

Death: 0.53%

Periprosthetic Infection: 0.71%

Pulmonary emboli: 0.41%

Patella fracture:

Component Loosening:

Tibial tray wear:

Peroneal Nerve Palsy: 0.3% to 2%

Periprosthetic Femur Fracture:

Periprosthetic Tibial Fracture:

Wound Complications / Skin slough: rare

Patellar Clunk Syndrome: rare

Patellofemoral Instability: 0.5%-29%

DVT:

Instability:

Popliteal artery injury: 0.05%

Quadriceps Tendon Rupture: 0.1%

Patellar Tendon Rupture: <2%

Stiffness:

Fat Embolism

MCL rupture

NEED AND SIGNIFICANCE OF STUDY:

Need of the study:

To reduce flexion contracture

To improve range of motion

To improve functional activity

Significance of the study:

This study is to evaluate the efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty.

Statement of the problem:

To study the efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty.

Hence the study is entitled as “efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty”.

Objectives:

To reduce flexion contracture

To improve range of motion

To analyze the effect of dynamic knee splint

Null hypothesis:

The null hypothesis can be stated as follows there is no significant difference in knee flexion contracture after the application of dynamic knee splint.

Alternate hypothesis:

The hypothesis can be stated as follows there is significant difference in knee flexion contracture after the application of dynamic knee splint.

2. REVIEW OF LITERATURE:

1. TOTAL KNEE ARTHROPLASTY:

Simon H Palmer, MD, Consultant Surgeon: Sep 21, 2010 Osteoarthritis destruction of the knee is the most common reason for total knee replacement.

Jayant joshi, prakash kotwal says that total knee replacement relieves pain, provides mobility & corrects deformity.

2. FLEXION CONTRACTURE:

J. Ilyas; A.H. Deakin; C. Brege; and F. Picard Flexion contracture is a common deformity encountered in patients requiring total knee arthroplasty (TKA).

Department of orthopaedics, golden jubilee national hospital, clydebank, glasgow, g81 4hx, uk. One hundred and four continuous TKA were completed by a single consultant using the OrthoPilot (BBraun, Aesculap) navigation system and Columbus implants. Seventy-four knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension.

Ouellet D, Moffet H. Arthritis Rheum October 2002 Large movement deficits are present, especially in single-limb support pre-op and 2 months following TKA.

Huei-Ming Chai, PHD. November 24, 2008 total knee arthroplasty limits range of motion

3. DYNAMIC SPLINT:

Dennis l armstrong, m.d. Buck willis, phd evaluates the efficacy of dynamic knee extension splinting for knee flexion contracture following TKA.

Finger E, Willis FB Health Physical Education, Recreation, Texas State University, Cases Journal 2008, Physical therapy alone did not fully reduce the contracture and dynamic splinting was then prescribed for daily low-load, prolonged-duration stretch.

Finger E, Willis B 29Dec2008: Dynasplint offers extension Systems to aid in rehabilitation and recovery from flexion contracture.

Clinical studies have demonstrated greatest average reduction in rehabilitation time and cost with the use of Dynasplint Systems in conjunction with physical therapy.

Willis FB Biomechanics.2008 Jan; 15 After surgery, a patient is often left with shortened connective tissue and may have a difficult time walking normally again. Wearing a dynamic knee splint will lengthen and remodel the tissue to restore range of motion.

McClure P, Blackburn L, Dusold C Ideally, wearing your Dynasplint for 6-8 continuous hours yields the best results as it allows a safe, long lasting remodeling of the soft tissue.

Cliffordr.Wheeless, Iii, Md.December3, 2008. The purpose of this report is to review the use of external fixator for the gradual correction of severe knee flexion contractures that limit patient function.

James f. Mooney iii, md, l. Andrew koman Posted: 05/01/2001 Average preoperative flexion contracture was 80.5°. Each patient achieved full extension. There was one recurrence, despite bracing, which was managed with replacement of the fixator and soft tissue procedures

4. CONVENTIONAL PHYSICAL THERAPY FOR KNEE ARTHRITIS:

Jan.K.Richardson, Pt, Phd, Ocs Said that arthritis is a degenerative disease of the cartilage and bones that results in pain and stiffness in affected joint. There is no cure for arthritis, but physical therapy can make living easier and less painful.

Brigham And Women’s Hospital Department of Rehabilitation Services Physical Therapy .ROM along with proper soft tissue balance is required to ensure proper biomechanics in the knee joint. Aggressive post-operative PT has been shown to be effective in improving patient outcomes and shortening length of stay

Balint G And Sz Ebenyl.B Showed that therapeutic exercises decreases pain, increases muscle fatigue and range of motion as well as improve endurance and aerobic capacity. Weight reduction is proven in obese patients with OA of knee. Therapeutic heat and cold, electrotherapy, acupuncture are widely used.

Dr. Margriet van baar reported that significant beneficial effects from exercise therapy including improvements in self reported pain, disability, walking ability and overall sense of well being.

Dorr LD. J Arthroplasty June 2002 CPM helps achieve knee range of motion quicker in first post-op weeks but at final follow-ups, no difference in final range of motion

Byrne, et al. Clin Biomech October 2002 Deficits in knee strength balanced by increased hip extensor work; rehab should optimize bilateral hip and knee function after TKA

McManus et al 2006, Jorge et al 2006 the higher frequencies (90-130Hz) to stimulate the pain gate mechanisms & thereby mask the pain symptoms.

Ozcan et al, 2004 Low frequency nerve stimulation is physiologically effective (as with TENS and NMES) and this is the key to IFT intervention.

Adedoyin, R. A., et al. (2002).IFT acts primarily on the excitable (nerve) tissues, the strongest effects are likely to be those which are a direct result of such stimulation (i.e. pain relief and muscle stimulation).

National Taiwan University Hospital, November 2008 PNF stretching techniques has been used frequently for patients with total knee arthroplasty in clinical practice to increase range of motion effectively and reduced knee pain during exercise.

Huei-Ming Chai, PHD November 24, 2008 PNF stretching technique is a therapeutic technique using the PNF concept to the related muslces either to increase neuro-inhibition mechanism for releasing muscle spasm and elongating muscle length, or to increase neuro-excitation mechanism for enhancing muscle strength

Harold B. James H. Beaty, MD Range-of-motion exercises, muscle strengthening, gait training, and instruction in performing activities of daily living are important.

5. GONIOMETRIC MEASURENT FOR ROM:

Carlos Lavernia, MD, Range of motion assessment through direct observation without a goniometer provides inaccurate findings.

Mark D. Rossi, PhD, PT, CSCS The Journal of Arthroplasty Vol. 23 No. 6 Suppl. 1 2008 Measured scores using a goniometer provided an improved degree of accuracy, but results appear to be dependent on the clinician performing the measurement.

Richard l. Gajdosik Associate Professor Physical therapists may accept most knee goniometric measurements as clinically valid, and the evidence indicates that most of these measurements are reliable.

6. KNEE SOCIETY SCORE:

Gil Scuderi, MD-Chair; Jim Benjamin, MD; Jess Lonner, MD; Bob Bourne, MD and Norm Scott, MD, 2007,The Knee Society rating system (KSS) was first published in CORR in 1989 and has become the standard clinical evaluation system for reporting results for patients undergoing Total Knee Replacement.

John N. Insall, MD, Lawrence D. Dorr, Scott, MD Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989 Nov:The Knee Society has proposed this new rating system to be simple but more exacting and more objective.

MD, Richard D. Scott, MD, and W. Norman It is hoped the knee society rating system will become universally accepted and will be adopted by all authors, even if they wish to report results using a customary scoring method as well.

3. MATERIALS AND METHODOLOGY:

MATERIALS:

Evaluation tool:

Goniometry

Knee society score

Outcome measure:

Range of motion

Knee score

Function score

Material used:

Dynamic knee splint

METHODOLOGY:

(A) Study design:

30 subjects with flexion contracture following unilateral TKA assigned in two groups.

GROUP A:

15 subjects: Dynamic Splint Along With Conventional Physiotherapy.

GROUP B:

15 subjects: Conventional Physiotherapy.

(B) Study setting:

This study was carried out in the department of physical medicine and rehabilitation, Sri Ramakrishna hospital, Coimbatore.

(C) Study duration:

This study was carried out for a period of 6 months.

(D) Sampling:

Random sampling.

INCLUSION CRITERIA:

Age: 45 to 70 years.

Both sex

Flexion contracture : 20 – 12 deg (post operatively)

Unilateral TKA

Reduced flexibility in AROM of knee extension

Pain that is worsened by bending over while legs are straight

Impaired gait pattern

Ability to understand informed consent and experiment responsibilities

EXCLUSION CRITERIA:

Fractures

Bilateral TKA

TKA < 2 months

Knee sepsis

Osteomyelitis or any orthopedic infection

Extensor mechanism dysfunction

Psoriasis

Knee joint neuropathy

Previous Stroke or Brain Injury

STATISTICS TOOL:

The data collected was analyzed using independent t-test. The test was carried out between two groups. Independent’t’ test was used to compare the effectiveness of treatment between the groups.

t =

S =

X1 = Difference between pretest and posttest values of Group I

X2 = Difference between pretest and posttest values of Group II

= Mean difference of Group I

= Mean difference of Group II

n1 = No. of samples in Group I

n2 = No. of samples in Group II

S = Combined standard deviation

TREATMENT:

Dynamic knee Extension splint:

The Rebound Effect

http://www.dynasplint.com/uploads/user-uploads/rebound2.gif

53% Average Reduction in Time and Cost Associated with ROM Rehabilitation

“High-force, short-duration stretching favors recoverable, elastic tissue deformation, whereas low-force, long-duration stretching enhances permanent plastic deformation. In the clinical setting, high force application has a greater risk of causing pain and possibly ruptures of tissue. Dynasplint Systems improve range of motion by creating permanent, non-traumatic tissue elongation and remodeling, thus virtually eliminating the range of motion rebound effect often observed in the clinical setting.

RangerKnee2

Features & Benefits

LLPS (Low-Load, Prolonged-Duration Stretch) technology has been proven to successfully treat joint stiffness and limited range of motion.

Early application can reduce time and cost associated with range of motion rehabilitation

Simple, adjustable and reproducible bilateral tensioning System

Available for rent or purchase

Biomechanically correct

Comfortable to wear

Each Dynasplint System is recycled to reduce waste and help the environment

A Dynasplint Systems consultant will fit your patients and oversee their treatment to ensure the best possible results

Over a quarter of a million patients have been successfully treated with Dynasplint Systems

Conveniently labeled and easy to use

Patient Wearing Protocol

Please review the tension your Dynasplint consultant set for you initially.

In the beginning, the splint should be worn for 2-4 hours.

Do not increase the tension until you can tolerate overnight wear. Time is the most important factor and your first goal should be 6-8 hours of pain free wear.

After achieving this time goal, when you take the splint off if you have less than 1 hour of post-wear stiffness, turn tension up by one on both sides.

However if you are unable to wear the splint for a prolonged period of time, decrease the tension by a half to one full turn.

During the process of regaining your range of motion, if you have any question or concerns contact your Dynasplint consultant.

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CONVENTIONAL TREATMENT:

MODALITIES FOR PAIN CONTROL, EDEMA REDUCTION:

Moist Heat

Functional electrical stimulation

Transcutaneous electrical stimulation

Ice therapy

Interferential therapy

Galvanic Stimulation

JOINT MOBILIZATION:

Flexion restriction

Position: patient seated

Posterior glide of tibia on femur-grade 3 Oscillation with 30 second hold, Repeated 5 times with patellar mobilization of inferior glides (5 mins)

Extension restriction

Position: patient prone with patella off of table

Anterior glide of tibia on femur- grade 3 oscillation and static hold (10 secs in 3 repetitions) with patellar mobilization superior glides (5 mins)

EXERCISE PROGRAM:

Closed and open kinetic chain strengthening exercises

Proprioceptive/balance exercises targeting the trunk and lower extremity musculature

Partial body weighted squats

Gait training

Range of motion exercises

Heel slide (supine& sitting)

Stretching (prone/supine) to increase knee extension ROM

GAIT TRAINING:

Forward Walking

Sidestepping

Backward or Retro-Walking

FUNCTIONAL TRAINING:

Standing

Transfer Activities

Lifting

Carrying

Pushing or Pulling

Squatting or Crouching

Return-to-Work Tasks

ENDURANCE TRAINING:

Upper body exercise.

Ambulation activities

One-leg cycling, using non-operative leg with resistance to motion.

BALANCE/PROPRIOCEPTION TRAINING:

Tandem Walking

Lateral Stepping over/around objects

Weight-Shifting Activities

Closed Kinetic Chain Activities

5. DATA ANALYSIS AND INTERPRETATION:

KNEE EXTENSION ROM: GROUP I

Pre test

(Two months after TKA)

Post test

(conventional PT with SPLINT)

Difference

X1

Mean=12.93

PRE TEST AND POST KNEE EXTENSION ROM: GROUP I

KNEE EXTENSION ROM: GROUP II

Pre test

(Two months after TKA)

Post test

(conventional PT without splint)

Difference

X2

Mean=11.46

t=2.82

s.dev=1.42

degrees of freedom = 28

The probability of this result, assuming the null hypothesis, is 0.009

PRE TEST AND POST KNEE EXTENSION ROM: GROUP II

KNEE SCORE AND FUNCTION SCORE:

S.No.

Parameters

Groups

Mean

S.D.Value

‘t’ Value

Knee Scores

Group A

4.47

3.06

Group B

Function Score

Group A

35.6

4.98

3.01

Group B

30.1

MEAN DIFFERENCE BETWEEN

KNEE SCORE AND FUNCTION SCORE

DEMOGRAPHIC DATA

THE AGE OF THE SAMPLES BETWEEN 45 -70 YEARS IN EACH GROUP

Age (years)

No. of Samples

Total

Group A

Group B

45-50

50-55

55-60

60-65

65-70

TOTAL NUMBER OF MALES AND FEMALES IN EACH GROUP

Sex

No. of Samples

Total

Group A

Group B

Male

Females

TOTAL NUMBER OF RIGHT AND LEFT SIDE INVOLVEMENT IN EACH GROUP

Side of involvement

No. of Samples

Total

Group A

Group B

Right

Left

5. DISCUSSION

Total knee arthroplasty (TKA) is considered the treatment of choice for patients with intractable pain and substantial functional disabilities who have not had acceptable relief and functional improvement after conservative treatment. Knee flexion contracture is a common pathology following TKA affecting up to 61% of these patients.

The purpose of the study is to determine the effectiveness of dynamic splinting in treating patients with flexion contracture following Unilateral TKA.

Literature review states that there is significant difference between dynamic splinting and conventional physiotherapy management in reducing flexion contracture following Unilateral TKA.

A total of thirty patients with unilateral TKA were selected under inclusive criteria and were randomly allocated into an experimental group and control group as Group A and group B respectively. In each group 15 Individuals were allotted

In Group A, dynamic splint along with conventional physiotherapy was given and in Group B, Conventional physiotherapy alone was given. Both Groups were treated for a period of 6 months and the pre test and post test values are taken on the 1st (2 months after TKA) and at the end of sixth months. In between Follow up assessments were done at regular interval of every two weeks to judge the prognosis.

Statistical analysis performed between the Group A and Group B and the results showed the following outcome.

The range of motion and functional improvement among the patients following the intervention was evaluated by Goniometry and knee society score respectively.

Parameter

Groups

Mean

“t” Value

“P” Value

Range of motion

12.9

2.82

0.009

11.5

Knee score

3.06

0.005

Function score

35.6

3.01

0.005

30.1

With goniometric measurement the range of motion showed a significant improvement of about12.9 and 11.5 for Group A and Group B respectively. “t” value for the independent T test calculated between the Group is 2.82 which is significant at the level of 0.009 level at 28 degrees of freedom.

With knee society score measurement the knee score showed a significant improvement of about18 and 13 for Group A and Group B respectively. “t” value for the independent T test calculated between the Group is 3.06 which is significant at the level of 0.005 level at 28 degrees of freedom.

With knee society score measurement the function score showed a significant improvement of about35.6 and 30.1 for Group A and Group B respectively. “t” value for the independent T test calculated between the Group is 3.01 which is significant at the level of 0.005 level at 28 degrees of freedom.

6. CONCLUSION

From statistical analysis it is clear that there was a mean reduction in flexion contracture of about 12.9 of Group A when compared to 11.5 with that of Group B. The calculated’t’ value was 2.82 which is greater than the table value at 28 degrees of freedom

With knee society score it was evident that the Group A (knee score and function score) showed a significant mean improvement of about 18 and 35.6 when compared to 13 and 30.1 with Group B (knee score and function score) respectively. The calculated’t’ value was 3.06 which is greater than the table value at 28 degrees of freedom.

Hence it is cleared that dynamic splinting reduces flexion contracture from 20-12deg (two month after TKA) to 5-0 deg (after the application of dynamic splint)

So the statistical analysis infers us to reject null hypothesis and there by accepting the alternative hypothesis i.e. there is significant difference in knee flexion contracture after the application of dynamic knee splint.

Hence it is suggested that providing a dynamic splint is effective in reducing flexion contracture and improving functional status in treatment of knee flexion contracture following unilateral TKA.

LIMITATION OF STUDY

Sample size is smaller.

It is a time bound study.

The study was carried on with few objective parameters in recording the efficacy of treatment.

The study concentrated only on unilateral TKA

SUGGESTIONS

The study could have been done with long term follow up and more number of patients, to analyze the outcome.

The study could have employed some more parameters to evaluate the clinical outcome more accurately and precisely

Further studies can be done, to analyze the effects of dynamic splint in bilateral TKA.

Further studies can be done, to compare the effects of dynamic splint in unilateral and bilateral TKA.

BIBLIOGRAPHY

1. David J. Magee, Orthopedic Physical Assessment, Second edition, W.B. Saunders company London 1992.

2. Kothari C.R ; Research methodology methods and techniques, wiswaprakasan.

3. Robert Dontelli ; orthopaedic P.T

4. Bent And Brotzmen ; Orthopaedic Rehabilitation.

5. Carolyn Kisner & Lynn Allen Colby; Therapeutic Exercises Foundation & Techniques , New Delhi, Jaypee Brothers 1996 , Third edition.

6. Carrie M.Hall, Therapeutic Exercise moving towards function, Walters kluwer company.

7. Jayant Joshi, Essentials of orthopedics & applied physiotherapy , New Delhi B.I. Churchill Livingstone pvt Ltd 1993.

8. T.S. Ranganathan, A Text book of Human Anatomy, New Delhi, S Chand & company , 1990 Fourth Edition

9. B.D Chaurasia, Human Anatomy Third edition, CBS Publishers New Delhi.

10. Carolyn M. Hicks & Research for Physiotherapist, Project design analysis, Second addition, Churchill living stone, New York, Tokyo.

11. Cynthia C. Norkin Pamela K. Levangies joint structure & Function, Third edition.

12. Grays anatomy: ed 13, 1899

13. J.Maheshwari, MS ortho: essestial orthopaedics.

14. Jagmohan singh: text book of electrotherapy 3rd edition 2005

15. Ann Thomson et al: tidy’s physiotherapy, London, butterworth, heinman, 191 12th edition

16. Patricia A. Downie, cash textbook of orthopaedics & Rheumatology for physiotherapist, jaypee brothers, 1993: 1st edition.

17. Mayilvahanan Natarajan: text book of orthopaedics & tramatology 4th edition.

18. Susan B.O.sullaivan, physical rehabilitation assessment & treatment, 4th edition jaypee brothers, new delhi 2001

19. Joan M. Walker, Antonie helewa, physical therapy in arthritis, A division of hartcourt brace & company.

APPENDICIES

APPENDIX: 1

Basic evaluation chart

POST OPERATIVE ASSESSMENT FOR TOTAL KNEE REPLACEMENT

Subjective Assessment

Name :

Age :

Sex : M/F

Occupation :

Address :

Date of Admission :

Referred by :

Date of surgery :

Side operated : Right / Left

Height ;

Weight :

IP/OP number :

Chief complaints :

Vital signs

Temperature (Beat/Min)

Pulse rate (F)

Respiratory Rate (mm/Hg) :

Blood Pressure (Breaths/min)

Pain assessment

Side of pain

Site of pain

Type of pain

Nature of pain

Duration of pain

Intensity

Aggravating factors

Reliving factors

Grading of pain by visual / analogue scale

No pain

Slight pain

Moderate pain

Severe pain

Medical History

i) Past Medical History – Any previous disease or injury

ii) Present Medical History

Onset

Duration

Intensity

Aggravating factors

Activities of daily living

iii) Personal History – Smoker or alcohol

iv) History of job

v) Surgical history

Name of surgeon

On Palpation

Inflammatory signs : Warmth and Tenderness

Crepitation

Muscles spasm

Oedema : Pitting / Non Pitting

On Examination

Musculo skeletal

Joint ROM

Joint

Movement

Active

Passive

Pain free

Pain full

Pain free

Pain full

Hip

Flexion

Extension

Abduction

Adduction

External rotation

Internal rotation

Knee

Flexion

Extension

Medical rotation

Lateral rotation

Ankle

Dorsiflexion

Plantarflexion

Inversion

Eversion

Muscle power

Muscle wasting – quadriceps

Deep tendon Reflexes

Deformites

Limb length measurements

Gait Assessment

Type of gait

Step length

Stride length

Base width

Cadance

External appliances (Splints or orthosis)

Type of walking aids

Respiratory Assessment

Type of respiration (Thoraco Abdomen, Abdomino – thoracic)

Pattern of respiration (Asymmetry or Symmetry)

Depth of respiration (shallow or deep)

Accessory muscles of respiration

Chest expansion

â€¢ Axilla

â€¢ Nipple

â€¢ Xiphisternum

Functional Assessment

Problem list

Management

Short term management

Aims

Long-term management

Short term managem

Means

Long-term management

APPENDIX 2:

DYNASPLINT SYSTEM, RANGE OF MOTION AND COMMON DIAGNOSES

FOR ORTHOPAEDICAL CONDITIONS:

1. Knee extension dynasplint system (ked)

ROM=65° flexion to 25° hyperextension

2. Knee flexion dynasplint system (kfd):

ROM=50° flexion to 140° flexion

COMMON DIAGNOSES: (extension & flexion)

Total knee replacements, Tibial plateau fractures, Tendon and ligament repairs (ACL, PCL), Open reduction internal fixation (ORIF), Burns, Meniscectomy, Tendon releases

FOR NEUROLOGICAL CONDITIONS:

1. Knee extension neurological dynasplint system (ken):

ROM=130° flexion to 40° flexion

2. Double-jointed knee extension dynasplint system (ked-dj):

ROM=130° flexion to 50° hyperextension

COMMON DIAGNOSES:

Head trauma and spinal cord injuries, Cerebral palsy (CP), cerebral vascular accident (CVA), and other neurological conditions.

FOR AMPUTEE:

1. Knee amputee extension dynasplint system (bka-ed):

ROM=65° flexion to 25° hyperextension

COMMON DIAGNOSES:

Distal limb removal

APPENDIX: 3:

GONIOMETRY OF THE KNEE

Motion

Recommended Testing Position

Stabilization

Center

Proximal Arm

Distal Arm

Start

End

Flexion

Supine, knee in ext. Initially hip in 00 ext, abd, add, but as knee flexes, hip also flexes

Stabilize femur to prevent rotation, abduction & adduction

Over lateral epicondyle of femur

Lateral midline of femur, referencing greater trochanter

Lateral midline of fibula, reference lateral malleolus & fibular head

http://at.uwa.edu/gon/KnExt.jpg

http://at.uwa.edu/gon/KnFlex.jpg

Extension

Supine, knee in ext. Hip in 00 ext, abd, add.

Stabilize femur to prevent rotation, abduction & adduction

Over lateral epicondyle of femur

Lateral midline of femur, referencing greater trochanter

Lateral midline of fibula, reference lateral malleolus & fibular head

http://at.uwa.edu/gon/KnExt.jpg

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