1. Clinical Problem Solving I: Case Presentation FALL 2016
Jake Hillyard

2. Clinical Details and Patient Intro
Clinical experience at a local Acute Care Hospital spending majority of time on Orthopedic Floor
63 yr. old male
Lives in 2 story home with stairs to 1st floor and 1 handrailing
Progressive Knee Osteoarthritis and Meniscal damage
Elective R Total Knee Replacement
Pertinent PMH: Bronchitis, R Meniscal Repair, Knee Arthroscopy, Hx of DVT
No serious comorbidities

3. History of Injury Patient experienced a fall at work in 2010
Diagnosed with Meniscal tear and microfractures on femoral condyles
Participated in conservative Physical Therapy to manage meniscal tear and progressive knee OA with little reported effect
Underwent meniscal repair with no difference in pain and arthroscopy Dec 2014 and Jan 2016
Pain escalated to a need for surgery

4. Prior Patient Activity Level
Patient lived a HIGHLY active lifestyle for many years
Played semi-professional soccer in ‘70’s
Began cycling in an effort to save his knees
Joined the high mileage cycling crowd and in the 90’s cycled over 7,300 miles in one calendar year. Averages to 20 miles a day.
Patient reported exercising regularly prior to surgery

5. Initial Evaluation post op day 1
ROM: Good AROM throughout with exception of R knee due to dressing thickness and lack of muscle control
R Knee ROM not officially measured with goniometer
Strength: 5/5 MMT throughout but R knee not tested. Patient demonstrated a lack of R knee strength in weight bearing and showed a propensity to buckle when not focused on activity.
Sensation: Decreased in RLE

6. Initial Evaluation post op day 1 cont’d.
Transfers: Independent with exception of sit-to-stand and stand-to-sit which required contact guarding
Gait: 180 ft. with rolling walker and demonstrated step to pattern with rolling walker and exhibited decreased knee flexion during swing
Vital Signs were normal prior to and throughout eval
Motivated and eager to improve
Total Joint Hospital Guidelines: 25 ft.

7. ICF Model Impairments Participation Restrictions Activity Limitations
Pain
Decreased Knee ROM
Decreased Quad control
Decreased knee flexion during swing
Participation Restrictions
Activity Limitations
Unable to teach at technical college
Abnormal gait due to pain
Altered social life with gait distance limitation
Unable to sit for extended periods
Unable to sleep continuously

8. Treatment Plan Gait training – with rolling walker
Stairs training – utilizing 1 handrail only
LE exercises:
Quad Sets (R) x 10
Ankle Pumps (Bil) x15
Heel Slides (R) x 10
Sitting Knee Flex/Ext (R) x 10

9. Treatment Goals At Discharge, patient will be able to:
Ambulate 200 ft. with rolling walker and contact guard
Achieve 90° of knee flexion
Negotiate 5 steps with 1 railing with stand by assist

10. Treatment post op day 2
Gait Training: Ambulated 180 ft. demonstrated step through pattern with rolling walker
Stairs Training: Negotiated 10 steps utilizing 1 hand railing with stand- by assist
LE Exercises:
Patient’s vitals remained normal throughout treatment and showed little to no fatigue
Total Joint Hospital Guidelines: 50 ft.
Quad Sets (R) x 10
Ankle Pumps (Bil) x15
Heel Slides (R) x 10
Sitting Knee Flex/Ext (R) x 10

11. Treatment post op day 3 Never actually took place
Doctor decided to discharge patient early based upon patient’s high gait ability and endurance and ability to negotiate stairs
Goal of measuring 90° not achieved due to discharge

12. Clinical Question
For a 63-year-old male preparing for a TKA, is greater lower extremity strength predictive of better functional outcome measures following a TKA surgery?
Hypothesis: Yes, I predict that greater lower extremity strength will improve functional outcome measures following a TKA surgery.

13. Article #1 Prognostic Factors for Functional Outcome
of Total Knee Replacement: A Prospective Study
Sharma L., Sinacore J., Daugherty C., Keusis D., Stulberg D.,
Lewis M., Baumann G., Chang R.
Published in the Journal of Gerontology: Medical Sciences
1996. Vol. 51A No.4. M152-M157

14. Study Details Prospective Cohort Study (N = 47)
Goal was to determine the relationship between prognostic factors and functional outcomes assessed 3 months after surgery
Prognostic Factors:
Baseline Physical Functioning
Baseline Psychological Functioning
Baseline Social Functioning
Gender
Other Medical and Demographic Variables

15. Data Compilation – 1 month pre, 3 months post
Short Form 36 (0-100)
Physical Functioning
Social Functioning
Psychological Functioning
Self Motivation Inventory (SMI)
Bodily Pain
Mental Health
Role Functioning (emotional)
Cumulative Illness Rating Scale
Quadriceps/Hamstrings Strength
Cybex Isokinetic Dynamometer
Mid-range
Mean of 3 attempts

17. Conclusions/Limitations
Lower Extremity Strength was not seen to be a strong predictor of functional outcome measures. Rather improvements were attributed largely to psychosocial factors.
Study Limitations
Small Sample Size
Use of 1 clinic to make large generalizations
Age of Study (1996)

18. Article #2 Preoperative Quadriceps Strength Predicts Functional
Ability One Year After Total Knee Arthroplasty
Mizner R., Petterson S., Stevens J., Axe M., Snyder-Mackler L.
Published by The Journal of Rheumatology
(8):

19. Study Details Prospective Cohort Study (N = 40)
Goal was to determine the predictive value of preoperative quadriceps strength on functional performance 1 year post surgery
Outcomes Measured
Quadriceps Strength
Knee ROM
TUG and SCT
SF36
KOS-ADLS
Pain (from SF36)

20. Data Compilation – 2 weeks pre, 12 months post
Quadriceps Strength
Timed Up and Go (TUG)
Isometric in electromechanical dynamometer
Stair Climbing Test (SCT)
Hip flexed 90°, knee flexed to 75°
Superimposed E-Stim to ensure max
Force produced normalized by BMI
Short Form 36
Knee ROM
Knee Outcome Survey/Activities of Daily Living Scale (KOS-ADLS)
Flexion and Extension measured with standard goniometer

23. Conclusions/Limitations
Quadriceps strength was determined to be a strong predictor of functional performance on the TUG and SCT, but not on the self- reported functional questionnaires 1 year after TKA.
Study Limitations:
Measurements taken at 1 year only
Small Sample Size
Higher % of men
Pain Assessment not specific to Knee

24. Final Conclusions
Lower extremity strength may have predictive value for patients undergoing a Total Knee Arthroplasty, especially with regards to functional tasks such as climbing stairs and moving throughout the home or community. More research with larger sample sizes and more frequent data collection points is needed to add to the predictive value of lower extremity strength.

25. Back to my patient… Good Prognosis. Limitations: Positives:
No official outcome measures utilized prior to surgery
No official muscle strength measurements prior to surgery
Positives:
Previous activity level
Early discharge
High gait distance/endurance
High relative motivation and drive
Good Prognosis.

26. Questions?