Consideration of Physiotherapy for the Improvement of Knee Joint Range of Motion after Total Knee Replacement in Patients with Hemopilic Arthropathy

Ⅰ. Introduction

Hemophilia A and B are X-linked coagulation disorders caused by the deficiency of factor VIII (FVIII) and factor IX (FIX), respectively. The degree of clotting factor deficiency influences the phenotype and the severe form of the disease (FVIII/FIX <1 IU dL-1). Spontaneous bleeding episodes occurring in the joints and muscles represent the more common manifestations of these diseases. Over 90% of bleeding episodes in patients with hemophilia (PWHs) occur within the musculoskeletal system, and of these, 80% occur within the joints. This presence of blood within the joints has also been shown to damage the articular cartilages directly. Recurrent bleeding in the joints causes synovial proliferation and neoangiogenesis, increasing the joints’ susceptibility to further bleeding and leading to the development of the so-called “target joints.” Iron from repeated hemarthroses accumulates in the synovium and promotes a cytokine-mediated inflammatory response leading to the progressive destruction of both the cartilage and bone. The final result of these changes is referred to as chronic hemophilic arthropathy, which is characterized by pain, deformity, and severe contractures (Solimeno 2012). The knee is the most common target joint, presenting with subsequent degenerative arthritis. When advanced hemophilic arthropathy has evolved, total knee replacement (TKR) is recommended for pain relief and functional status improvement. The aim of this study was to assess the availability of modalities of physiotherapy after TKR in patients with hemophilic arthropathy.

Ⅱ. Materials and methods

Ⅲ. Results

The average age at the time of TKR was 42 years with an average follow-up of 70 days (range, 6-141 days). Physiotherapy after TKR improved the ROM parameters. The youngest age among the patients was 30 years, and oldest age was 61 years (Table 2).

The post-operative average ROM was 39.4°, which improved to 63.6° at the final outcome after physiotherapy. The minimum post-operative and follow-up ROMs were 20° and 35°, respectively. The ceiling post-operative and follow-up ROMs were 70° and 100°, respectively. The average number of physiotherapy was 43 (range, 3-84) (Table 3).

The statistical post-operative and follow-up ROMs were .169 and .173. Based on the significance probability of the Kolmogorov-Smirnov testa, the post-operative ROM was .160, and the follow-up ROM was .136. Because there were P-values greater than .05, the null hypothesis adopted was the normal distribution (Table 4).

The t-value was -5.703, with the P-value of .000. Based on the null hypothesis, there was no difference between the average ROMs of the two groups. The P-value was less than .05; thus, the null hypothesis was not valuable. This indicates that there was a difference between the post-operative ROM and follow-up ROM. The average of both the post-operative and follow-up ROMs was -24.21053, which indicates that the ROM increased to 24.21° after physiotherapy. The standard deviation was 18.50399; its average was 4.24511. The lowest limit in the 95% confidence interval was -33.12916, and the upper limit was -15.29189 (Table 5).

Ⅳ. Discussion

The results of this study showed that the ROM of the knee joint increased after physiotherapy. The requirement for physiotherapy input following TKR for the stiff knee is paramount. However, the results of TKR in patients with end-stage hemophilic arthropathy cannot be compared with those in patients with osteoarthritis.

There are some differences between hemophilic arthropathy and osteoarthritis. First, quadriceps contracture is more severe in hemophilic arthropathy. Second, it is difficult to differentiate between the pain that originates from bleeding and the surgery itself.

It is beneficial if the physiotherapists have had experiences in managing PWHs so that they are not excessively fearful of causing joint bleeding and can utilize the appropriate amount of force in assisted active ROMs.

This study has some limitations. First, it has a small sample size with a short follow-up duration. A lack of a control group also prevents us from making any comparative analysis. A longer follow-up duration is then required to assess the effect of physiotherapy and whether such good results are maintained over time. Second, we cannot actually treat patients directly yet because we are still students. Thus, we only depended on the data and had little knowledge on the effect of the individual modalities of physiotherapy.

To date, there is no study conducted on the modalities of physiotherapy after TKR in PWHs in Korea.

Ⅴ. Conclusions

Aggressive physical therapy and a high level of patient cooperation are essential for sustained improvement in the ROM gained at surgery. Unfortunately, the fibrous tissues tend to reform rapidly in many severe cases. The patients will have a good ROM initially and then lose such a range gradually over a period of weeks to months, ending up with a very restricted range and fibrous ankyloses in some cases. This occurs despite post-operative CPM and rigorous physical therapy. In patients whose ROMs are slowly gained after knee replacement, knee manipulation under general anesthesia may help. Forces must be balanced around the knee to avoid factures of the distal femur or proximal tibia as many of these patients have osteopenia. Manipulation is best performed within 3 weeks of surgery before adhesions become too strong.

Managing PWHs represents a challenge for physiotherapists because in comparison with the general population, they require different physiotherapeutic techniques and need dedicated post-operative care. Hence, the contribution of skilled physiotherapists is crucial in achieving good outcomes.

Acknowledgments

We would like to thank Se Jin Kwon and Jong Seon Kim, who are physiotherapists working for PWHs at the KHF Clinic in Seoul.

Se Jin Kwon has been working at the Physical Therapy Department of the KHF Clinic in Seoul since 1992. He has had an extensive experience on the treatment of PWHs with TKR.

References

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