Neuromuscular electrical stimulation after one-stage total knee revision to restore quadriceps strength: a case study
Abstract :
Background and Purpose: Total knee arthroplasty (TKA) is one of the most successful surgeries to prolong mobility and reduce pain associated with osteoarthritis of the knee.1 However for a variety of reasons the patient may outlive their TKA prosthesis requiring a TKA revision.1 It has been shown patients rarely recover their quadriceps strength after TKA, even at the 6 and 13 year mark.2 The weakness seen within the quadriceps post-surgery is more significant than disuse atrophy; there is also neurological component which is referred to as arthrogenic muscle inhibition (AMI). The reduced motor unit output is thought to be due to altered afferent stimulus potentially due to edema, joint laxity and damaged nerves. This quadriceps inhibition has been identified as a key aspect in TKA rehabilitation. 3 Neuro muscular electrical stimulation (NMES) allows the therapist to bypass the cortical inhibition by providing stimulus directly to the muscle to evoke an action potential greater than the patient is capable of generating volitionally.3 Case Description: The patient is a 70-year-old male seen 6 weeks post-operatively for a one- stage TKA revision due to MSSA infection of the original prosthesis. Conservative treatment including debridement, antibiotics and implant retention (DAIR), failed to control the MSSA infection leading to a one-stage revision. The patient presented to an outpatient orthopedic clinic with impaired quadriceps strength (among other deficits) and was treated with a combination of NMES in conjunction with traditional physical therapy targeting strength and ROM deficits. Outcomes: Outcome measures utilized to track quadriceps strength and functional outcomes were the timed up and go (TUG), the lower extremity functional scale (LEFS), and manual muscle testing. The patient improved in all outcome measures beyond the MCID. Discussion: The patient made significant progress toward recovering quadriceps strength, improving his functional mobility, and reducing his fall risk. Neuromuscular electrical stimulation is a potential modality to attenuate quadriceps strength after a TKA revision, however additional research is required to determine the most effective protocols.
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