CLINICAL FEATURE KEYWORDS Total knee replacement / Compression bandaging / Enhanced recovery Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication August 2013.
Compression bandaging improves mobility following total knee replacement in an enhanced recovery setting by A Cheung, H Lykostratis and I Holloway Correspondence address: Ian Holloway, Department of Orthopaedic Surgery, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ. Email: [email protected]
The early functional outcome was assessed in 180 patients undergoing total knee replacement (TKR) using compression bandaging versus standard crepe bandaging. Patients with a compression bandage following TKR were significantly more likely to be discharged with a walking stick (p=0.002) and less likely to be discharged with a rollator frame (p=0.001). These patients demonstrated an improved range of knee flexion and ability to straight leg raise at discharge. Introduction Total knee replacement (TKR) for end stage osteoarthritis is one of the most common orthopaedic operations performed in the UK. According to the National Joint Registry (2012) 84,653 knee replacement procedures were performed in England and Wales in 2011. The aim of an enhanced recovery program following TKR (Malviya et al 2011) is to improve patient outcomes and speed recovery after surgery (NHS Institute for Innovation and Improvement 2008). A multidisciplinary team is involved perioperatively to optimise medical comorbidities, educate patients and organise discharge planning. Postoperatively, physiotherapy and a standardised pain management protocol are initiated immediately (Isaac et al 2005). Following TKR, the knee is typically swollen as a result of bleeding within the joint and soft tissue inflammation, which can increase pain, reduce mobility and delay subsequent discharge (Charambilides et al 2005). Various measures can be taken to reduce swelling including bandaging and cryotherapy (icepack). There has been little evidence previously to suggest that these measures are effective (Adie et al 2012) although one study has suggested that compression bandaging improves pain relief following TKR (Andersen et al 2008).
84
There are several potential advantages in reducing swelling and improving mobility following TKR. The primary benefit is to improve the patient experience by decreasing postoperative pain. Secondary benefits are to ensure a speedy yet safe recovery from hospital and to reduce the length and cost of hospital stay. Compression bandaging following TKR represents a simple, inexpensive intervention which may improve patient care.
Aim The aim of this study is to compare the effect of compression bandaging versus standard crepe bandaging upon perioperative function following TKR.
Methods The study was performed at an elective orthopaedic unit in the UK. The study population consisted of patients undergoing unilateral cemented total knee replacement for end stage osteoarthritis between July 2010 and November 2011. All patients were enrolled in an enhanced recovery program. All patients were operated on by one of six consultant orthopaedic surgeons, using standard surgical techniques and local infiltration anaesthesia. Following wound closure either a compression bandage, consisting of a
Figure 1 Compression bandaging following total knee replacement
layer of soft padding surrounded by an overlapping layer of cohesive inelastic compression bandage (Actico 12cm x 6m; Activa Healthcare Ltd, Staffordshire, England), was applied firmly from the toes to the groin (Figure 1), or a conventional bandage was applied, consisting of an inner layer of wool and an outer layer of crepe bandaging around the knee. Bandages were applied for 24 hours post-operatively;
April 2014 / Volume 24 / Issue 4 / ISSN 1750-4589
CLINICAL FEATURE
One hundred patients were given a compression bandage following surgery, whilst 80 received a standard wool and crepe bandage
the type of dressing used was according to surgeon preference. Following surgery, all patients were admitted to the postoperative recovery unit until deemed safe for transfer to the orthopaedic ward. Postoperatively, a standardised pain protocol was used and all patients were seen and evaluated by an enhanced recovery physiotherapist. Mobilisation occurred within four hours of return to the ward. A standardised postoperative enhanced recovery programme was used for all patients. The primary outcomes of the study were: level of mobility on day of surgery according to a locally developed scoring system (Table 1), and the use of walking aids at discharge. Secondary outcomes were range of knee
93) and was 70 years (range 38-92) in the standard group. There were 65 female and 35 male patients in the compression group and 61 female and 19 male patients in the standard group. There was no difference in age and sex between the two groups. Sixty three (63%) of the compression bandage group and 50 (63%) of the standard group were seen on day of surgery. The remainder were seen on the following day due to time and staffing constraints.
Level of mobility There were no differences in mobility between the two groups on day of surgery (Figure 2) but significant differences existed at discharge (Figure 3). Patients with a compression bandage were more likely to be discharged with a walking stick, and much less likely to be discharged with a rollator frame.
Range of movement There was an improved range of knee flexion and ability to straight leg raise at
Level 0 Unable to perform knee exercises lying in bed Level 1 Able to perform knee exercises lying in bed Level 2 Able to sit on edge of bed and perform knee exercises Level 3 Able to stand and perform knee exercises Table 1 Postoperative level of mobility on day of surgery
flexion and ability to straight leg raise (SLR) above 45° on initial assessment and at discharge, and length of stay.
Figure 2 Level of mobility on day of surgery
The Mann-Whitney U test (VassarStats) for non-parametric data and Fisher’s exact test 2-tailed (GraphPad Software Inc.) for nominal data were used for statistical analysis. Values of p
Compression bandaging improves mobility following total knee replacement in an enhanced recovery setting by A Cheung, H Lykostratis and I Holloway Correspondence address: Ian Holloway, Department of Orthopaedic Surgery, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ. Email: [email protected]
The early functional outcome was assessed in 180 patients undergoing total knee replacement (TKR) using compression bandaging versus standard crepe bandaging. Patients with a compression bandage following TKR were significantly more likely to be discharged with a walking stick (p=0.002) and less likely to be discharged with a rollator frame (p=0.001). These patients demonstrated an improved range of knee flexion and ability to straight leg raise at discharge. Introduction Total knee replacement (TKR) for end stage osteoarthritis is one of the most common orthopaedic operations performed in the UK. According to the National Joint Registry (2012) 84,653 knee replacement procedures were performed in England and Wales in 2011. The aim of an enhanced recovery program following TKR (Malviya et al 2011) is to improve patient outcomes and speed recovery after surgery (NHS Institute for Innovation and Improvement 2008). A multidisciplinary team is involved perioperatively to optimise medical comorbidities, educate patients and organise discharge planning. Postoperatively, physiotherapy and a standardised pain management protocol are initiated immediately (Isaac et al 2005). Following TKR, the knee is typically swollen as a result of bleeding within the joint and soft tissue inflammation, which can increase pain, reduce mobility and delay subsequent discharge (Charambilides et al 2005). Various measures can be taken to reduce swelling including bandaging and cryotherapy (icepack). There has been little evidence previously to suggest that these measures are effective (Adie et al 2012) although one study has suggested that compression bandaging improves pain relief following TKR (Andersen et al 2008).
84
There are several potential advantages in reducing swelling and improving mobility following TKR. The primary benefit is to improve the patient experience by decreasing postoperative pain. Secondary benefits are to ensure a speedy yet safe recovery from hospital and to reduce the length and cost of hospital stay. Compression bandaging following TKR represents a simple, inexpensive intervention which may improve patient care.
Aim The aim of this study is to compare the effect of compression bandaging versus standard crepe bandaging upon perioperative function following TKR.
Methods The study was performed at an elective orthopaedic unit in the UK. The study population consisted of patients undergoing unilateral cemented total knee replacement for end stage osteoarthritis between July 2010 and November 2011. All patients were enrolled in an enhanced recovery program. All patients were operated on by one of six consultant orthopaedic surgeons, using standard surgical techniques and local infiltration anaesthesia. Following wound closure either a compression bandage, consisting of a
Figure 1 Compression bandaging following total knee replacement
layer of soft padding surrounded by an overlapping layer of cohesive inelastic compression bandage (Actico 12cm x 6m; Activa Healthcare Ltd, Staffordshire, England), was applied firmly from the toes to the groin (Figure 1), or a conventional bandage was applied, consisting of an inner layer of wool and an outer layer of crepe bandaging around the knee. Bandages were applied for 24 hours post-operatively;
April 2014 / Volume 24 / Issue 4 / ISSN 1750-4589
CLINICAL FEATURE
One hundred patients were given a compression bandage following surgery, whilst 80 received a standard wool and crepe bandage
the type of dressing used was according to surgeon preference. Following surgery, all patients were admitted to the postoperative recovery unit until deemed safe for transfer to the orthopaedic ward. Postoperatively, a standardised pain protocol was used and all patients were seen and evaluated by an enhanced recovery physiotherapist. Mobilisation occurred within four hours of return to the ward. A standardised postoperative enhanced recovery programme was used for all patients. The primary outcomes of the study were: level of mobility on day of surgery according to a locally developed scoring system (Table 1), and the use of walking aids at discharge. Secondary outcomes were range of knee
93) and was 70 years (range 38-92) in the standard group. There were 65 female and 35 male patients in the compression group and 61 female and 19 male patients in the standard group. There was no difference in age and sex between the two groups. Sixty three (63%) of the compression bandage group and 50 (63%) of the standard group were seen on day of surgery. The remainder were seen on the following day due to time and staffing constraints.
Level of mobility There were no differences in mobility between the two groups on day of surgery (Figure 2) but significant differences existed at discharge (Figure 3). Patients with a compression bandage were more likely to be discharged with a walking stick, and much less likely to be discharged with a rollator frame.
Range of movement There was an improved range of knee flexion and ability to straight leg raise at
Level 0 Unable to perform knee exercises lying in bed Level 1 Able to perform knee exercises lying in bed Level 2 Able to sit on edge of bed and perform knee exercises Level 3 Able to stand and perform knee exercises Table 1 Postoperative level of mobility on day of surgery
flexion and ability to straight leg raise (SLR) above 45° on initial assessment and at discharge, and length of stay.
Figure 2 Level of mobility on day of surgery
The Mann-Whitney U test (VassarStats) for non-parametric data and Fisher’s exact test 2-tailed (GraphPad Software Inc.) for nominal data were used for statistical analysis. Values of p
