Does the addition of hip strengthening exercises improve outcomes following total knee arthroplasty? A study protocol for a randomized trial

Margaret B Schache, Jodie A McClelland, Kate E Webster, Margaret B Schache, Jodie A McClelland, Kate E Webster

Abstract

Background: Total knee arthroplasty (TKA) is effective in reducing pain and improving function for end-stage knee osteoarthritis. However, muscle weakness and functional limitations persist despite assistance from post-operative rehabilitation programs that traditionally focus on quadriceps strengthening and range of movement exercises. Hip abductor muscle weakness is evident in knee osteoarthritis and hip muscle strengthening reduces knee pain in this group. Following TKA, people with weak hip abductor strength perform more poorly on measures of physical function. However, very little is known of the effectiveness of including hip abductor strengthening exercises in post-operative rehabilitation. The aim of this trial is to compare the effects of targeted hip abductor strengthening to those of traditional care in a TKA rehabilitation program on muscle strength, patient reported outcomes and functional performance measures.

Methods/design: This protocol describes a single-blinded randomized controlled trial, where 104 participants referred for inpatient rehabilitation following TKA will be recruited. Participants will be randomized using computer-generated numbers to one of two groups: usual care or usual care with additional hip strengthening exercises. Participants will attend physiotherapy daily during their inpatient length of stay, and will then attend between six and eight physiotherapy sessions as an outpatient. Primary outcomes are isometric hip abductor strength and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes are stair climb test, 6 min walk test, timed up and go, 40 m fast-paced walk test, 30 second chair stand test, isometric quadriceps strength, Lower Extremity Functional Scale (LEFS) and SF-12. Outcome measures will be recorded at baseline (admission to inpatient rehabilitation), and then 3 weeks, 6 weeks and 6 months post admission to rehabilitation.

Discussion: The findings of this study will determine whether the addition of targeted hip strengthening to usual care rehabilitation improves physical performance and patient reported outcomes following TKA when compared to usual care rehabilitation. This will then determine whether targeted hip strengthening exercises should be included in traditional rehabilitation programs to improve the outcomes following total knee arthroplasty.

Trial registration: The trial protocol was registered with the Australian Clinical Trial Registry ( ACTRN12615000863538 ) on 18 August 2015.

Keywords: Exercise; Hip strengthening; Randomized controlled trial; Rehabilitation; Total knee arthroplasty.

Figures

Fig. 1
Fig. 1
Flow diagram of study protocol

References

    1. Page CJ, Hinman RS, Bennell KL. Physiotherapy management of knee osteoarthritis. Int J Rheum Dis. 2011;14(2):145–151. doi: 10.1111/j.1756-185X.2011.01612.x.
    1. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001;60(2):91–97. doi: 10.1136/ard.60.2.91.
    1. Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 2010;40(9):559–567. doi: 10.2519/jospt.2010.3317.
    1. Levine M, McElroy K, Stakich V, Cicco J. Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics. 2013;36(3):e319–e324. doi: 10.3928/01477447-20130222-20.
    1. Petterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstab A, Newcomb W, et al. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum. 2009;61(2):174–183. doi: 10.1002/art.24167.
    1. Piva SR, Almeida G, Gil AB, Teixeira PE, Fitzgerald GK. Effectiveness and feasibility of a balance training program post total knee arthroplasty: pilot randomized trial. J Orthop Sports Phys Ther. 2009;39(1):A29–A30.
    1. Meier W, Mizner R, Marcus R, Dibble L, Peters C, Lastayo PC. Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches. J Orthop Sports Phys Ther. 2008;38(5):246–256. doi: 10.2519/jospt.2008.2715.
    1. Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. 2009.
    1. Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol: what makes the difference? J Arthroplasty. 2003;18(3 Suppl 1):27–30. doi: 10.1054/arth.2003.50080.
    1. Westby MD, Backman CL. Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group study. BMC Health Serv Res. 2010;10:119. doi: 10.1186/1472-6963-10-119.
    1. Bade M, Stevens-Lapsley JE. Restoration of physical function in patients following total knee arthroplasty: an update on rehabilitation practices. Curr Opin Rheumatol. 2012;24(2):208–214. doi: 10.1097/BOR.0b013e32834ff26d.
    1. Mizner RL, Snyder-Mackler L. Altered loading during walking and sit-to-stand is affected by quadriceps weakness after total knee arthroplasty. J Orthop Res. 2005;23(5):1083–1090. doi: 10.1016/j.orthres.2005.01.021.
    1. Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998;78(3):248–258.
    1. Hinman RS, Hunt MA, Creaby MW, Wrigley TV, McManus FJ, Bennell KL. Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis Care Res. 2010;62(8):1190–1193. doi: 10.1002/acr.20199.
    1. Childs JD, Sparto PJ, Fitzgerald GK, Bizzini M, Irrgang JJ. Alterations in lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis. Clin Biomech. 2004;19(1):44–49. doi: 10.1016/j.clinbiomech.2003.08.007.
    1. Al-Zahrani KS, Bakheit AM. A study of the gait characteristics of patients with chronic osteoarthritis of the knee. Disabil Rehabil. 2002;24(5):275–280. doi: 10.1080/09638280110087098.
    1. Farr JN, Going SB, Lohman TG, Rankin L, Kasle S, Cornett M, et al. Physical activity levels in patients with early knee osteoarthritis measured by accelerometry. Arthritis Rheum. 2008;59(9):1229–1236. doi: 10.1002/art.24007.
    1. Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, McManus FJ, Hodges PW, et al. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthr Cartil. 2010;18(5):621–628. doi: 10.1016/j.joca.2010.01.010.
    1. Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a home program of hip abductor exercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 2010;90(6):895–904. doi: 10.2522/ptj.20090294.
    1. Alnahdi AH, Zeni JA, Snyder-Mackler L. Hip abductor strength reliability and association with physical function after unilateral total knee arthroplasty: a cross-sectional study. Phys Ther. 2014;94(8):1154–1162. doi: 10.2522/ptj.20130335.
    1. Piva SR, Teixeira PE, Almeida GJ, Gil AB, DiGioia AM, III, Levison TJ, et al. Contribution of hip abductor strength to physical function in patients with total knee arthroplasty. Phys Ther. 2011;91(2):225–233. doi: 10.2522/ptj.20100122.
    1. Chan AW, Tetzlaff JM, Altman DG, Laupacis A, Gotzsche PC, Krleza-Jeric K, et al. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Ann Intern Med. 2013;158(3):200–207. doi: 10.7326/0003-4819-158-3-201302050-00583.
    1. Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P, Group C. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;148(4):295–309. doi: 10.7326/0003-4819-148-4-200802190-00008.
    1. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35(8):487–494. doi: 10.2519/jospt.2005.35.8.487.
    1. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. J Orthop Sports Phys Ther. 2007;37(12):754–762. doi: 10.2519/jospt.2007.2471.
    1. Jacobs CA, Lewis M, Bolgla LA, Christensen CP, Nitz AJ, Uhl TL. Electromyographic analysis of hip abductor exercises performed by a sample of total hip arthroplasty patients. J Arthroplasty. 2009;24(7):1130–1136. doi: 10.1016/j.arth.2008.06.034.
    1. Thorborg K, Bandholm T, Petersen J, Weeke KMO, Weinold C, Andersen B, et al. Hip abduction strength training in the clinical setting: With or without external loading? Scand J Med Sci Sports. 2010;20(2):70–77. doi: 10.1111/j.1600-0838.2010.01186.x.
    1. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–1359. doi: 10.1249/MSS.0b013e318213fefb.
    1. Dobson F, Hinman RS, Roos EM, Abbott JH, Stratford P, Davis AM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthr Cartil. 2013;21(8):1042–1052. doi: 10.1016/j.joca.2013.05.002.
    1. Parent E, Moffet H. Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch Phys Med Rehabil. 2002;83(1):70–80. doi: 10.1053/apmr.2002.27337.
    1. Peer MA, Lane J. The Knee Injury and Osteoarthritis Outcome Score (KOOS): A Review of Its Psychometric Properties in People Undergoing Total Knee Arthroplasty. J Orthop Sports Phys Ther. 2013;43(1):20–28. doi: 10.2519/jospt.2013.4057.
    1. Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS) - validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes. 2003;1:17. doi: 10.1186/1477-7525-1-17.
    1. Schache MB, McClelland JA, Webster KE. Reliability of measuring hip abductor strength following total knee arthroplasty using a hand-held dynamometer. Disabil Rehabil. 2015;20:1–4.
    1. Katoh M, Yamasaki H. Comparison of reliability of isometric leg muscle strength measurements made using a hand-held dynamometer with and without a restraining belt. J Phys Ther Sci. 2009;21(1):37–42. doi: 10.1589/jpts.21.37.
    1. Farquhar S, Snyder-Mackler L. The Chitranjan Ranawat Award: The nonoperated knee predicts function 3 years after unilateral total knee arthroplasty. Clin Orthop Relat Res. 2010;468(1):37–44. doi: 10.1007/s11999-009-0892-9.
    1. Mizner RL, Petterson SC, Clements KE, Zeni JA, Jr, Irrgang JJ, Snyder-Mackler L. Measuring functional improvement after total knee arthroplasty requires both performance-based and patient-report assessments: a longitudinal analysis of outcomes. J Arthroplasty. 2011;26(5):728–737. doi: 10.1016/j.arth.2010.06.004.
    1. Yoshida Y, Mizner RL, Ramsey DK, Snyder-Mackler L. Examining outcomes from total knee arthroplasty and the relationship between quadriceps strength and knee function over time. Clin Biomech. 2008;23(3):320–328. doi: 10.1016/j.clinbiomech.2007.10.008.
    1. Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskelet Disord. 2005;6:3. doi: 10.1186/1471-2474-6-3.
    1. Almeida GJ, Schroeder CA, Gil AB, Fitzgerald GK, Piva SR. Interrater reliability and validity of the stair ascend/descend test in subjects with total knee arthroplasty. Arch Phys Med Rehabil. 2010;91(6):932–938. doi: 10.1016/j.apmr.2010.02.003.
    1. Bruun-Olsen V, Heiberg KE, Wahl AK, Mengshoel AM. The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial. Disabil Rehabil. 2013;35(23):2008–2015. doi: 10.3109/09638288.2013.770084.
    1. Choi S, Trang A, McCartney CJ. Reporting functional outcome after knee arthroplasty and regional anesthesia: a methodological primer. Reg Anesth Pain Med. 2013;38(4):340–349. doi: 10.1097/AAP.0b013e318295d973.
    1. Jakobsen TL, Kehlet H, Husted H, Petersen J, Bandholm T. Early progressive strength training to enhance recovery after fast-track total knee arthroplasty: a randomized controlled trial. Arthritis Care Res. 2014;66(12):1856–1866. doi: 10.1002/acr.22405.
    1. Kennedy DM, Stratford PW, Riddle DL, Hanna SE, Gollish JD. Assessing recovery and establishing prognosis following total knee arthroplasty. Phys Ther. 2008;88(1):22–32. doi: 10.2522/ptj.20070051.
    1. Naylor JM, Crosbie J, Ko V. Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial. J Rehabil Med. 2015;47(3):235–241. doi: 10.2340/16501977-1919.
    1. Su EP, Perna M, Boettner F, Mayman DJ, Gerlinger T, Barsoum W, et al. A prospective, multi-center, randomised trial to evaluate the efficacy of a cryopneumatic device on total knee arthroplasty recovery. J Bone Joint Surg (Br) 2012;94(11):153–156. doi: 10.1302/0301-620X.94B11.30832.
    1. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–148. doi: 10.1111/j.1532-5415.1991.tb01616.x.
    1. Boonstra MC, De Waal Malefijt MC, Verdonschot N. How to quantify knee function after total knee arthroplasty? Knee. 2008;15(5):390–395. doi: 10.1016/j.knee.2008.05.006.
    1. Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis. J Orthop Sports Phys Ther. 2011;41(5):319–327. doi: 10.2519/jospt.2011.3515.
    1. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport. 1999;70(2):113–119. doi: 10.1080/02701367.1999.10608028.
    1. Gill S, McBurney H. Reliability of performance-based measures in people awaiting joint replacement surgery of the hip or knee. Physiother Res Int. 2008;13(3):141–152. doi: 10.1002/pri.411.
    1. Gill SD, De Morton NA, Mc BH. An investigation of the validity of six measures of physical function in people awaiting joint replacement surgery of the hip or knee. Clin Rehabil. 2012;26(10):945–951. doi: 10.1177/0269215511434993.
    1. Hill KD, Bernhardt J, McGann AM, Maltese D, Berkovits D. A new test of dynamic standing balance for stroke patients: reliability, validity and comparison with healthy elderly. Physiother Can. 1996;48(4):257–262. doi: 10.3138/ptc.48.4.257.
    1. Coleman S, McQuade J, Rose J, Inderjeeth C, Carroll G, Briffa NK. Self-management for osteoarthritis of the knee: does mode of delivery influence outcome? BMC Musculoskelet Disord. 2010;11:56. doi: 10.1186/1471-2474-11-56.
    1. Goncalves RS, Pinheiro JP, Cabri J. Evaluation of potentially modifiable physical factors as predictors of health status in knee osteoarthritis patients referred for physical therapy. Knee. 2012;19(4):373–379. doi: 10.1016/j.knee.2011.05.010.
    1. Hale LA, Waters D, Herbison P. A randomized controlled trial to investigate the effects of water-based exercise to improve falls risk and physical function in older adults with lower-extremity osteoarthritis. Arch Phys Med Rehabil. 2012;93(1):27–34. doi: 10.1016/j.apmr.2011.08.004.
    1. Hinman RS, Bennell KL, Crossley KM, McConnell J. Immediate effects of adhesive tape on pain and disability in individuals with knee osteoarthritis. Rheumatology (Oxford) 2003;42(7):865–869. doi: 10.1093/rheumatology/keg233.
    1. Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL. Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Rheum. 2008;59(7):943–951. doi: 10.1002/art.23823.
    1. Hinman RS, Bennell KL, Metcalf BR, Crossley KM. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology (Oxford) 2002;41(12):1388–1394. doi: 10.1093/rheumatology/41.12.1388.
    1. Koblbauer IF, Lambrecht Y, van der Hulst ML, Neeter C, Engelbert RH, Poolman RW, et al. Reliability of maximal isometric knee strength testing with modified hand-held dynamometry in patients awaiting total knee arthroplasty: useful in research and individual patient settings? A reliability study. BMC Musculoskelet Disord. 2011;12:249. doi: 10.1186/1471-2474-12-249.
    1. Schache MB, McClelland JA, Webster KE. Lower limb strength following total knee arthroplasty: a systematic review. Knee. 2014;21(1):12–20. doi: 10.1016/j.knee.2013.08.002.
    1. Alnahdi AH. Outcome measures capturing ICF domains in patient with total knee arthroplasty. Int J Rehabil Res. 2014;37(4):281–289. doi: 10.1097/MRR.0000000000000083.
    1. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999;79(4):371–383.
    1. Stratford PW, Binkley JM, Watson J, Heath-Jones T. Validation of the LEFS on patients with total joint arthroplasty. Physiother Can. 2000;52(2):97.
    1. Stratford PW, Kennedy DM. Performance measures were necessary to obtain a complete picture of osteoarthritic patients. J Clin Epidemiol. 2006;59(2):160–167. doi: 10.1016/j.jclinepi.2005.07.012.
    1. Stratford PW, Kennedy DM, Hanna SE. Condition-specific Western Ontario McMaster Osteoarthritis Index was not superior to region-specific Lower Extremity Functional Scale at detecting change. J Clin Epidemiol. 2004;57(10):1025–1032. doi: 10.1016/j.jclinepi.2004.03.008.
    1. Stratford PW, Kennedy DM, Maly MR, Macintyre NJ. Quantifying self-report measures’ overestimation of mobility scores postarthroplasty. Phys Ther. 2010;90(9):1288–1296. doi: 10.2522/ptj.20100058.
    1. Ware J, Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–233. doi: 10.1097/00005650-199603000-00003.
    1. Ware JE, Jr, Sherbourne CD, The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–483. doi: 10.1097/00005650-199206000-00002.
    1. Clement ND, Burnett R. Patient satisfaction after total knee arthroplasty is affected by their general physical well-being. Knee Surg Sports Traumatol Arthrosc. 2013;21(11):2638–2646. doi: 10.1007/s00167-013-2523-y.
    1. Blakeney WG, Khan RJ, Palmer JL. Functional outcomes following total knee arthroplasty: a randomised trial comparing computer-assisted surgery with conventional techniques. Knee. 2014;21(2):364–368. doi: 10.1016/j.knee.2013.04.001.
    1. Dowsey MM, Nikpour M, Choong PF. Outcomes following large joint arthroplasty: does socio-economic status matter? BMC Musculoskelet Disord. 2014;15:148. doi: 10.1186/1471-2474-15-148.
    1. Hamilton D, Henderson GR, Gaston P, MacDonald D, Howie C, Simpson AH. Comparative outcomes of total hip and knee arthroplasty: a prospective cohort study. Postgrad Med J. 2012;88(1045):627–631. doi: 10.1136/postgradmedj-2011-130715.
    1. Maniar RN, Baviskar JV, Singhi T, Rathi SS. To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty. 2012;27(2):193–200.e1. doi: 10.1016/j.arth.2011.04.009.
    1. Mockford BJ, Thompson NW, Humphreys P, Beverland DE. Does a standard outpatient physiotherapy regime improve the range of knee motion after primary total knee arthroplasty? J Arthroplasty. 2008;23(8):1110–1114. doi: 10.1016/j.arth.2007.08.023.
    1. Noticewala MS, Geller JA, Lee JH, Macaulay W. Unicompartmental knee arthroplasty relieves pain and improves function more than total knee arthroplasty. J Arthroplasty. 2012;27(8 Suppl):99–105. doi: 10.1016/j.arth.2012.03.044.
    1. Poitras S, Beaule PE, Dervin GF. Validity of A Short-Term Quality of Life Questionnaire in Patients Undergoing Joint Replacement: The Quality of Recovery–40. J Arthroplast. 2012;27(9):1604–8.e1. doi: 10.1016/j.arth.2012.03.015.
    1. Clement ND, MacDonald D, Simpson AH. The minimal clinically important difference in the Oxford knee score and Short Form 12 score after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014;22(8):1933–1939. doi: 10.1007/s00167-013-2776-5.
    1. Faul F, Erdfelder E, Lang AG, Buchner A. G Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191. doi: 10.3758/BF03193146.
    1. Australian Orthopaedic Association . National Joint Replacement Registry. Annual Report. Adelaide: AOA; 2015.
    1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–785. doi: 10.2106/JBJS.F.00222.
    1. Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gomez-Barrena E, et al. International survey of primary and revision total knee replacement. Int Orthop. 2011;35(12):1783–1789. doi: 10.1007/s00264-011-1235-5.
    1. McClelland JA, Webster KE, Feller JA. Gait analysis of patients following total knee replacement: a systematic review. Knee. 2007;14(4):253–263. doi: 10.1016/j.knee.2007.04.003.
    1. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005;35(7):424–436. doi: 10.2519/jospt.2005.35.7.424.
    1. Rossi MD, Hasson S, Kohia M, Pineda E, Bryan W. Mobility and perceived function after total knee arthroplasty. J Arthroplasty. 2006;21(1):6–12. doi: 10.1016/j.arth.2005.02.013.
    1. Senden R, Grimm B, Meijer K, Savelberg H, Heyligers IC. The importance to including objective functional outcomes in the clinical follow up of total knee arthroplasty patients. Knee. 2011;18(5):306–311. doi: 10.1016/j.knee.2010.07.008.

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