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A research report submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Science in Physiotherapy. / The purpose of this retrospective study was to assess the Subjective, objective and functional results of intra-articular anterior cruciate ligament (ACL) reconstructions using the patellar tendon. The subjects of one orthopaedic surgeon were assessed to eliminate surgical variability. Twenty active males, aged 20 - 35 were assessed twelve to fortyeight months post-operatively. Each subject completed a questionnaire and underwent various functional and subjective tests. Eighteen subjects (90 %) were satisfied with the outcome of their operation. Fourteen (70%) complained of intermittent pain or cdscomfort. Six (30%) complained of some form of post-operative giving way. Nineteen (95 %) had returned to sporting activity but most modified their sport or level of participation. Knee stability was restored post-operatively. Nineteen (95%) had a side-to-side difference of three rnillimetres (mm) or less on Lachman testing and eighteen (90 %) a side-to-side difference of 3mm or less on anterior drawer testing. Thirteen (65 %) had a 3mm or less side-to-side difference on KT1000 testing at 20 pounds (lbs) and 14 (70%) a side-to-side difference of 3mm or less on manual maximum testing. Isokinetic muscle testing revealed persistent quadriceps deficits greater than 20 % in seven subjects (35%) and three (15%) had similar hamstring deficits. Various factors may affect post-operative function. These include the length of rehabilitation, pain, residual quadriceps weakness and restoration of stability. / AC 2018

A research report submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Science in Physiotherapy. / The purpose of this retrospective study was to assess the Subjective, objective and functional results of intra-articular anterior cruciate ligament (ACL) reconstructions using the patellar tendon. The subjects of one orthopaedic surgeon were assessed to eliminate surgical variability. Twenty active males, aged 20 - 35 were assessed twelve to forty eight months post-operatively. Each subject completed a questionnaire and underwent various functional and subjective tests. Eighteen subjects (90 %) were satisfied with the outcome of their operation. Fourteen (70%) complained of intermittent pain or discomfort. Six (30%) complained of some form of post-operative giving way. Nineteen (95 %) had returned to sporting activity but most modified their sport or level of participation. Knee stability was restored post-operatively. Nineteen (95%) had a side-to-side difference of three rnillimetres (mm) or less on Lachman testing and eighteen (90 %) a side-to-side difference of 3mm or less on anterior drawer testing. Thirteen (65 %) had a 3mm or less side-to-side difference on KT1000 testing at 20 pounds (lbs) and 14 (70%) a side-to-side difference of 3mm or less on manual maximum testing. Isokinetic muscle testing revealed persistent quadriceps deficits greater than 20 % in seven subjects (35%) and three (15%) had similar hamstring deficits. Various factors may affect post-operative function. These include the length of rehabilitation, pain, residual quadriceps weakness and restoration of stability. / AC2018

Thigh muscle strength and endurance were measured following partial arthroscopic meniscectomy of the knee in 24 patients divided into group 1 (age < 20 yr), group 2 (age 24-40 yr), and group 3 (age > 50 yr). Subjects were studied during and after release from isokinetic rehabilitation. Isokinetic testing was performed at 1.04, 2.09, 3.14, 4.19, and 5.24 radians/second, with release from rehabilitation when quadriceps strength achieved 85% recovery of the non-surgical leg.No significant difference existed among the 3 groups in days from the time of surgery to the start of the first test or for the weeks to release from rehabilitation. Approximately 50% quadricep muscle strength loss was observed at the time of the initial isokinetic test. Quadriceps torque (mean + SE) measured in newton-meters for group 1 at the 1.04 rad/sec speed showed the surgical leg significantly weaker (P<0.001) than the non-surgical leg when tested at the initial test (101.6 +18.2 vs. 189.6 +17.2) and at release from rehabilitation (157.4 +13.3 vs. 176.3 +15.2). Torque measured at the other 4 speeds reached non-significance by the second or third week of rehabilitation. Isokinetic testing for groups 2 and 3 showed surgical leg strength significantly weaker (P<0.05) at the initial test and at week 1 of rehabilitation for the 5 testing speeds, with 85% return of strength by weeks 2 or 3. Strength recovery for all 3 groups showed no significant weakness between legs for hamstring torque after the initial or after the first week of rehabilitation. Percent of knee extensor torque achieved by the knee flexor muscles of the surgical leg for the 3 groups showed significantly greater (P<0.001) values only for the initial test at speeds 1.04 and 2.09 rad/sec. Measures of total work, average power, and endurance calculated from work tests showed little change in muscle endurance between legs.These data indicate that quadricep muscle function is negatively affected following arthroscopic meniscectomy. Release from rehabilitation when surgical to non-surgical leg strength is between 85% to 90X appears to be a valid measure for most patients, which indicates age alone does not appear to be a limiting factor in regaining strength.

Joint mobility is dependent on comfort, thus pain is associated with mobility. This study examined the relationship between pain perception and joint mobility in arthritis patients before and after total knee arthroplasty. Pain perception was indicated by pain intensity, pain distress and pain expectation; joint mobility was represented by the degree of knee joint flexion. Visual analogue scales were used for pain intensity, pain distress and pain expectation; knee joint flexion as measured using a goniometer. Data were collected on 24 subjects preoperatively (T1), immediately postoperatively (T2) and forty-eight to seventy-two hours postoperatively (T3). Twenty-four subjects participated in the study. Significant paired t-test resulted for joint flexion at T1 and T3 and pain expectation at T2 and T3. Pearson product-moment correlation coefficients were significant for pain intensity and pain distress at all three times, pain intensity and joint flexion at T1 and pain intensity at T1 and at T2.

Anteromedial osteoarthritis of the knee (AMOA) has been defined anatomically, histologically and radiologically and yet little is known about the epidemiology of the disease or the risk factors involved in the development of the disease. The broad aim of this thesis was to combine clinical insight with the utilisation of modern, large epidemiological datasets to provide information to inform better the clinical management of patients with AMOA. Specifically, the prevalence and incidence of AMOA, the time taken to progress from early disease to severe disease that may require surgical intervention, the radiological characterisation of disease and the assessment of mechanical risk factors implicit in the development of this pattern of disease are investigated. A cross-sectional study of the radiological prevalence of AMOA in a symptomatic cohort in a specialist secondary care knee clinic showed that AMOA was the commonest pattern of knee OA, present in more than 60&percnt; of symptomatic subjects. Less than 25% of subjects with AMOA presented with advanced or 'bone-on-bone' disease, emphasising the clinical importance of understanding the progression from earlier stages of disease to this advanced stage. A 20-year longitudinal radiographic study was performed on 1000 women to describe the prevalence, incidence and progression of AMOA. The prevalence of AMOA was 43&percnt; and the incidence over 20-years was 0.4. Life table analysis showed that the risk of developing advanced AMOA in a previously normal knee was 2.6&percnt;. Of those subjects with early radiological AMOA, 11&percnt; progressed to advanced 'bone-on-bone' disease within 10 years and 37% within 20 years. The role of mechanical risk factors in the development of AMOA showed that both anatomical limb and proximal tibial alignment were significantly more varus aligned in those that developed AMOA at 20-years. Assessment of the shape of the medial tibial plateau in a longitudinal MRI study showed that the angle of the upslope at the anterior aspect of the plateau was significantly increased in the group that subsequently developed AMOA. To enable AMOA to be studies in future MRI studies, the MRI description of the disease was defined. In summary, AMOA was shown to be the most common pattern of knee OA both in symptomatic surgical cohorts and in the community. The progression of the disease from an early stage to an advanced stage, which may require surgical intervention, was described for the first time. To enable better the recognition of AMOA in modern epidemiological studies, the MRI description of AMOA was defined and the clinical relevance of modern MRI was discussed. The anatomical alignment of the limb, the alignment of the proximal tibia and the morphology of the tibial plateau were all shown to have a role in the development of AMOA. Addressing these mechanical factors may provide a therapeutic surgical target for the management of patients with AMOA.

Arthroscopic knee surgery can be challenging because there is no intuitive relationship between the arthroscopic image, shown on a screen above the patient, and the camera in the surgeon's hand. As a result, arthroscopic surgeons require extensive training and experience. This thesis describes a computer system to help improve target acquisition in arthroscopy by visualizing the location and alignment of an arthroscope using augmented virtuality. A 3D computer model of the patient's joint (from CT) is shown, along with a model of the tracked arthroscopic probe and the projection of the camera image onto the virtual joint. We performed a user study to determine the effectiveness of this navigated display; the study showed that for novice residents, the navigated display improved target acquisition. However, residents with at least two years of experience performed worse. For surgeons, no effect on performance was found. / Thesis (Master, Computing) -- Queen's University, 2010-11-25 23:29:46.526

The purpose of this research study was to evaluate pain, strength, balance, and function in subjects before and after total knee arthroplasty. Thirteen subjects were tested prior to total knee arthroplasty. Seven of the original subjects returned to the laboratory and were tested one month after knee replacement surgery. At each testing session subjects completed questionnaires including a pain visual analog scale (VAS), Falls questionnaire, global rating of knee function, Western Ontario McMaster Universities (WOMAC) osteoarthritis index, and Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS). Strength was tested via unilateral, isometric squat. Knee range of motion was measured using a standard goniometer. Functional activities including walking, sit to stand transfers, and stepping on and off a curb were assessed using the Balance Master Force Plate system (Neurocom International). Balance activities including tandem walk, modified clinical test of sensory interaction on balance (mCTSIB), limits of stability (LOS), and sensory organization tests (SOT) were also assessed using the SMART Equitest (Neurocom International). There was a trend towards decreased pain on VAS post- surgery although the results were not significantly different (p = 0.0585). Subjective rating of function was improved on the composite WOMAC Osteoarthritis Index score (p = 0.0313). No differences were found after surgery for strength in the involved limb, balance tasks, or ability to perform functional activities. From this study we conclude that total knee arthroplasty does not have a deleterious effect on function or balance in the immediate post-operative period even through the knee is still in an acutely inflamed state. Further testing is needed to evaluate the effect of TKA on more strenuous functional activities and balance tasks and at larger post-operative intervals. / School of Physical Education, Sport, and Exercise Science

A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy, to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg 2018 / Knee osteoarthritis (OA) is the most prevalent form of OA and it is present in over 33% of adults aged 50 years and above. Patients with end-stage knee OA have poor health outcomes including severe knee pain, functional limitations and poor quality of life (QoL) with decreased physical activity (PA) and increased sedentary behaviour (SB). In spite of the cost-effectiveness of total knee arthroplasty (TKA) in improving patients’ health outcomes (as measured using patient-reported outcome measures (PROMs)), the objectively measured PA shows little or no change after surgery and SB has received very little attention following TKA. However, published studies have only been conducted in populations from high-income countries and no studies have assessed PA and SB in knee OA patients from low-middle income countries including South Africa. Furthermore, the detailed patterns by which patients with knee OA accumulate PA and SB before and after TKA have not been described. Studies have mainly focused on measuring overall PA or moderate to vigorous PA (MVPA) and/or patients’ adherence to the PA guidelines with very little attention to low intensity activities of the movement continuum (SB and light activity- LPA). Furthermore, different activity monitors have been used with very few of them capable of measuring low intensity activities. Assessing activity behaviours incidental in activities of daily living (ADL) (such as sitting, standing and walking) before and after TKA may be clinically useful as activities of older adults undergoing TKA mainly constitute these low intensity activities. With no previously published systematic review on changes in SB following TKA, the objective of the first study of this thesis was to integrate available evidence on changes in SB in patients with knee OA after a primary TKA. A systematic literature search from January 2002 to 31 October 2017 was performed across seven electronic databases, for longitudinal and cross-sectional studies published in English on objectively (through accelerometry) and/or subjectively measured changes in SB following TKA. Ten studies reporting on SB with a total of 1,028 participants were included in the review. Three studies reported changes in SB with two showing a reduction in SB and one, with high risk of bias, showing an increase in SB after TKA. Seven studies showed no change in SB following TKA. The second study of this thesis was a longitudinal design comprising of two parts (Study 2A and B). Participants wore two activity monitors (ActiGraph GT3X+ and ActivPAL) to measure PA and SB for seven consecutive days (24 hours/day) at baseline (preoperative), six weeks and six months after TKA. Therefore, the second objective (Study 2A) of this thesis was to objectively measure changes in volume and pattern of PA and SB (using ActiGraph GT3X+ accelerometer) in patients with knee OA from baseline to six months after TKA and to assess changes in PROMs following TKA. Eighty-nine patients (13 males, 76 females between 55 and 80 years of age) scheduled for primary TKA took part in the study. Physical activity and SB were measured with an ActiGraph GT3X+ accelerometer for seven consecutive days (24 hours/day) and range of motion (ROM) was measured prior to TKA, and six weeks and six months after TKA. The University of California Los Angeles (UCLA) Activity index and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to assess self-reported activity and physical function respectively. Of the initial 89 patients recruited, 57 completed the six months followup and 45 had valid activity data at the 6 months follow-up. The proportion of time (% of waking day) patients spent in light physical activity (LPA) increased from baseline [29.0 (26.6-31.4)%] to 6 months [34.8 (31.3-38.3)%; p=0.008]. However, time spent in moderate to vigorous PA (MVPA) did not change from baseline [median (interquartile range): 2.0 (7.8) min/day] to six months after TKA [3.4 (11.6) min/day, p>0.05]. Approximately 9%, 5% and 18% of the patients met the PA guidelines at baseline, and six weeks and six months after TKA respectively. The proportion of time (% of waking day) patients spent in SB decreased after TKA [baseline: mean (95% CI): 70.1 (67.5-72.7)%; six months: 64.0 (60.6-67.9)%; p=0.009]. The interruptions to SB increased between baseline and six months after TKA [mean (95% CI): 85.0 (80.0-90.0) to 93.0 (88.0-98.0) breaks/day, p=0.014]. There was a significant improvement in WOMAC score [median (interquartile range): 71.0 (27.0) vs. 4.0 (11.3), p<0.001], UCLA score [median (interquartile range): 2.0 (1.0) vs. 5.0 (1.0), p<0.001] as well as ROM [mean range: (0.0 - 90.0)° vs (0.0 - 110)°, p<0.05] between baseline and six months after TKA. Study 2A showed that LPA increased and SB decreased as measured using ActiGraph GT3X+. In addition, self-reported functional capacity (FC) or functional ability (as measured with PROMs) improved after TKA. The third objective (Study 2B) of this thesis was to objectively assess changes in the times spent sitting, standing and walking following TKA and to examine their associations with the changes in PROMs after TKA. The same patients in Study 2A also wore a second activity monitor, the ActivPAL (which accurately measures low intensity activities and posture) for the same periods of time as described in Study 2A above. Patients spent significantly more of their waking wear time walking at six months after TKA (mean% (95% CI): 10.8% (9.4-12.1)), than preoperatively (mean% (95% CI): 8.3% (7.7-10.0)), p=0.039), however, the percentage of daily time spent standing did not change at six months after TKA (mean% (95% CI): 34.2% (29.8-38.6)) compared to percentage time preoperatively (mean% (95% CI): 32.4% (28.6-35.5)), p=0.530). Patients decreased their average daily time spent sitting from preoperative to six months after TKA by 33.7 mins/day (95% CI: -18.9 – 106.3, p=0.099). Patients took significantly more steps per day at six months after TKA [mean (95% CI: 3670 (2886-4020)] steps/day compared to preoperatively 2570 (2366-3189) steps/day, p<0.001. Participants also increased their cadence (steps/min) six months after surgery [mean (95% CI): 33 (31-34) vs. 38 (33-39), p=0.004]. There were no associations between objectively measured changes in the time spent sitting, standing and walking and changes in PROMs (p>0.05). The studies presented in this thesis have novel aspects that extend the body of knowledge on activity behaviours of patients with knee OA undergoing TKA. The studies in this thesis report the first systematic review on changes in SB of knee OA patients following TKA. This thesis is the first to objectively measure the detailed patterns of PA and SB in patients with knee OA undergoing TKA from a low-middle income country (South Africa). Furthermore, this thesis is also the first to use two accelerometers to generate detailed activity behaviour in patients with knee OA undergoing TKA. Lastly, this thesis is the first to assess the association between changes in times spent sitting, standing and walking in relation to changes in health outcomes in knee OA patients after TKA. In conclusion, the systematic review showed that SB has been superficially described and there is insufficient evidence to suggest that time spent in SB decreases following TKA. Majority of the studies reported no change in SB after TKA. The longitudinal study showed that, following TKA, there was a decrease in the overall time spent in SB and an increase in the number of breaks in SB that appeared to be replaced by LPA. Participants’ volume and average daily cadence increased following TKA. In addition, participants decreased their time spent sitting by over half an hour at six months after TKA. However, there were no associations between changes in the times spent sitting, standing and walking and changes in measures of participants’ health outcomes (PROMs) following TKA. Both objective and subjective measures should be used to accurately assess improvements in patients’ health outcomes following TKA. This comprehensive analysis of detailed daily activity behaviours can be used to employ feasible interventions for increasing the duration of LPA (standing and walking) and decreasing sedentary time (sitting/lying) to improve quality of life and overall health following TKA. / XL2019

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences