Total Knee Arthroplasty: Difference between revisions

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'''Original Editors - &nbsp;'''  
'''Original Editors '''- [[User:Lynn Wright|Lynn Wright]]


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'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
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== Definition/Description  ==
== Definition/Description  ==


Patients with a total knee arthroplasty have had their total knee joint replaced by a new artificial joint. This replacement has been carried out by a surgical process. One piece of the artificial knee is attached to the femoral condyles, the other is attached to the upper part of the tibia. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.<ref>Palmer, Simon H., and M. J. Cross. "Total knee arthroplasty." Available on http://emedicine. medscape. com (ultimo accesso: 15 maggio, 2009) (2014).</ref> In 50% of the cases the patella is also replaced. Reasons for a patella replacement are osteolysis, maltracking of the patella, failure of the implant,... The aim of the patella reconstruction is to restore the extensor mechanism. It depends on the level of bone loss, which kind of patella prosthesis is placed. The main reason why patients receive a 'new' knee is the presence of osteoarthritis.<ref>Kloiber, J., E. Goldenitsch, and P. Ritschl. "Patellar bone deficiency in revision total knee arthroplasty." Der Orthopade (2016).</ref><br>  
Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee, the femoral condyles and tibial plateau, are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.<ref>Palmer, Simon H., and M. J. Cross. "Total knee arthroplasty." Available on http://emedicine. medscape. com (ultimo accesso: 15 maggio, 2009) (2014).</ref> In 50% of the cases the patella is also replaced. Reasons for a patella replacement are osteolysis, maltracking of the patella, failure of the implant,... The aim of the patella reconstruction is to restore the extensor mechanism. It depends on the level of bone loss, which kind of patella prosthesis is placed. The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function..<ref>Kloiber, J., E. Goldenitsch, and P. Ritschl. "Patellar bone deficiency in revision total knee arthroplasty." Der Orthopade (2016).</ref><br>  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


[[Image:Structures of the knee.png|right|300x300px|The most important structures of the knee]]The [[Knee]] is a hinge joint (articulatio gynglymus). This type of joint permits motion in only one plane. The knee is a special hinge joint; its principal motion is flexion-extension, but rotation is also possible. There are three bones that form the knee joint: the upper part of the [[Tibia]] , the lower part of the femur and the patella. The bones are covered with a thin layer of cartilage, which ensures that there is no friction between the bones and also acts as a kind of shock absorber. On both the lateral and medial sides of the knee, there is a meniscus, which adheres the tibia to the femur, but is also a shock absorber. The three bones are kept together by ligaments and are surrounded by a capsule.<br>
[[Image:Structures of the knee.png|right|300x300px|The most important structures of the knee]] The [[Knee]] is a modified hinge joint, allowing motion through flexion and extension, but also a slight amount of internal and external rotation. There are three bones that form the knee joint: the upper part of the [[Tibia]] , the lower part of the femur and the patella. The bones are covered with a thin layer of cartilage, which ensures that friction is limited between the bones. On both the lateral and medial sides of the knee, there is a meniscus, which adheres the tibia to the femur, but is also a shock absorber. The three bones are kept together by ligaments and are surrounded by a capsule.
 
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== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==
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<u>Pre-operative complaints</u><br>Obesity, age, varus/valgus, previous injuries,...<sup>2</sup> (evidence level: 2a) are deciding factors in the prevalence of knee joint degeneration. Overload and undercharge are equally damaging for the cartilage, alternation between compression and discharge is necessary for correct nutrition of the cartilage.  
<u>Pre-operative complaints</u><br>Obesity, age, varus/valgus, previous injuries,...<sup>2</sup> (evidence level: 2a) are deciding factors in the prevalence of knee joint degeneration. Overload and undercharge are equally damaging for the cartilage, alternation between compression and discharge is necessary for correct nutrition of the cartilage.  


<br>'''Pain<ref>Peat, G., R. McCarney, and P. Croft. "Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care." Annals of the rheumatic diseases 60.2 (2001): 91-97.</ref>'''  
'''Pain<ref>Peat, G., R. McCarney, and P. Croft. "Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care." Annals of the rheumatic diseases 60.2 (2001): 91-97.</ref>'''  


Pain is the main complaint of persons with a degenerated knee joint, and it is mostly felt in the whole knee. However, sometimes the pain can only be felt on the inside, outside or behind the [[Patella]]. At first pain is felt only after rest periods; this is also called ‘starting pain’; after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods, and it can affect sleep at night.  
Pain is the main complaint of persons with a degenerated knee joint, and it is mostly felt in the whole knee. However, sometimes the pain can only be felt on the inside, outside or behind the [[Patella]]. At first pain is felt only after rest periods; this is also called ‘starting pain’; after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods, and it can affect sleep at night.  


<br>'''Stiffness/rigidity'''  
'''Stiffness/rigidity'''  


This is initially felt after night rest, the well-known morning stiffness. This stiffness gradually increases, occasioning the patient difficulty in dressing, putting shoes/socks on and with other daily activities.  
This is initially felt after night rest, the well-known morning stiffness. This stiffness gradually increases, occasioning the patient difficulty in dressing, putting shoes/socks on and with other daily activities.  


<br>'''Walking difficulties '''<br>When degeneration is advanced the patient will continuously limp with pain. After a time the patient may need a walking aid. Instability can also be present in both the varus and the valgus position of the knee. In most cases cycling is often easier than walking.
'''Walking difficulties '''


<br><u>Post-operative complaints</u><br>Stiffness is the most prevalent early local complication of primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.<ref>Etiology and Surgical Interventions for Stiff Total Knee Replacements.</ref> <br>When a knee prosthesis fails, there are several potential painful complications. Knee device failure can be the result of a patient being obese or performing excessive high-impact activities. Sometimes, the prosthesis fails because of the manufacturer’s faulty design.  
When degeneration is advanced the patient will continuously limp with pain. After a time the patient may need a walking aid. Instability can also be present in both the varus and the valgus position of the knee. In most cases cycling is often easier than walking.  


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<u>Post-operative complaints</u>


'''These are the possible complications:'''<br>• Loosening or fracture of the prosthesis components <br>• Joint instability and dislocation<br>• Component misalignment and breakdown<br>• Nerve damage<br>• Bone fracture<br>• Swelling and joint pain<br><br>  
Stiffness is the most prevalent early local complication of primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.<ref>Etiology and Surgical Interventions for Stiff Total Knee Replacements.</ref> <br>When a knee prosthesis fails, there are several potential painful complications. Knee device failure can be the result of a patient being obese or performing excessive high-impact activities. Sometimes, the prosthesis fails because of the manufacturer’s faulty design.


== Differential Diagnosis  ==


<u>Osteoarthritis:</u><br>Osteoarthritis is a degenerative process at the level of the cartilage and should be well distinguished from arthritis, which is about a synovial inflammatory process. Osteoarthritis is the main motivation for total knee arthroplasty. <ref name="Skou et al.">Skou, Søren T., et al. "A randomized, controlled trial of total knee replacement." New England Journal of Medicine 373.17 (2015): 1597-1606.</ref>&nbsp;(evidence level: 1b)


<u>Other differential diagnosis:</u><br>Rheumatoid arthritis, previous injuries to the knee occasioning, for example, the (partial) removal of the meniscus, too much varus or valgus of the knee,... <br>  
'''These are the possible complications:'''<br>• Loosening or fracture of the prosthesis components <br>• Joint instability and dislocation<br>• Component misalignment and breakdown<br>• Nerve damage<br>• Bone fracture<br>• Swelling and joint pain<br><br>  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
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[[Image:Improving blood circulation.jpg|left]]  
[[Image:Improving blood circulation.jpg|left]]  
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• Press the knee down and pull the patella up. This exercise is called the quadriceps setting<br>  
• Press the knee down and pull the patella up. This exercise is called the quadriceps setting<br>  


[[Image:Quadriceps settings.jpg|left]]  
[[Image:Quadriceps settings.jpg|left]]  
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• Put a pillow under the knee and straighten the leg<br>  
• Put a pillow under the knee and straighten the leg<br>  
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[[Image:Straighten the leg.jpg|left]]  
[[Image:Straighten the leg.jpg|left]]  


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• Lift the straightened leg up and: &nbsp;- make circles<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - move inside and outside horizontally.<br>This exercise is important to recuperate full extension in the knee.  
• Lift the straightened leg up and: &nbsp;- make circles<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - move inside and outside horizontally.<br>This exercise is important to recuperate full extension in the knee.  


[[Image:Lift straightened leg.jpg|left]]  
[[Image:Lift straightened leg.jpg|left]]  
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• Glide the heel over the floor, pull the knee up and straighten it back. This exercises the flexion and extension of the knee. This exercise can also be performed later on while the patient is sitting on a chair.<br>Excercises while the patient is sitting down:  
• Glide the heel over the floor, pull the knee up and straighten it back. This exercises the flexion and extension of the knee. This exercise can also be performed later on while the patient is sitting on a chair.<br>Excercises while the patient is sitting down:  

Revision as of 19:23, 10 July 2017

Definition/Description[edit | edit source]

Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee, the femoral condyles and tibial plateau, are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.[1] In 50% of the cases the patella is also replaced. Reasons for a patella replacement are osteolysis, maltracking of the patella, failure of the implant,... The aim of the patella reconstruction is to restore the extensor mechanism. It depends on the level of bone loss, which kind of patella prosthesis is placed. The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function..[2]

Clinically Relevant Anatomy[edit | edit source]

The most important structures of the knee

The Knee is a modified hinge joint, allowing motion through flexion and extension, but also a slight amount of internal and external rotation. There are three bones that form the knee joint: the upper part of the Tibia , the lower part of the femur and the patella. The bones are covered with a thin layer of cartilage, which ensures that friction is limited between the bones. On both the lateral and medial sides of the knee, there is a meniscus, which adheres the tibia to the femur, but is also a shock absorber. The three bones are kept together by ligaments and are surrounded by a capsule.

Epidemiology /Etiology[edit | edit source]

When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The main cause of need for a total knee prosthesis is Osteoarthritis. [3] (evidence level: 1b)  Because of the presence of osteoarthritis, the cartilage of the joint becomes damaged and is no longer able to absorb shocks. There are a lot of external risk factors that can cause knee osteoarthritis. For example: overweight, previous knee injuries, the (partial) removal of a meniscus,... [4]  (evidence level: 2a) Other causes are rheumatoid arthritis, fractures and congenital factors. There might also be some genetic factors in the development of osteoarthritis, but more research is necessary. (evidence level: 2b)
Total knee arthroplasty is mostly performed on women and increases with age.[4]

Characteristics/Clinical Presentation[edit | edit source]

Pre-operative complaints
Obesity, age, varus/valgus, previous injuries,...2 (evidence level: 2a) are deciding factors in the prevalence of knee joint degeneration. Overload and undercharge are equally damaging for the cartilage, alternation between compression and discharge is necessary for correct nutrition of the cartilage.

Pain[5]

Pain is the main complaint of persons with a degenerated knee joint, and it is mostly felt in the whole knee. However, sometimes the pain can only be felt on the inside, outside or behind the Patella. At first pain is felt only after rest periods; this is also called ‘starting pain’; after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods, and it can affect sleep at night.

Stiffness/rigidity

This is initially felt after night rest, the well-known morning stiffness. This stiffness gradually increases, occasioning the patient difficulty in dressing, putting shoes/socks on and with other daily activities.

Walking difficulties

When degeneration is advanced the patient will continuously limp with pain. After a time the patient may need a walking aid. Instability can also be present in both the varus and the valgus position of the knee. In most cases cycling is often easier than walking.

Post-operative complaints

Stiffness is the most prevalent early local complication of primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.[6]
When a knee prosthesis fails, there are several potential painful complications. Knee device failure can be the result of a patient being obese or performing excessive high-impact activities. Sometimes, the prosthesis fails because of the manufacturer’s faulty design.


These are the possible complications:
• Loosening or fracture of the prosthesis components
• Joint instability and dislocation
• Component misalignment and breakdown
• Nerve damage
• Bone fracture
• Swelling and joint pain

Diagnostic Procedures[edit | edit source]

In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient should also undergo an MRI scan of the knee in hospital.
A prosthesis is a device often placed in people with osteoarthritis. Some signs and symptoms are significant for this group of patients who, most commonly, are women, in their fourth and fifth decades of life, with polyarthritis.
However, not a lot is known about this issue, and it is still unclear how the process starts and develops. It is important to recognize that osteoarthritis also impacts the physical and psychosocial life of the patient.

There are also some risk factors we need to keep in mind. It is possible that, after surgery, peri-prosthetic joint infection will occur; this often happens to men, younger than fifty years, diabetic patients. A PJI can be defined as an infection involving the joint prosthesis and adjacent tissue. Commonly reported signs or symptoms of PJI include pain, joint swelling, warmth around the joint, fever,... .[7] We also need to be aware of a patient’s other medical conditions.[8] (evidence level: 1b)

Obesity is also a factor we need to keep in mind, so the best thing to do is to encourage the patient to do something about his or her weight prior to surgery. This will be important for a better and faster recovery.[9] (evidence level: 1b)

Stages Knee OA.jpg

These are the different stages of osteoarthritis that you can see at a MRI. For more information, you can visit the page of Knee osteoarthritis.

Outcome Measures[edit | edit source]

- Knee disability and Osteoarthritis Outcome score (KOOS) to see if there are any difficulties in the execution of daily activities.

- The Timed Get Up and Go Test (TUG) to see whether the patient is able to walk independently after the surgery or if he needs a walking aid.

- Visual Analogue Scale (VAS) to have an idea about the degree of pain the patient is going through.


(also see Outcome Measures Database)

Examination[edit | edit source]

Pre-operative tests
First the examiner should ask the patient about the history of complaints and also about expectations from surgery. He will then examine the knee (comparing it to the other knee) and the body condition in general.
After this different tests could be carried out to determine whether the patient needs total knee arthroplasty:
- Active research to have a full picture of the patient’s functions.
- Passive research: flexion/extension range of motion, measured by a goniometer. The preoperative ROM is a strong predictor of the postoperative ROM after TKR.
- Muscle function examination.

Post-operative tests[10]
- Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an orthopedist or an emergency doctor.
- Palpation: post-operative swelling, hypertonia (adductors), pain and warmth.


Medical Management
[edit | edit source]

Total knee arthroplasty.jpg

The purpose of the surgical procedure is to achieve pain free movement again, with full functionality of the joint, and to recreate a stable joint with a full range of motion.
Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia and a part for the patella (not always) and a polyethylene joint. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate chosen for each patient.
During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.[11] (evidence level: 1b)
The first day after surgery is a rest day. After the second or third day, the medical team starts to mobilize the knee. After day four active exercise therapy can begin in hospital, and will be continued by the physical therapist in the environment where the patient lives. Therapists will train the muscle power and work to achieve a full range of motion again, especially when full extension needs to be re-developed. We aim for the restoration of full flexion, extension and rotation. [12]



Physical Therapy Management
[edit | edit source]

Before surgery:
The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be ready to practice a correct version of the appropriate exercises. In this way recovery can begin very rapidly. It is also important that the functional status of the patient before surgery be as good as possible. This will help recovery after surgery. Furthermore the patient can also start a training program before surgery. The patient has to train his postural control, needs to perform functional exercises and develop the strength of the lower extremities.[13] (evidence level: 1b)

After surgery:
In several studies the effect of physiotherapy after total knee arthroplasty was examined. Generally these studies have shown that physiotherapy is always beneficial. The reports are not always clear regarding the kind of physiotherapy practiced, but all stress the importance of the patient moving. For example aqua therapy, balance training or cycling were added to the basic therapy, but there was no difference between the results obtained by the various therapies. One study compared a group of patients who didn't receive physiotherapy and a group who did. In this study it was clear that physiotherapy actually has its benefits. (evidence level: 1a)

There are four steps in the revalidation process. The first step is mobilizations, then static strength, followed by dynamic strength, and ending with stabilization. The mobilizations and static strength training can be started at almost the same time. The first day after surgery it is important to stimulate blood circulation. Therefore the patient can be asked to perform a flexion and extension with the feed.
Already from day 2, one can start to walk with the patient with an ambulator or walker. The therapist also starts mobilization exercises regarding flexion and extension; usually these exercises are performed on a shuttle bench. The flexion and extension of the knee can also be immediately practiced actively . [14]

The following exercises are examples:
Excercises with the patient lying down

• Pull the feet to you and release. Turn with the feet. This exercise is important to improve the blood circulation.

Improving blood circulation.jpg

• Press the knee down and pull the patella up. This exercise is called the quadriceps setting

Quadriceps settings.jpg

• Put a pillow under the knee and straighten the leg

Straighten the leg.jpg



• Lift the straightened leg up and:  - make circles
                                                       - move inside and outside horizontally.
This exercise is important to recuperate full extension in the knee.

Lift straightened leg.jpg

• Glide the heel over the floor, pull the knee up and straighten it back. This exercises the flexion and extension of the knee. This exercise can also be performed later on while the patient is sitting on a chair.
Excercises while the patient is sitting down:

Heel glide.jpg












• Pull the toes up, so that only the heel stays on the floor

Pull the toes up.jpg













• Straighten the leg; using the other leg to help. This exercise is important to recuperate extension in the knee.

Straighten the leg, using the other leg.png

• Pull the leg up and move it in- and outside.


• Glide the heel over the floor, pull the knee up and straighten them back.

Excercises in standing

• Stand alternating on the heels and toes; a chair can be used to help balance. Stand on one leg and try to put your weight on it.
• Curve gently through your knees. 14 (evidence level: 1b)[15]

Key Research[edit | edit source]

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources
[edit | edit source]

add appropriate resources here

Clinical Bottom Line
[edit | edit source]

The knee prosthesis is the most commonly placed prosthesis in the human body, the main cause is general wear and degeneration of the joint. There are several risk factors, such as obesity, that we have to keep in mind, and cannot underestimate, in this degeneration process with loss of stability and other structural and functional problems.
Pre and post-operative exercise therapy are both shown to be effective, however, further research is needed.

Recent Related Research (from Pubmed)
[edit | edit source]

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References[edit | edit source]

  1. Palmer, Simon H., and M. J. Cross. "Total knee arthroplasty." Available on http://emedicine. medscape. com (ultimo accesso: 15 maggio, 2009) (2014).
  2. Kloiber, J., E. Goldenitsch, and P. Ritschl. "Patellar bone deficiency in revision total knee arthroplasty." Der Orthopade (2016).
  3. Cite error: Invalid <ref> tag; no text was provided for refs named Skou et al.
  4. 4.0 4.1 Blagojevic, M., et al. "Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis." Osteoarthritis and cartilage 18.1 (2010): 24-33.
  5. Peat, G., R. McCarney, and P. Croft. "Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care." Annals of the rheumatic diseases 60.2 (2001): 91-97.
  6. Etiology and Surgical Interventions for Stiff Total Knee Replacements.
  7. Zimmerli, Werner, Andrej Trampuz, and Peter E. Ochsner. "Prosthetic-joint infections." New England Journal of Medicine 351.16 (2004): 1645-1654.
  8. Lee, Qunn Jid, Wai Ping Mak, and Yiu Chung Wong. "Risk factors for peri-prosthetic joint infection in total knee arthroplasty." Journal of Orthopaedic Surgery 23.3 (2015).
  9. Effect of body mass index on functional outcomes following arthroplasty procedures
  10. Jakobsen, Thomas Linding, et al. "Early Progressive Strength Training to Enhance Recovery After Fast‐Track Total Knee Arthroplasty: A Randomized Controlled Trial." Arthritis care; research 66.12 (2014): 1856-1866.
  11. Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, Qiu G. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee. 2014; 21(6): 1263-1268
  12. Total Knee Arthroplasty . A Guide to Get Better Performance, Johan Bellemans Michael D Ries Jan MK Victor , Berlin, Heidelberg : Springer Medizin Verlag Heidelberg, 2005
  13. Huber EO, de Bie RA, Roos EM, Bischoff-Ferrari HA. Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial. BMC Musculoskelet Disord. 2013 May
  14. Artz N,Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD.Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis.BMC MusculoskeletDisord. 2015;16: 15-...
  15. Total Knee Arthroplasty . A Guide to Get Better Performance, Johan Bellemans Michael D Ries Jan MK Victor , Berlin, Heidelberg : Springer Medizin Verlag Heidelberg, 2005