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CONTINUOUS PASSIVE MOTION AFTER PRIMARY TOTAL

KNEE ARTHROPLASTY
DOES IT OFFER ANY BENEFITS?
RICHARD O. POPE,

SHEILA CORCORAN,

KIERAN MCCAUL,

DONALD W. HOWIE

From the Royal Adelaide Hospital, Australia

We report a prospective randomly controlled trial to


examine the effectiveness of continuous passive motion
(CPM) in improving postoperative function and range
of movement after total knee arthroplasty (TKA).
We allocated 53 patients (57 knees) to one of three
postoperative regimes: no CPM (n = 19); CPM at 0 to
40 (0 to 40 CPM; n = 18); and CPM at 0 to 70 (0 to 70
CPM; n = 20). Those in the CPM groups had CPM for
48 hours and all patients had an identical regime of
physiotherapy. There was an even distribution of
various cemented and cementless TKAs in each group.
Patients were assessed preoperatively and at one week
and at one year postoperatively.
At one week, there was a statistically significant
increase in the range of flexion and total range of
movement in the 0 to 70 CPM group compared with the
no-CPM group. At one year we found no significant
differences in mean flexion, overall range of movement,
fixed flexion deformity or functional results in the three
groups. Those who had CPM had a significant increase
in analgesic requirement (p = 0.04). There was an
increased mean blood drainage postoperatively in those
who had 0 to 70 CPM (1558 ml) compared with those
with no CPM (956 ml) (t = 2.96, p = 0.005) and with 0 to
40 CPM (1017 ml) (t = 2.62, p = 0.01).

R. O. Pope, FRACS, Consultant Orthopaedic Surgeon


D. W. Howie, PhD, FRACS, Professor and Head
Department of Orthopaedics and Trauma
S. Corcoran, BSc, Dip Physio, Supervising Physiotherapist,
Orthopaedics
Department of Physiotherapy
Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000,
Australia.
K. McCaul, MPH, Head, Health Statistics Unit
Epidemiology Branch, PO Box 6, Rundle Mall, South Australia 5000,
Australia.

Our findings show that CPM had no significant


advantage in terms of improving function or range of
movement, and that its use increased blood loss and
analgesic requirements.
J Bone Joint Surg [Br] 1997;79-B:914-7.
Received 13 December 1996; Accepted after revision 14 May 1997

Continuous passive motion (CPM) has been suggested as


treatment for many conditions affecting the synovial
1-5
joints such as full-thickness defects of articular cartil3,4
5
6
age, acute septic arthritis and haemarthroses. It has also
been shown to induce neochondrogenesis in free intra4,7
articular periosteal autografts.
The claimed beneficial
effects include good compliance, relative freedom from
pain, maintenance of range of movement, and a reduced
incidence of complications. CPM has thus been advocated
for the postoperative management of total knee arthroplasty
8
(TKA). Coutts, Toth and Kaita reported that it increased
the rate at which full range of movement returned, reduced
the hospital stay, decreased pain and the need for manipulation under anaesthesia, enhanced wound healing and
reduced the incidence of deep-vein thrombosis.
9
Ritter, Gandolf and Holston have challenged these
results, stating that the disadvantages included an increase
in flexor tightness around the knee resulting in an extension
lag, an increased length of time spent in bed limiting
walking, considerable purchase and maintenance costs,
increased need for physiotherapy, and mismatching of the
unit due to different leg sizes and shapes. They also
suggested that CPM affected only the range of movement
and swelling and not muscular activity or power.
We aimed to determine whether CPM plus physiotherapy
soon after TKA improved fixed flexion or maximal flexion
or functional score compared with physiotherapy alone. We
also recorded other variables such as analgesic requirement,
blood loss and complications.

Correspondence should be sent to Dr R. O. Pope at Wakefield Orthopaedic


Clinic, 270 Wakefield Street, Adelaide, South Australia 5000, Australia.

MATERIALS AND METHODS

1997 British Editorial Society of Bone and Joint Surgery


0301-620X/97/67516 $2.00

Between April 1988 and April 1989 we performed a prospective study on all patients having a primary TKA,

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THE JOURNAL OF BONE AND JOINT SURGERY

CONTINUOUS PASSIVE MOTION AFTER TKA

Table I. Details of the patients in the three treatment groups


Gender

Age in years

Group

Male

Female

Mean

No CPM
CPM 0 to 40
CPM 0 to 70

5 (27.7)*
6 (35.3)
9 (50.0)

13 (72.2)
11 (64.7)
9 (50.0)

69.6 (64.4 to 74.98) 57 to 79


72.5 (70.0 to 75.0)
61 to 84
72.7 (70.4 to 75.0)
63 to 82

Range

* percentage
95% confidence interval

performed by one of six orthopaedic surgeons. The patients


were assessed and examined preoperatively and were randomly allocated according to admission to one of three
treatment groups: no CPM, CPM 0 to 40 and CPM 0 to 70.
Two patients with preoperative fixed flexion deformities of
over 30 were excluded.
Initially, there were 62 patients (70 knees), but one
patient (two knees) was excluded because CPM continued
beyond 48 hours and another because of postoperative
instability. Seven patients were not reviewed: one died
from pulmonary embolism, one had a psychiatric illness
and five live at an excessive distance from the hospital.
This left 53 patients (57 knees) who were reviewed at 12
months postoperatively. Four had a staged second TKA
during the study period, for which postoperative CPM was
again randomly allocated. There were 19 knees in the no
CPM group, 18 in the 0 to 40 CPM group and 20 in the 0
to 70 CPM group.
Table I gives details of the patients. There was no
significant difference in gender in the three treatment
groups, although the no-CPM and 0 to 40 CPM groups had
more females than the 0 to 70 CPM group (p = 0.04), or in
the age of the patients (p = 0.6). Of the 57 knees, 49 had
osteoarthritis and 8 rheumatoid arthritis.
At each assessment we recorded the range of movement
of the knee by goniometer, the patients mobility and need
10
for walking aids, each scored out of 10 points. Pain
11
disability scored a maximum of 50 points, giving a total
maximum score of 70.
We compared blood loss in Redivac drainage postoperatively, since tourniquets were not released until the
wounds had been closed. No prophylactic anticoagulation
was used. We recorded and compared the narcotic analgesic
requirement until the time of discharge. To correct for
different narcotic analgesics we converted dosages to milligrams of morphine (10 mg of morphine = 20 mg of Omnopon = 100 mg of pethidine).
Patients were reviewed at three and six months postoperatively, having been assessed by at least one of the
authors at one week in hospital. All attended a research
clinic at 12 months.
Postoperative management The no-CPM group had the
affected knee placed in an extension splint in the recovery
room, and patients in all three groups began physiotherapy
the next day. The splint was removed twice daily for a
standard exercise regime which involved ten of each of the
following exercises: static quadriceps contraction over a
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915

rolled towel, attempted straight-leg raising, active knee


flexion and extension through the maximum possible range,
static gluteal contractions and ankle pumping. The splint
was removed from the no-CPM group on the third day.
Patients in all groups started to walk on day three with no
subsequent restriction of active movement.
In the CPM groups the machine was applied to the
affected limb in the recovery room. The 0 to 40 CPM
patients had an initial range of 0 to 40 increased by 10
twice, on the day after surgery and on the following day, so
that flexion of 0 to 60 had been achieved before removal
of the machine at 48 hours. The 0 to 70 CPM group started
at a flexion range of 0 to 70 increasing to a final range of
0 to 90. CPM was on for at least 20 out of every 24 hours
and was set at the slowest speed so that one cycle took 1.5
minutes.
We considered that a clinically significant difference
would be a difference in knee flexion of 15, which is the
difference between normal gait and that required to descend
12
11
average stairs. The PCA knee score system also accepts
that an increase of 15 is needed to move a knee score from
reasonable to maximum. The mean range of flexion reported after cemented and cementless TKA is from 102 to 108
using bandage immobilisation for three days followed by
13
active and active-assisted exercises.
We calculated the power of our study from the standard
deviation of preoperative flexion in the group which
14
received no CPM (n = 19, SD = 18). The power to detect
a difference of 15 in flexion was calculated to be 73%. The
minimum difference that the study could detect with a
power of 80% was 16 of flexion. The sample size of our
study was therefore deemed adequate.
Statistical analysis. We used analysis of variance (ANOVA) or of covariance (ANCOVA) where appropriate for
differences between the three groups. The four patients
with bilateral TKRs introduced a degree of covariance
between observations. To ensure that the calculated p
values and standard errors correctly reflected this dependency in the data, we performed the analysis using PROC
15
MIXED in SAS. This allowed individual patients in the
study to be modelled as random effects, thus adjusting for
any covariance between observations within the same
individual.
Neither fixed flexion deformity nor functional score
showed normal distributions. A Kruskal-Wallis analysis of
variance assumes that all test subjects are independent,
which was not the case. We therefore transformed the
difference in functional scores and the difference in fixed
16
flexion using a Box-Cox transformation and performed
the analysis using a random-effects ANOVA as described
above.
RESULTS
There were some differences at one week after operation,
but after one year all three groups had achieved ranges of

916

R. O. POPE,

S. CORCORAN,

K. MCCAUL,

D. W. HOWIE

Table II. Mean fixed flexion deformity (FFD), flexion and range of movement (ROM) in degrees, with associated 95% confidence intervals,
preoperatively and at one week and one year postoperatively
FFD

Flexion

Preop

1 week

1 Year

ROM

Preop

1 Week

1 Year

Preop

1 Week

1 Year

No CPM

11.8
6.2
7.1
105.8
56.8
100.0
93.9
50.5
92.9
(7.7 to 16.0) (3.2 to 9.2) (4.3 to 9.9) (97.5 to 114.1) (48.5 to 65.2) (92.7 to 107.3) (83.5 to 104.4) (41.5 to 59.6) (85.1 to 100.7)

CPM 0 to 40

7.2
11.3
6.9
104.2
70.3
103.8
96.9
58.6
96.9
(3.0 to 11.5) (7.9 to 14.7) (4.1 to 9.8) (95.7 to 112.7) (61.7 to 78.9) (96.4 to 111.3) (86.3 to 107.6) (49.3 to 67.9) (88.9 to 104.9)

CPM 0 to 70

7.8
8.2
5.3
101.8
78.3
102.0
94.0
69.5
96.8
(3.7 to 11.8) (4.5 to 11.9) (2.6 to 7.9) (93.7 to 109.8) (70.1 to 86.4) (83.9 to 109.1) (83.9 to 104.1) (60.7 to 78.3) (89.2 to 104.3)

Table III. Median (range) functional scores recorded preoperatively


and at one year postoperatively for the three treatment groups
Functional score
Preop
No CPM
CPM 0 to 40
CPM 0 to 70

Table IV. Mean blood loss (ml) and analgesia (mg morphine), with
95% confidence intervals, required postoperatively for the three
treatment groups

Postop

33 (0 to 58)
29 (0 to 56)
29 (0 to 58)

No CPM
CPM 0 to 40
CPM 0 to 70

52 (25 to 70)
56 (20 to 70)
52 (10 to 70)

movement comparable with their preoperative state. At one


year, we found no significant differences between the
groups for mean flexion, overall range, fixed flexion
deformity or functional results.
Flexion. Table II shows mean fixed flexion deformity,
mean flexion and mean range of movement for each of the
three groups preoperatively and at one week and one year
postoperatively. After adjustment for preoperative levels,
the mean fixed flexion deformity at one year was 7.1 in the
group that received no CPM, 6.9 in the 0 to 40 CPM group
and 5.3 in the 0 to 70 CPM group. These differences were
not statistically significant (p = 0.32).
Mean flexion at one year was 100.0 for the no-CPM
group, 103.8 for the 0 to 40 CPM group, and 102.0 for the
0 to 70 CPM group (p = 0.67). The range of movement at
one year was 92.9 for no CPM, 96.9 in the 0 to 40 CPM
group and 96.8 in the 0 to 70 CPM group (p = 0.74).
Functional score. Table III shows the median functional
scores preoperatively and at one year. Within each group
there was a significant improvement, but there was little
difference between groups. The difference in functional
score calculated for each individual and transformed using
a Box-Cox method also showed no significant difference
between the three groups (p = 0.80).
Blood loss and analgesia. Table IV shows the mean blood
loss and mean level of postoperative analgesia required for

Blood loss

Analgesia

956 (671 to 1242)


1017 (724 to 1311)
1558 (1280 to 1837)

48.1 (32.3 to 63.9)


72.6 (56.3 to 88.8)
81.5 (66.1 to 96.9)

each group. Patients who received no CPM lost an average


of 956 ml of blood compared with 1017 ml for the 0 to 40
CPM group and 1558 ml for the 0 to 70 CPM group. These
differences were significant (p = 0.008). There was no significant difference between the no-CPM and the 0 to 40
CPM group (p = 0.77), but between the 0 to 40 and the 0 to
70 CPM groups the difference was significant (t = 2.62,
p = 0.01.
We had used both cemented and cementless prostheses
(Table V). Addition of the type of prosthesis to the above
model did not significantly improve its fit (F1,52 = 0.23,
p = 0.64), but the significance of CPM group remained
(p = 0.01). Patients receiving a cementless prostheses lost
an average of 103 ml more blood than those who had a
cemented prosthesis.
The mean analgesic requirement (Table IV) in the noCPM patients (48.1 mg) was lower than for the other two
groups (0 to 40, 72.6 mg; 0 to 70, 81.5 mg; p = 0.01). The
no-CPM group required a much lower level of analgesia
than the 0 to 40 group (p = 0.04), but there was no significant difference between the CPM groups (p = 0.45).
Complications. One patient in the no-CPM group required
manipulation under anaesthesia for poor range of movement, two in the 0 to 40 CPM group required revision due
to patellar dislocation, and one patient in the 0 to 70 CPM
group died from pulmonary embolism.

Table V. Prosthesis type, cemented or cementless, by study group


Kinematic
No CPM
CPM 0 to 40
CPM 0 to 70

Miller-Galante

Whiteside

Cemented

Cementless

PCA
Cemented

Cementless

Cemented

Cementless

Cemented

Cementless

1
-

4
2
2 (1)

2
6 (2)
8 (1)

2 (2)*
1

6 (5)
5
4 (3)

4
5
5 (3)

* numbers in parentheses represent those which had patellar replacement (these components are always cemented)
THE JOURNAL OF BONE AND JOINT SURGERY

CONTINUOUS PASSIVE MOTION AFTER TKA

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18

DISCUSSION
9

Our findings support those of Ritter et al in confirming no


significant difference in ranges of movement after one year.
We also compared two different regimes of CPM and also
found that the 0 to 70 CPM group had significantly more
pain and increased blood loss. A longer period of time on
9
CPM may have been more beneficial, but Ritter et al
investigated five days on CPM, finding no significant benefit over physiotherapy alone.
1
Basso and Knapp studied the duration of CPM in each
24 hours, finding no advantage in full 24-hour use over five
17
hours per day. Nielsen, Rechnagel and Nielsen compared
CPM for two hours twice daily plus physiotherapy with
physiotherapy alone and found no difference in the final
range of movement.
8
Coutts et al reported that a 0 to 70 CPM group required
more analgesia postoperatively, but recorded only the frequency of requests and did not state the administration
mode or the dose. We consider that the increased pain on
CPM is a clinically significant problem in terms of
increased nursing requirements and therefore increased
costs of patient care.
We found that an increase in blood loss in the 0 to 70

CPM group was another disadvantage. Goletz and Henry


used 0 to 30 CPM, increasing by 10 to 15 daily, and
found no difference in blood loss compared with a control
19
group. Campbell reported increased blood loss with
CPM; 40% of patients in the control group required transfusion compared with 70% of the CPM group. Avoidance
of transfusion is important to minimise the transmission of
disease. We did not record the duration of time in hospital
since discharge was governed more by social circumstances
and the timing of ward rounds than by the ranges of
movement.
9
We support the findings of Ritter et al that CPM plus
physiotherapy does not improve the range of movement at
one year after TKA when compared with physiotherapy
alone, and we found no differences in function. Coutts et
8
al had different results probably because they compared
CPM with immobilisation in plaster for four days with no
physiotherapy.
We have shown definite clinical disadvantages in the
short term in our CPM groups with no worthwhile
improvement in the range of movement or function.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.

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