Page 35 - JCTR-10-5

Marshall et al. | Journal of Clinical and Translational Research 2024; 10(5): 296-306 297
Quadriceps strength loss after TKA is also significant, with the same inclusion and exclusion criteria. Participants between
patients experiencing up to a 60% loss in the 1 month after the ages of 50 and 85 years, who were undergoing a primary
st
surgery [8-10]. Pre-operative quadriceps strength levels are unilateral TKA secondary to end-stage osteoarthritis, were
typically not regained for 6 months [9,10], and, perhaps most consecutively recruited. They were excluded if they had any of
concerning, strength may never reach the levels of aged-matched the following: (i) discharge to a location other than home after
peers without any history of knee pathology [11-15]. Early surgery; (ii) history of heart failure, lymphatic insufficiency,
quadriceps strength loss after TKA is thought to be predominately hepatic disease, pre-existing pitting edema, varicose vein
due to the inability to fully activate the quadriceps muscle ligation, or any other condition associated with chronic swelling
voluntarily, also known as arthrogenic muscle inhibition of either lower extremity; (iii) uncontrolled diabetes; (iv) body
(AMI) [8,16,17]. AMI accounts for 65% of the variance in mass index (BMI) >40 kg/m ; (v) no caregiver or the inability to
2
acute quadriceps strength loss after TKA and is thought to touch toes, which may affect donning/doffing the compression
impede the effectiveness of voluntary strengthening during garment; or (vi) any ongoing neurologic, cardiac, or other
rehabilitation [8,17]. This could explain why even high-intensity, unstable orthopedic conditions that limit the function or ability
progressive resistance protocols after surgery have failed to to participate in outcome measures testing. ICG participants
mitigate quadriceps strength loss [18,19]. The mechanisms were recruited from April 2021 to July 2022 by two orthopedic
underlying AMI are not fully understood, but joint pain [8,16,20] surgeons from one institution in the Denver metro area.
and swelling [21-24] have been implicated. Pain and swelling
may reduce the excitability of the quadriceps by affecting the 2.2. Interventions
afferent discharge of the joint sensory receptors [21].
Researchers and clinicians alike have attempted to 2.2.1. Inelastic compression garment
mitigate swelling after TKA with little success. The use Both ICG and DCG cohorts were measured with the inelastic
of cryotherapy has mixed findings, which may be due to compression garment 1 – 2 weeks before surgery as part of their
variations in study methodology [25-29]. Similarly, the effect baseline testing session. The garment (CircAid Juxtafit upper
of kinesiotape [29-33], manual lymphatic drainage [33-36], leg and knee garment combined with a lower leg garment; Medi
or a combination of both [37] has been inconclusive. The USA, United States of America [USA]) has adjustable straps
use of elastic compression bandages, including modified
Robert Jones bandages, has also proven ineffective after that enable quick and precise setting of various compression
TKA [38-42]. Conversely, the use of an inelastic compression ranges using a standardized garment tensioning tool (Figure 1).
garment has recently displayed promise [36,43]. Carmichael Throughout the intervention period, the garment straps were
et al. [36] found up to 54% less swelling in the first 21 days applied using gradient compression to promote venous and
after TKA when compared to a control group that wore standard lymphatic return using the following pressures: 40 mmHg
elastic, non-adjustable thromboembolic deterrent (T.E.D.) hose (lower leg), 30 mmHg (knee), and 20 mmHg (thigh). Participants
only. In this study, however, the inelastic compression garment were trained in garment donning/doffing preoperatively. They
was not applied until 3 – 4 days after surgery, potentially limiting were asked to wear the garment for 12 waking hours each day,
its ability to maximally mitigate peak swelling. Peak swelling, removing it at night to sleep. They could remove the garment for
not cumulative swelling, has been associated with decreased brief periods throughout the day for hygiene and rehabilitation,
quadriceps strength and functional performance [7]. Applying as needed. Finally, they were asked to wear the garment until
the same inelastic garment immediately after surgery could post-operative day 21.
further attenuate peak swelling and consequently improve patient
recovery.
Therefore, the purpose of this study was to evaluate the
feasibility of an inelastic compression garment donned in
the operating room immediately after TKA (i.e., immediate
compression garment [ICG]). In addition, we sought to
investigate the initial efficacy of ICG on peak swelling,
quadriceps activation, strength, and pain as compared to the
Carmichael et al. [36] study that used the same garment applied
3 – 4 days after surgery (i.e., delayed compression garment
[DCG]). We hypothesized that ICG would be feasible, and,
when compared to DCG, it would have lower peak swelling,
superior quadriceps activation and strength, and reduced pain.
2. Methods

2.1. Study design and participants
This was a prospective feasibility study with a comparison
to a historical cohort (DCG). The ICG and DCG cohorts had Figure 1. Inelastic compression garment

DOI: http://doi.org/10.36922/jctr.24.00026