title: Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation.
abstract: BACKGROUND
  While total knee arthroplasty reduces pain and provides a functional range of motion of the knee, quadriceps weakness and reduced functional capacity typically are still present one year after surgery. The purpose of the present investigation was to determine the role of failure of voluntary muscle activation and muscle atrophy in the early loss of quadriceps strength after surgery.
  
  
  METHODS
  Twenty patients with unilateral knee osteoarthritis were tested an average of ten days before and twenty-seven days after primary total knee arthroplasty. Quadriceps strength and voluntary muscle activation were measured with use of a burst-superimposition technique in which a supramaximal burst of electrical stimulation is superimposed on a maximum voluntary isometric contraction. Maximal quadriceps cross-sectional area was assessed with use of magnetic resonance imaging.
  
  
  RESULTS
  Postoperatively, quadriceps strength was decreased by 62%, voluntary activation was decreased by 17%, and maximal cross-sectional area was decreased by 10% in comparison with the preoperative values; these differences were significant (p < 0.01). Collectively, failure of voluntary muscle activation and atrophy explained 85% of the loss of quadriceps strength (p < 0.001). Multiple linear regression analysis revealed that failure of voluntary activation contributed nearly twice as much as atrophy did to the loss of quadriceps strength. The severity of knee pain with muscle contraction did not change significantly compared with the preoperative level (p = 0.31). Changes in knee pain during strength-testing did not account for a significant amount of the change in voluntary activation (p = 0.14).
  
  
  CONCLUSIONS
  Patients who are managed with total knee arthroplasty have profound impairment of quadriceps strength one month after surgery. This impairment is predominantly due to failure of voluntary muscle activation, and it is also influenced, to a lesser degree, by muscle atrophy. Knee pain with muscle contraction played a surprisingly small role in the reduction of muscle activation.
authors.affiliation: Department of Physical Therapy, 301 McKinly Laboratory, University of Delaware, Newark, Deleware 19716, USA.
authors.forename: Ryan L
authors.initials: RL
authors.lastname: Mizner
authors.forename: Stephanie C
authors.initials: SC
authors.lastname: Petterson
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Stevens
authors.forename: Krista
authors.initials: K
authors.lastname: Vandenborne
authors.forename: Lynn
authors.initials: L
authors.lastname: Snyder-Mackler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction; D018482:Muscle, Skeletal / Q000473:pathology* / Q000503:physiopathology*; D009133:Muscular Atrophy / Q000209:etiology*; D010146:Pain / Q000503:physiopathology; D011184:Postoperative Period; D012044:Regression Analysis; D013848:Thigh