Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-012-2144-x

KNEE

Improved single-limb balance after total knee arthroplasty

Sung Do Cho Chang Ho Hwang

Received: 22 December 2011 / Accepted: 16 July 2012

Springer-Verlag 2012

Abstract
Purpose Unsteady ambulation shortly after total knee
arthroplasty (TKA) may cause falling. Postural sway may
predict the risk of falling. This prospective single-blinded
observational study therefore evaluated the effects of TKA
on single-limb standing balance (SLSB) and factors related
to change in SLSB.
Methods Patients with varus deformity and medial compartment degeneration were evaluated between September
and December 2010. The Western Ontario and McMaster
Universities Osteoarthritis Index and Kellgren/Lawrence
scale were assessed, as were varus angle, number of painful
knees, isometric peak torque of the quadriceps femoris,
balance index of double limbs, and postural sway of single
limbs.
Results Twelve patients were enrolled and 11 were analysed. The mean SD postural sway of single limbs
(i.e., SLSB) was reduced significantly after TKA, from
30.3 20.8 cm to 18.5 9.3 cm (p = 0.02). Amelioration was in proportion to pre-operative postural sway
(b = 0.92).
Conclusions SLSB in patients with varus knees with
osteoarthritis was improved significantly 11 days after
TKA. Poorer pre-operative SLSB was associated with
better post-operative SLSB. TKA may be useful for

S. D. Cho
Department of Orthopedic Surgery, Ulsan University Hospital,
University of Ulsan College of Medicine, 290-3 Jeonha-dong,
Dong-gu, Ulsan 682-714, Republic of Korea
C. H. Hwang (&)
Department of Physical Medicine and Rehabilitation, Ulsan
University Hospital, University of Ulsan College of Medicine,
290-3 Jeonha-dong, Dong-gu, Ulsan 682-714, Republic of Korea
e-mail: chhwang1220ciba@yahoo.co.kr

the immediate reduction of falling in patients with

osteoarthritis.
Level of evidence Therapeutic study, case series, Level
IV.
Keywords Knee
Osteoarthritis
Arthroplasty

Postural balance

Introduction
Patients with osteoarthritis (OA) of the knee may show
impairments in proprioception [2, 3, 24] and standing
balance [14, 27]. For example, postural sway was greater
in 77 patients with knee OA than in normal subjects [14]
and was increased in 314 elderly patients with radiographic knee OA [27]. This increased postural sway may
lead to falls and consequent fractures. The risk of falls in
patients with hip and knee OA was found to be associated with impaired standing balance, but with impaired
proprioception [9]. Impairments in proprioception and
standing balance are important issues in OA patients
undergoing total knee arthroplasty (TKA), since a history
of falls prior to surgery is a risk factor for similar
accidents within 1 year after TKA [38]. Since OA
patients show a distorted response to abrupt perturbation
[6, 37], and single-limb standing is more difficult to
maintain than double-limb standing, falls are more likely
to occur during single-limb support. It may therefore be
more informative to evaluate single limb rather than
double-limb standing balance, although most studies to
date have focused on the latter.
Decreased proprioception in knee OA patients has been
found to improve following TKA [20, 37]. Although many
studies have assessed standing balance following TKA,

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Knee Surg Sports Traumatol Arthrosc

most were performed from 2 months to 1 year after TKA

[1, 11, 12, 17, 33]. Studies assessing immediate postoperative changes in standing balance reported that TKA
did not have an immediate restorative effect [1, 11, 12, 17].
An understanding of standing balance in OA patients
undergoing TKA may be useful in assessing risks of falling, especially during the rehabilitative period when
ambulation is at its most unsteady [39].
TKA has been shown to improve standing balance about
6 months after surgery [37]. The anatomical correction of
bone and soft tissue structures immediately after TKA may
substantially alter afferent sensations around the knee [17,
36], resulting in changes in standing balance. We therefore
hypothesized that TKA may improve single-limb standing
balance (SLSB). We therefore evaluated the effect of TKA
on SLSB in knee OA patients and sought to identify factors
predictive of pre- and post-operative SLSB. To the best of
our knowledge, this is the first study to evaluate pre- and
post-TKA SLSB in knee OA patients.

Materials and methods

This prospective, single-blinded (i.e., assessor-blinded),
clinical observational study was performed on in-patients
at a general hospital from September to December 2010.
All participants wore long trousers and a mask so that the
assessor was blinded as to whether TKA had been performed. The study protocol was approved by our institutional review board, and all patients provided written
informed consent. This trial has been registered at ClinicalTrials.gov (NCT01192334).
Patients with radiographic varus deformity and medial
compartment degeneration who were scheduled for unilateral TKA were recruited. We excluded patients with a
history of surgery on the same leg, except for arthroscopy;
patients who had participated within the prior 6 months in
a sports training programme designed to improve leg
function; patients with arthritis or serious pain in the lower
back or hip that affected standing; patients with neurological or musculo-skeletal disorders that affected standing; patients not classified as American Society of
Anesthesiologists physical status class IIII; and patients
who refused to participate.
Prior to TKA, all patients underwent evaluation by a
single orthopaedic surgeon. Methods of evaluation included the Western Ontario and McMaster Universities
Osteoarthritis (WOMAC) Index [4], the Kellgren/Lawrence (KL) scale [21], a visual analogue scale (VAS) for
pain, the varus angle made by the intersection of the line
along the long axis of the femur and tibia on a simple AP
X-ray while standing [25], and the number of painful knee
joints. In addition, a single physiotherapist assessed the

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maximum isometric peak torque of the quadriceps femoris,

the balance index, and the postural sway of each patient.
Postural sway was considered a measure of SLSB.
After one rehearsal using sub-maximum effort, peak
torque was determined by measuring the full isometric
contraction of the quadriceps femoris with a 60.0 adjustment of knee flexion for 5.0 s. This task was performed 3
times, at intervals of 15.0 s, and the highest score was
chosen [18].
Dynamic standing balance of double limbs was determined using the Biodex Stability System (Biodex Medical
Systems, New York, USA), an unsteady platform that
could tilt in the coronal and sagittal planes with real-time
resistance to tilting and connected to a data-gathering
computer. After warming up at the easiest level, patients
were asked to stand on an unstable platform set at a low
level of difficulty (i.e., more resistant to tilting: level 8) and
to maintain standing balance for 20.0 s with both arms
adducted to the flank, staring forward at a fixed point, and
with medial ankle surfaces touching. After 3 such trials, the
level of difficulty was increased (i.e., less resistant to tilting: level 6), and patients performed another 3 trials at this
level [37]. A safety bar was used if serious unsteadiness
occurred (Fig. 1). A balance index was calculated by
measuring the amount of time the board spent in a deviated

Fig. 1 Evaluation of double-limb standing balance (the balance

index)

Knee Surg Sports Traumatol Arthrosc

position and the degree of angulation from the neutral

centre. The inter-class correlation coefficient of this balance index ranged from 0.4 to 0.9 [16]. Preliminary test
retest reliability on our measurement ranged from 0.7 to
0.8.
Static balance performance for postural sway was
assessed using a horizontal plain stationary force platform
(RMI, CEGEDIM, Boulogne-Billancourt, France) that
sensed weight distribution and determined pressure shifts
(60.0 Hz sample rate) using electrical-coupled monitoring
of the horizontal and perpendicular forces [7]. SLSB was
determined by monitoring balance performance of a single
limb with eyes open or closed [34]. Patients were asked to
place one bare foot of a single leg on the centre of the
platform, with the contra-lateral knee in flexion at 90.0,
the hips in a neutral position, and both arms facing the
flanks, asked to hold a standing posture for 10.0 s as calmly
as possible while looking forward at a fixed spot. This trial
was performed 3 times. If standing lasted less than 10.0 s
in any of the 3 trials, the task was performed for a total of
10 trials, and success or failure was recorded. The same
task was subsequently performed 3 times with eyes closed.
A safety bar was used if serious unsteadiness occurred. The
mean value of 3 successful trials was recorded (Fig. 2).
Since postural sway had a bi-variate distribution of weight
in two dimensions, the raw data on displaced lengths of
the anteriorposterior and mediallateral postural sway

coordinates were collected simultaneously and used to

calculate total postural sway. The intra-class correlation
coefficient of balance performance by a normal population
has been reported to range from 0.7 to 0.9 [13]. Preliminary
testretest reliability on our measurement ranged from 0.6
to 0.9. In a preliminary evaluation, we found that the mean
pre-operative postural single-limb sway of three knee OA
patients was 27.9 19.8 cm.
TKA was performed using a posterior-stabilized cruciate sacrificing method with a medial para-patellar approach
and patellar distraction. The implants were of fixed bearing
type, either Advance Medial Pivot (Wright Medical,
Arlington, TN, USA) or Nexgen LPS (Zimmer, Warsaw,
IN, USA), and were cemented using Simplex P (Howmedica, Rutherford, NJ), which covered the entire inner
side of the femoral implant including the posterior condylar
part, aligned with tibial and femoral alignment guides, and
as many sub-periosteal releases as needed. Post-operative
pain was controlled by intravenous patient-controlled
analgesia.
Patients commenced physiotherapy, consisting of passive range of motion exercises, cold packs, and full weight
bearing, as soon as possible after surgery.
The WOMAC index and postural sway were measured
on the day the post-operative VAS pain score matched the
pre-operative score. Balance index and peak torque were
not assessed due to the possibility of accidents, including
falls, or loosening of the implanted metal.
Statistical analysis

Fig. 2 Evaluation of single-limb standing balance (balance performance monitoring)

Data were analysed using WilcoxonMannWhitney

U tests, paired t-tests, and multiple regression analysis,
using two-tailed and parametric methods. All calculations
were performed using SPSS 17.0KO for Windows (SPSS
Inc, Chicago, Illinois, USA). An a level of \0.5 was
considered significant, and a power value of 80 % was
applied. The drop-out ratio was predicted to be 20 %.
Based on a previous study [17], we predicted a standardized difference of 1.2 for postural sway. Using the Altman
nomogram, we calculated that the study required 12
patients, accounting for possible dropouts. Differences in
pre- and post-operative postural sway were analysed using
paired t-tests, with sub-group comparisons in patients with
1 or 2 painful knee joints analysed by using Wilcoxon
MannWhitney U tests. ShapiroWilk tests and histograms
were used to confirm that variables were distributed normally. VAS pain score and the number of painful knee
joints were natural log transformed because they showed
right deviated distributions. Multiple linear regression
analysis with stepwise selection was used to investigate
correlations factors associated with postural sway, including the WOMAC index, varus angle, VAS pain score,

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Knee Surg Sports Traumatol Arthrosc

number of painful knee joints, maximum isometric peak

torque of the quadriceps femoris, and balance index. The
KL scale was analysed using multiple linear regression
analysis with dummy variables because the scale was an
ordinal variable.

Results
Of the 36 patients evaluated, 21 were excluded, mostly due
to requirements for bilateral TKA, and 3 patients refused to
participate. Twelve patients were recruited between September and November 2010, but one dropped out due to
incomplete post-operational assessment; thus, 11 patients
were analysed (Table 1). All participants underwent baseline assessment 4.5 1.4 days before surgery and followup assessment 11.3 1.0 days after surgery.
Post-operatively, mean maximum flexion of the knee was
110.7 15.9, and mean extension was -2.1 3.7.
Maximal flexion and extension were defined as the terminal
range of motion at which a patient first felt minimal pain.
Of the 11 patients, 10 could perform single-limb
standing for 10.0 s with eyes open, although one could
complete this task with eyes closed; thus, data on SLSB
with eyes closed were excluded from statistical analyses.
Postural sway was reduced significantly, from 30.3 20.8 cm
preoperatively to 18.5 9.3 cm postoperatively (mean

Table 1 Pre-operative and post-operative characteristics (N = 11)

Characteristics
Male/female (number)

0/11

Age (year)

61.7 7.3

Day from 1st evaluation to surgery

4.5 1.4

Day from surgery to 2nd evaluation

11.3 1.0

VASa (log value)

2.0 0.1

Quadriceps femoris peak torque (N-m)

62.4 31.0

KL scale

3.6 0.2

BIc (easy mode)

1.1 0.2

BI (difficult mode)

1.2 0.6

Number of painful knee joint (log value)

0.6 0.3

Pre-operative

Post-operative

WOMAC indexd

60.2 6.9

55.1 12.5

Postural sway of single limb (cm)

30.3 20.8

18.5 9.3

Varus angle (Degrees)

11.8 7.5

3.8 3.5

Values are mean SD

a

Visual analogue scale

Kellgren/Lawrence scale

Balance index

Western Ontario and McMaster Universities Osteoarthritis Index

123

difference, 12.6 15.5 cm; p = 0.02). There were no significant differences between sub-groups with unilateral and
bilateral painful knees (n.s.).
The F value for post-operative SLSB improvement was
36.1 (p = 0.01), indicating that the model was statistically
significant and that at least one variable was significantly
associated with improved SLSB. The R2 value was 0.84,
indicating that 84 % of SLSB improvement was due to
these variables. We found that the only variable associated
with SLSB improvement was pre-operative postural sway.
The variance inflation factor (VIF) was 1.0, indicating an
absence of multicolinearity; and the b coefficient was 0.92,
indicating a positive correlation. No other pre-operative
factors, including age, VAS pain score, varus angle, BI,
number of painful knee joints, WOMAC index, peak torque, or KL scale, were correlated with SLSB improvement.
Multivariate analysis assessed whether factors such as
age, VAS pain score, varus angle, BI, number of painful
knee joints, WOMAC index, peak torque, and KL scale
were associated with pre-operative SLSB. None of these
variables was a significant predictor of pre-operative
SLSB.
None of the patients experienced any serious accidents,
including falls or fractures during testing.

Discussion
Our key results were that patients regained previously
impaired SLSB 11 days after TKA in varus knees and that
these improvements were proportional to the degree of
decreased SLSB. TKA resulted in a 59.0 % reduction in
the postural sway of single limbs from 30.3 20.8 cm to
18.5 9.3 cm.
Prompt improvement in SLSB may be due to reduced
inhibition from motor activation resulting from decreases in
joint effusions, pain and/or inflammation, and by changes in
the resting length and functional range of muscles [17].
These factors, however, were likely not responsible for the
improvements observed in our patients, because the time
from surgery to follow-up assessment (11.3 1.0 days)
was too short to cause changes in these variables. Similarly,
no improvements in arthrogenic muscle inhibition were
observed 4 weeks after extensive knee injury [19].
Kinaesthesia and proprioception are critical for controlling
motor performance and coordination [10], with impairments in kinaesthesia and proprioception having negative
effects on standing balance [37]. Decreased join space has
been associated with impaired joint sensation, and normalization of joint space following TKA may have a
positive effect on joint sensation [36]. Thus, TKA can
improve joint sensations [37], enhancing standing balance.
Microscopically, many factors may be involved in these

Knee Surg Sports Traumatol Arthrosc

changes. Surgical release of the tight ligaments and joint

capsule may induce changes in the mechanical properties of
joint receptors and subsequent alteration of afferent sensory
information [17]. Patients with knee OA show distorted
patterns of motor activation [6] and impairments in the
response of motor coordination to abrupt perturbations [37].
Correction of mal-alignment may diminish lift-off of the
lateral condyle and subsequent loadings on lateral structures
[17], as well as restoring stability and motor activation.
These combinations of corrected afferent senses and instability may improve SLSB. However, we could not definitely
rule out the simple effects of analgesia and physiotherapy
on post-operative pain.
It was found that pre-operative postural single-limb
sway was a comparatively strong predictor of SLSB
improvement after TKA (p = 0.01, b = 0.92). Surprisingly, this relationship was found to be an inverse one, with
poor pre-operative SLSB being a predictor of good postoperative SLSB. This relationship appears to be unique to
TKA, since a previous study reported no such relationship
between pre- and post-operative SLSB in patients undergoing a medial tibial osteotomy [17]. The difference
between studies, however, may be due to differences in
mean subject age (46.0 vs. 61.7 years) and mean degree of
mal-alignment correction (6.7 vs. 8.0). It correlates with
our finding that a posterior-stabilized TKA improves the
clinical outcomes significantly in patients with severe
preoperative varus deformity than in patients with mild
deformity [26]. Patients with bilateral knee OA and severe
structural destruction show better joint stability, indicative
of good SLSB, likely due to enhanced co-contraction of the
quadriceps and hamstring muscles and increased stiffness,
similar to patients with Parkinsonism [18]. That is patients
with poor pre-operative SLSB had shakier joints due to less
co-contraction of muscles than those with better SLSB,
suggesting that the former were at earlier stages of
impairment and had flexible functional ranges of muscle
motion and greater likelihood of improvement. Recovery
of voluntary activation deficits and maximal voluntary
contraction of the quadriceps femoris [5] or interlimb
symmetrization of kinematic and kinetic variables,
including ground reaction force, loading rates, knee flexion
stiffness, and knee flexion excursion [31], after TKA may
positively affect improvement, but time of assessment, 33
or 28 months respectively after TKA, should also be considered. Another possible explanation is the ceiling effect.
To the best of our knowledge, there has been only one
study of SLSB in elderly individuals (6085 years) in the
normal population [8]. If pre-operative SLSB scores are
around the upper limits of measurement, their improvement
would be dampened. Previous studies in patients with
degenerative knee OA have shown that radiographic
severity, isometric quadriceps peak torque, number of

aching knees, varus angle, and pain intensity were predictors of SLSB [18]. However, it was found that none of
these factors was associated with SLSB improvement.
Other interventions for improving standing balance have
been tested, with elastic bandages [15] and long-term
exercise [30] showing benefits in these patients. However,
the effects of TKA in OA patients remain unclear. In
contrast to our findings, total hip arthroplasty did not
improve SLSB in patients with hip OA [35]. However,
TKA did not have a negative effect on standing balance
[28], and standing balance improved [6 months after TKA
[37]. Although the latter finding is similar to ours, that
study assessed double-limb standing balance rather than
SLSB and evaluated standing balance 6 months after TKA.
Although previous studies reported that radiographic
severity, isometric quadriceps peak torque, varus angle,
number of aching knees, and pain intensity were predictors
of SLSB [18], it was found that none of these variables was
not a predictor of SLSB. Our findings, however, may have
been due to the small patient population.
Variables should be standardized. Radiographic severity, isometric quadriceps peak torque, varus angle, number
of aching knees, and pain intensity have been shown to
predict SLSB in patients with degenerative knee OA [18].
Although pain varies by time of day, medications, and
physiotherapy sessions, we measured post-operative SLSB
on the day the post-operative pain VAS score matched the
pre-operative score in each patient. The mean period
between the pre- and post-operative measurements was
11.3 days, which is a short period for asymptomatic knees
to develop new pain, thereby standardizing pain intensity
and the number of painful knees. Although other measurements, including radiographic grade, quadriceps peak
torque, and varus angle, could not be standardized, the
removal of defective bone during TKA is so complete that
radiographic severity is no longer a meaningful parameter.
Moreover, the key aim of TKA is to correct any varus
deformity; therefore, hence, varus angle is unlikely to
influence comparisons. Isometric peak torque may have
some effect on post-operative SLSB. However, time is
required for torque strengthening, and our measurements
were performed prior to the likelihood of isometric peaktorque strengthening.
Although all recruited patients were representative of
middle-aged individuals undergoing TKA for knee OA, the
deviation in sex ratio, pain intensity (mean VAS of
7.6 1.0), and disease severity (mean KL scale of
3.6 0.2) did not encompass all patients with knee OA.
Since knee OA occurs more in women than in men, and
most TKAs are performed only when severe pain disturbs
activities of daily living and structural destructions are
prominent, our results may be applicable to patients
scheduled to undergo TKA. TKA is performed on only one

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Knee Surg Sports Traumatol Arthrosc

peripheral joint and is designed to correct its mal-alignment.

However, the consequences of TKA are applicable to the
entire limb, improving functional end points such as SLSB.
Although we did not observe a significant improvement in
the WOMAC index (p = 0.24), the assessment time,
11.3 1.0 days after surgery, was too short to observe pain
relief and improvements in functional scales.
Per-protocol was utilized rather than intention-to-treatment analysis due to 1 of our patients violating protocol.
Per-protocol analysis, however, may overestimate findings
[29]. Due to the small number of included patients, this
study was not sufficiently powered to perform a multiple
linear regression analysis with 6 independent variables.
Due to improvements in proprioception following TKA
[20, 37], proprioception (surrogate end) and SLSB (functional end) should be compared. Female gender has been
reported to be a negative factor for standing balance [23].
Since most patients who undergo TKA in our country are
women, we enrolled only women; however, this gender
imbalance may have affected our findings. Although recent
studies reported that 3D evaluations of the alignment and
gap balances of lower limb [22] and computer-assisted gap
balancing technique [32] were more promising than the
conventional methods, these techniques were not included
in our study. Other limitations of our study include the
short-term follow-up time, its inclusion of patients at a
single-centre, and our lack of measurements of post-operative double-limb standing balance and peak-torque measurement due to safety considerations.
If unsteady ambulation is still persistent shortly after
TKA, falling can be one of the most common factors in the
increased medical costs over a post-operative period.
However, standing balance is improved so fast following
TKA that the incidence of post-operative falling may be
easily reduced by the regulation of other influencing factors, especially in the elderly patients.

Conclusion
We observed improvements in SLSB 11 days after TKA in
patients with degenerative knee OA and varus deformity.
SLSB improvement was proportional to the degree of preoperative SLSB deterioration, indicating that patients with
poor pre-operative SLSB would most likely obtain the
greatest benefits in SLSB following TKA.
Acknowledgments Authors give our thanks to Geum Mi Lee, nurse
practitioner, and Dae-Sik Son, resident, for their good coordination of
scheduling and contact with patients, Ju Yeon Lee, physiotherapist,
for her good devotion to assessment, and Choong Ryeol Lee, M.D.,
Ph.D., of department of Occupational and Environmental Medicine
for his devoted counseling on statistics. No commercial group or
individual being interested in the results of present study gave or is

123

going to give an economic or other benefit to the authors or affiliations to which the authors belong.

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