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The kneeling test is a valid method of assessing kneeling tolerance

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  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

No quantitative test exists to reliably assess kneeling tolerance before and after surgery. The aim of this study was to validate a kneeling test, designed to quantify kneeling tolerance.

Method

A total of 179 participants (324 knees) were enrolled into the study, including 124 asymptomatic knees, 98 with osteoarthritis (OA), 85 following total knee arthroplasty (TKA) and 17 following anterior cruciate ligament reconstruction (ACLR). Patients were asked to kneel on a custom-built platform on a soft, firm and hard surface, at both 90° and 110° of knee flexion. A kneeling score of 0–100 was established for 90° and 110° with 100 being a complete absence of pain or discomfort. A linear mixed model with random intercept was used to estimate differences between conditions (healthy, OA, ACLR and TKA). Pearson’s correlation coefficient was used to test the strength of the association between the kneeling test and the forgotten joint score (FJS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Test–retest reliability was estimated by the intraclass correlation coefficient (ICC).

Results

The kneeling test demonstrated good discriminative validity with differences at 110° between asymptomatic knees and knees with OA (difference = − 42, p < 0.001), following ACLR (− 12, p = 0.013) and TKA (− 26, p < 0.001). Similar differences were observed at 90°. The kneeling test demonstrated construct validity, with a moderately strong correlation observed between the kneeling test and the FJS and the WOMAC at 90° (FJS 0.474 [95%CI: 0.357, 0.577], WOMAC − 0.503 [− 0.389, − 0.602]) and 110° (FJS 0.579 [95% CI: 0.479, 0.665], WOMAC − 0.648 [− 0.560, − 0.722]). The ICC for the kneeling test at 90° and 110° was 0.843 (95% CI: 0.745, 0.905) and 0.926 (95% CI: 0.877, 0.956), respectively.

Conclusions

The kneeling test is a valid technique to quantitatively determine kneeling tolerance. It can aid in the assessment and modification of current surgical techniques to improve patient outcomes.

Level of evidence

III.

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References

  1. Amin RM, Vasan V, Oni JK (2019) Kneeling after total knee arthroplasty. J Knee Surg. https://doi.org/10.1055/s-0038-1676801

    Article  PubMed  Google Scholar 

  2. Barker KL, Hannink E, Pemberton S, Jenkins C (2018) Knee arthroplasty patients predicted versus actual recovery: what are their expectations about time of recovery following surgery and how long before they can do the tasks they want to do? Arch Phys Med Rehabil 99:2230–2237

    Article  Google Scholar 

  3. Barnes CL, Sharma A, Blaha JD, Nambu SN, Carroll ME (2011) Kneeling is safe for patients implanted with medial-pivot total knee arthroplasty designs. J Arthroplasty 26:549–554

    Article  Google Scholar 

  4. Behrend H, Giesinger K, Giesinger JM, Kuster MS (2012) The "forgotten joint" as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty 27:430–436.e431

    Article  Google Scholar 

  5. Bellamy N (1995) WOMAC osteoarthritis index: a user’s guide. Ontario, London

    Google Scholar 

  6. Berg P, Mjoberg B (1991) A lateral skin incision reduces peripatellar dysaesthesia after knee surgery. J Bone Jt Surg Br 73:374–376

    Article  CAS  Google Scholar 

  7. Borley N, Edwards D, Villar R (1995) Lateral skin flap numbness after total knee arthroplasty. J Arthroplasty 10:13–14

    Article  CAS  Google Scholar 

  8. Bourne R, Chesworth C, Davis A, Mahomed N, Charron K (2010) Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 468:57–63

    Article  Google Scholar 

  9. Calvert N, Milne L, Kuster M (2016) A comparison of kneeling ability after lateral or midline incisions in total knee arthroplasty. Eur J Orthop Surg Traumatol 26:915–919

    Article  Google Scholar 

  10. Coughlin KM, Incavo SJ, Doohen RR, Gamada K, Banks S, Beynnon BD (2007) Kneeling kinematics after total knee arthroplasty: anterior-posterior contact position of a standard and a high-flex tibial insert design. J Arthroplasty 22:160–165

    Article  Google Scholar 

  11. Han HS, Seong SC, Lee S, Lee MC (2008) Anterior cruciate ligament reconstruction : quadriceps versus patellar autograft. Clin Orthop Relat Res 466:198–204

    Article  Google Scholar 

  12. Hanson GR, Park SE, Suggs JF, Moynihan AL, Nha KW, Freiberg AA, Li G (2007) In vivo kneeling biomechanics after posterior stabilized total knee arthroplasty. J Orthop Sci 12:476–483

    Article  Google Scholar 

  13. Hassaballa M, Artz N, Weale A, Porteous A (2012) Alteration in skin sensation following knee arthroplasty and its impact on kneeling ability: a comparison of three common surgical incisions. Knee Surg Sports Traumatol Arthrosc 20:1983–1987

    Article  Google Scholar 

  14. Hassaballa MA, Porteous AJ, Newman JH (2004) Observed kneeling ability after total, unicompartmental and patellofemoral knee arthroplasty: perception versus reality. Knee Surg Sports Traumatol Arthrosc 12:136–139

    Article  CAS  Google Scholar 

  15. Hofer JK, Gejo R, McGarry MH, Lee TQ (2011) Effects on tibiofemoral biomechanics from kneeling. Clin Biomech (Bristol, Avon) 26:605–611

    Article  Google Scholar 

  16. Hopton BP, Tommichan MC, Howell FR (2004) Reducing lateral skin flap numbness after total knee arthroplasty. Knee 11:289–291

    Article  CAS  Google Scholar 

  17. Incavo SJ, Mullins ER, Coughlin KM, Banks S, Banks A, Beynnon BD (2004) Tibiofemoral kinematic analysis of kneeling after total knee arthroplasty. J Arthroplasty 19:906–910

    Article  Google Scholar 

  18. Jariwala AC, Parthasarathy A, Kiran M, Johnston LR, Rowley DI (2017) Numbness around the total knee arthroplasty surgical scar: prevalence and effect on functional outcome. J Arthroplasty 32:2256–2261

    Article  Google Scholar 

  19. Kartus J, Stener S, Lindahl S, Engstrom B, Eriksson BI, Karlsson J (1997) Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts. Knee Surg Sports Traumatol Arthrosc 5:222–228

    Article  CAS  Google Scholar 

  20. Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502

    Article  CAS  Google Scholar 

  21. Kovindha K, Ganokroj P, Lertwanich P, Vanadurongwan B (2019) Quantifying anterior knee pain during specific activities after using the bone-patellar tendon-bone graft for arthroscopic anterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol 15:6–12

    PubMed  Google Scholar 

  22. Liden M, Ejerhed L, Sernert N, Laxdal G, Kartus J (2007) Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-year follow-up. Am J Sports Med 35:740–748

    Article  Google Scholar 

  23. Palmer S, Servant C, Maguire J, Parish E, Cross M (2002) Ability to knee after total knee replacement. J Bone Jt Surg Br 84:220–222

    Article  CAS  Google Scholar 

  24. Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J (2007) A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 35:564–574

    Article  Google Scholar 

  25. Portland GH, Martin D, Keene G, Menz T (2005) Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy 21:281–285

    Article  Google Scholar 

  26. Riaz O, Nisar S, Phillips H, Siddiqui A (2015) Quantifying the problem of kneeling after a two incision bone tendon bone arthroscopic anterior cruciate ligament reconstruction. Muscles Ligaments Tendons J 5:181–186

    Article  Google Scholar 

  27. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, de Vet HC (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–42

    Article  Google Scholar 

  28. Tsukada S, Kurosaka K, Nishino M, Hirasawa N (2018) Cutaneous hypesthesia and kneeling ability after total knee arthroplasty: a randomized controlled trial comparing anterolateral and anteromedial skin incision. J Arthroplasty 33:3174–3180

    Article  Google Scholar 

  29. Weiss J, Noble P, Conditt M, Kohl H, Roberts S, Cook K, Gordon M, Mathis K (2002) What functional activites are important to patients with knee replacements. Clin Orthop Relat Res 404:172–188

    Article  Google Scholar 

  30. Wilkens KJ, Duong LV, McGarry MH, Kim WC, Lee TQ (2007) Biomechanical effects of kneeling after total knee arthroplasty. J Bone Jt Surg Am 89:2745–2751

    Article  Google Scholar 

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Funding

This study was not externally funded.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia

    Nicholas D. Calvert

  2. School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia

    Anne Smith

  3. Department of Orthopaedics, Sir Charles Gairdner Hospital, Perth, Australia

    Lukas Kuster

  4. Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Australia

    Maya Calvert

  5. School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Australia

    Jay Ebert & Tim Ackland

  6. Perth Orthopaedic and Sports Medicine Centre, West Perth, Australia

    Markus S. Kuster

Authors
  1. Nicholas D. Calvert
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  2. Anne Smith
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  3. Lukas Kuster
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  4. Maya Calvert
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Corresponding author

Correspondence to Nicholas D. Calvert.

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Conflict of interest

MK has received royalties from Zimmer and Springer publishing. ND, AS, LK, MC, JE, and TA declare they have no conflict of interest.

Ethical approval

All the participants gave their written consent and were recruited in agreement with the Helsinki Declaration. The study was approved by the ethics review board of Sir Charles Gairdner Hospital (ID: 2016-065), Perth Western Australia.

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Calvert, N.D., Smith, A., Kuster, L. et al. The kneeling test is a valid method of assessing kneeling tolerance. Knee Surg Sports Traumatol Arthrosc 27, 3705–3712 (2019). https://doi.org/10.1007/s00167-019-05505-3

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