Entire articulatio genus replacing has become the unequivocal intervention for terminal phase articulatio genus arthritis. It is one of the common orthopedic processs performed because the prevalence of arthritis is expected to turn well as population ages. Entire knee replacing improves functional position and alleviations pain.
The process has proven to both dependable and lasting. A successful entire articulatio genus replacing allows patient to restart about all activities of day-to-day populating with minimum trouble. In most instances patients no longer necessitate external AIDSs or chronic medicines. Finally entire articulatio genus replacing helps patients to keep their overall ego regard.
Entire articulatio genus replacing is indicated when there is unremitting terrible hurting in the articulatio genus with or without malformation. The pain/ malformation may be due to osteoarthritis, Rheumatoid arthritis and assorted non specific arthritis. It relieves hurting, provides mobility and right malformation.
Entire articulatio genus replacing is a surgical process in which injured or damaged parts of the articulatio genus articulation are replaced by unreal parts. The process is performed by dividing the musculuss and ligaments around the articulatio genus to expose the articulatio genus capsule. The articulatio genus capsule is unfastened, exposed within the joint. The terminal of the thighbone and shinbone were removed. The unreal parts are cemented into topographic point. The articulatio genus is composed of the metal shell at the terminal of the thighbone, metal and plastic channel in the shinbone and if necessary a fictile button in the stopper. In a sense, is instead a call from a articulatio genus surgery greening. The common pathology for entire knee replacing is knee flexure contracture.
Flexure contracture is defined as a shortening of the connective tissue and hence stiffness. This is due to a narrowing of the posterior capsule combined with a tightening of the biceps femur and indirect ligaments.
Hence rehabilitation plan should be undertaken shortly after TKA to keep joint scope of gesture.
In peculiar this survey examined the value of dynamic splinting in increasing scope of gesture and cut downing the flexure contracture. . Dynamic splint used biomechanical version for the care of the metropolis at the terminal of the scope of a physiological alteration of molecular accommodation to lengthen the connective tissue. The protocol of low burden, prolonged stretch the length of a uninterrupted dynamic tenseness decrease of the contracture.
ANATOMY OF KNEE JOINT:
The articulatio genus articulation is the largest and most complex articulation in the organic structure. It is synovial modified flexible joint articulation. It is formed by merger and median tibio- femoral and patella- femoral articulation.
It is comprised the
Femoral condyles: distal terminal of thighbone
Tibial condyles: proximal terminal of shinbone.
Patellar facetes: posterior surface of kneecap.
The articular surfaces of thighbone are block shaped. The femoral condyles are convex in both planes. They are extended interiorly by the block shaped patellar surfaces. The cervix of the block is represented anteriorly by the cardinal channel on the patellar surface and posteriorly by the intercondylar notch
The tibial surfaces are in return curved and comprises two curved and concave analogue troughs which are separated by a blunt distinction running antero- posteriorly distinction lodges the two intercondylar tubercles.
The tibial condyles correspond to the femoral condyles while the inter condylar tibial tubercles come to within the femoral intercondylar notch, these surfaces constitute functionally the tibio-femoral articulation.
The aspects of kneecap correspond to the patellar surface of the thighbone while the perpendicular ridge of the kneecap fits into the cardinal channel of the thighbone.
LIGAMENTS OF KNEE JOINT:
Medial indirect ligament:
It is flattened set rhomboidal in outine. It is attached above to the median epicondyle of thighbone, below to the median border and the bordering median surface of shinbone.
restrain valgus rotary motion
Lateral indirect ligament:
restrain varus rotary motion and resist internal rotary motion
Anterior cruciate ligament:
It is attached below to the anterior portion of the intercondylar country of shinbone between the anterior terminals of sidelong and median semilunar gristles. Above it is attached to the posterior portion of the median surface of sidelong femoral condyle.
To defy anterior supplanting of the shinbone on the thighbone when the articulatio genus is dead set.
To defy the varus or valgus rotary motion of the shinbone, particularly in the absence of the collateral ligament
Resist internal rotary motion of the shinbone.
Posterior cruciate ligament:
It is attached below to the posterior portion of intercondylar country of shinbone, buttocks to the fond regard of posterior terminal of median semilunar gristle. Above it is attached to the anterior portion of sidelong surface of the median condyle of thighbone.
To let femoral push back in flexure
Defy the subsequent interlingual rendition of the shinbone on the thighbone
Control the tibia external rotary motion of the articulatio genus still in diminution
The care of entire knee replacing PCL reversal has been shown to supply normal biomechanics of the kinematics of the thighbone on the shinbone. This besides is of import for bettering the lever arm of the quadriceps mechanism with flexure of the articulatio genus.
MUSCLES OF KNEE JOINT:
BURSAE AROUND THE KNEE JOINT:
The suprapatellar Bursa
The prepatellar Bursa
Superficial intrapatellar Bursa
Deep infrapatellar Bursa
A Bursa between sidelong indirect ligament and biceps tendon
A Bursa between sidelong indirect ligament and popliteus sinew
Popliteus Bursa lies between the popliteus and sidelong condyle of thighbone.
The tibial inter sinewy Bursa ( pes anserine Bursa )
A Bursa between median collateral ligament and semimembranous sinew
A Bursa between semimembranous sinews and shinbone.
A Bursa between sidelong caput of gastrocnemius and capsule.
Semimembranous Bursa ( brodies bursa )
The arterial supply to knee joint, is from the subdivisions of
Viewed in the sagittal plane, the thighbone ‘s jointing surface is convex while the shinbone ‘s in concave. We can foretell arthrokinematics based on the regulations of concave shape and convexness:
During Knee Extension
During Knee Flexion
Tibia Glides Anteriorly On Femur
Femur Glides Posteriorly On Tibia
Tibia Glides Posteriorly On Femur
from 20o articulatio genuss flexure to full extension
from full articulatio genus extension to 20o flexure
Tibia rotates externally
Femur rotates internally on stable shinbone
Tibia rotates internally
THE “ SCREW-HOME ” Mechanism:
Rotation between the shinbone and thighbone occurs automatically between full extension ( 0o ) and 20o of articulatio genus flexure. These figures illustrate the top of the right tibial tableland as we look down on it during knee gesture.
top of tibial tableland
top of tibial tableland
top of tibial tableland
During Knee Extension, the shinbone glides anteriorly on the thighbone.
During the last 20 grades of articulatio genus extension, anterior tibial semivowel persists on the shinbone ‘s median condyle because its articular surface is longer in that dimension than the sidelong condyle ‘s.
Prolonged anterior semivowel on the median side produces external tibial rotary motion, the “ screw-home ” mechanism.
THE SCREW-HOME MECHANISM REVERSES DURING KNEE FLEXION
top of tibial tableland
top of tibial tableland
top of tibial tableland
When the articulatio genus begins to flex from a place of full extension, posterior tibial semivowel begins foremost on the longer median condyle.
Between 0 deg. extension and 20 deg. of flexure, posterior semivowel on the median side produces comparative tibial internal rotary motion, a reversal of the screw-home mechanism.
Entire KNEE REPLACEMENT
Entire articulatio genus replacing is indicated when there is unremitting terrible hurting in the articulatio genus with or without malformation. The pain/ malformation may e due to osteoarthritis, Rheumatoid arthritis and assorted non specific arthritis. It relieves hurting, provides mobility and right malformation.
TKR is a surgical process where you replaced the injured parties or damaged articulatio genuss joint with unreal parts. The process is done by dividing the musculuss and ligaments around the articulatio genus to expose the capsule of the articulatio genus. The capsule of the articulatio genus is unfastened, is exposed within the municipality. At the terminal of the thighbone and the shinbone is removed. The replacings are cemented into topographic point. The articulatio genus is the metal shell at the terminal of the metal thighbone and shinbone through the plastic and, if appropriate, the fictile cap button.
In a manner this could be more suitably called a Knee resurfacing operation.
The entire articulatio genus replacing can be:
Unicompartmental arthroplasty: The Articular surface of thighbone and shinbone, either the medial or sidelong compartment of the articulatio genus are replaced by an implant. Eg: osteoathritis.
Bicomprtmental arthroplasty: In bicompartmental arthroplasty, the articular surface of shinbone and thighbone of both median and sidelong compartments of the articulatio genus articulations are replaced by an implant. The 3rd compartment i.e.. , the patellofemoral articulation is nevertheless left intact.
Tricomprtmental arthroplasty: the articular surface of the lower thighbone, upper shinbone and kneecap are replaced by prosthetic device. Most normally performed arthroplsty.
The prosthetic device consists of a tibial constituent, a metal femoral constituent and a high molecular weight polythene button for articular surface of the kneecap.
Restore mechanical alliance [ impersonal tibiofemoral alliance =
4A°-6A° of anatomic valgus ] ,
Horizontal joint line,
Soft tissue balance ( ligament ) ,
( Patella tracking ( Q-angle )
Sero negative arthrides
Crystal deposition disease
Pigmented villonoular synovitis
Holocene or curren joint infection
Sepsis or systematic infection
Painful solid articulatio genus merger
Debilated hapless wellness
Non working extensor mechanism
Painless, good working arthrodesis
Significant peripheral vascular diseases
Death: 0.53 %
Periprosthetic Infection: 0.71 %
Pneumonic emboli: 0.41 %
Tibial tray wear:
Peroneal Nerve Palsy: 0.3 % to 2 %
Periprosthetic Femur Fracture:
Periprosthetic Tibial Fracture:
Wound Complications / Skin gangrene: rare
Patellar Clunk Syndrome: rare
Patellofemoral Instability: 0.5 % -29 %
Popliteal artery hurt: 0.05 %
Quadricepss Tendon Rupture: 0.1 %
Patellar Tendon Rupture: & lt ; 2 %
Need AND SIGNIFICANCE OF STUDY:
Need of the survey:
To cut down flexure contracture
To better scope of gesture
To better functional activity
Significance of the survey:
This survey is to measure the efficaciousness of dynamic splinting for articulatio genus flexure contracture following a entire articulatio genus arthroplasty.
Statement of the job:
To analyze the efficaciousness of dynamic splinting for articulatio genus flexure contracture following a entire articulatio genus arthroplasty.
Therefore the survey is entitled as “ efficaciousness of dynamic splinting for articulatio genus flexure contracture following a entire articulatio genus arthroplasty ” .
To cut down flexure contracture
To better scope of gesture
To analyse the consequence of dynamic articulatio genus splint
The void hypothesis can be stated as follows there is no important difference in articulatio genus flexure contracture after the application of dynamic knee splint.
The hypothesis can be stated as follows there is important difference in articulatio genus flexure contracture after the application of dynamic knee splint.
2. REVIEW OF LITERATURE:
1. TOTAL KNEE ARTHROPLASTY:
Simon H Palmer, MD, Consultant Surgeon: Sep 21, 2010 Osteoarthritis devastation of the articulatio genus is the most common ground for entire knee replacing.
Jayant joshi, prakash kotwal says that entire knee replacing alleviations pain, provides mobility & A ; corrects malformation.
2. FLEXION Contracture:
J. Ilyas ; A.H. Deakin ; C. Brege ; and F. Picard Flexion contracture is a common malformation encountered in patients necessitating entire articulatio genus arthroplasty ( TKA ) .
Department of orthopedicss, aureate jubilee national infirmary, clydebank, Glasgow, g81 4hx, United Kingdom. One hundred and four uninterrupted TKA were completed by a individual adviser utilizing the OrthoPilot ( BBraun, Aesculap ) pilotage system and Columbus implants. Seventy-four articulatio genuss had preoperative flexure contracture ( including impersonal articulatio genuss ) while 30 were in hyperextension.
Ouellet D, Moffet H. Arthritis Rheum October 2002 Large shortages are present in the motion, particularly a limb to back up pre-op and 2 months after TKA.
Huei-Ming Chai, PHD. November 24, 2008 sum articulatio genus arthroplasty bounds scope of gesture
3. DYNAMIC SPLINT:
Dennis cubic decimeter armstrong, m.d. Buck Willis, Ph.D. evaluates the efficaciousness of dynamic knee extension splinting for articulatio genus flexure contracture following TKA.
FingeryE, WillisyFB Physical Health Education, Recreation, Texas State University, Case No. 2008, physical therapy was non sufficient to to the full cut down the contracture and dynamic arrested development was so prescribed a day-to-day low burden, prolonged stretch.
Finger E, Willis B 29Dec2008: Dynasplint offers extension Systems to help in rehabilitation and recovery from flexure contracture.
Clinical surveies have shown an mean decrease in rehabilitation clip and costs more to utilize Dynasplint systems in concurrence with physical therapy.
Willis FB Biomechanics.2008 Jan ; 15 After surgery, a patient is frequently left with sawed-off connective tissue and may hold a hard clip walking usually once more. Wearing a dynamic articulatio genus splint will lengthen and reconstruct the tissue to reconstruct scope of gesture.
McClure P, L Blackburn, Dusold C Ideally utilize your Dynasplint for 6-8 uninterrupted hours yields the best consequences, since it allows a safe and sustainable remodeling of soft tissues.
Cliffordr.Wheeless, Iii, Md.December3, 2008. The intent of this study is to reexamine the usage of external fixator for the gradual rectification of terrible articulatio genus flexure contractures that bound patient map.
James f. Mooney three, mendelevium, l. Andrew koman Posted: 05/01/2001 Average preoperative flexure contracture was 80.5A° . Each patient achieved full extension. There was one return, despite brace, which was managed with replacing of the fixator and soft tissue processs
4. CONVENTIONAL PHYSICAL THERAPY FOR KNEE ARTHRITIS:
Jan.K.Richardson, Pt, Phd, Ocs Said that arthritis is a degenerative disease of the gristle and castanetss that consequences in hurting and stiffness in affected articulation. There is no remedy for arthritis, but physical therapy can do life easier and less painful.
Brigham And Women ‘s Hospital Department of Rehabilitation Services Physical Therapy.ROM along with proper soft tissue balance is required to guarantee proper biomechanics in the articulatio genus articulation. Aggressive post-operative PT has been shown to be effectual in bettering patient results and shortening length of stay
Balint G And Sz Ebenyl.B Showed that curative exercisings decreases hurting, increases musculus weariness and scope of gesture every bit good as improve endurance and aerophilic capacity. Weight decrease is proven in corpulent patients with OA of articulatio genus. Curative heat and cold, galvanism, stylostixis are widely used.
Dr. Margriet new wave baar reported that important good effects from exercising therapy including betterments in ego reported hurting, disablement, walking ability and overall sense of good being.
Dorr J Arthroplasty LD.y June 2002 CPM achieves faster knee scope of hebdomads of the first movie after the operation, but still finally no difference in the concluding scope of gesture
Byrne et Al. Clin Biomech failing in October 2002 to equilibrate the addition in articulatio genus extensor hip rehabilitation work should optimise the bilateral hip and articulatio genus map after TKA
McManus et al 2006, Jorge et al 2006 the higher frequences ( 90-130Hz ) to excite the hurting gate mechanisms & A ; thereby dissemble the hurting symptoms.
Ozcan et Al, 2004 Low frequence nervus stimulation is physiologically effectual ( as with TENS and NMES ) and this is the key to IFT intercession.
Adedoyin, R. A. , et Al. ( 2002 ) .IFT acts chiefly on the excitable ( nervus ) tissues, the strongest effects are likely to be those which are a direct consequence of such stimulation ( i.e. hurting alleviation and musculus stimulation ) .
National Taiwan University Hospital, November 2008 pnf stretching techniques were often used in patients with entire knee replacing in clinical pattern to increase scope of gesture in an effectual and less knee hurting during preparation.
Huei-Ming Chai, PhD, November 24, 2008 PNF stretching is a curative technique utilizing the construct of pnf muslces linked either by increasing neural suppression mechanism for let go ofing musculus cramps and musculus length of clip, or to increase neuro -excitation to better musculus strength
Harold B. James H. Beaty, MD Range-of-motion exercisings, musculus strengthening, pace preparation, and direction in executing activities of day-to-day life are of import.
5. GONIOMETRIC MEASURENT FOR ROM:
Carlos Lavernia, MD, Range of gesture appraisal through direct observation without a goniometer provides inaccurate findings.
Mark D. Rossi, PhD, PT, CSCS The Journal of Arthroplasty Vol. 23 No. 6 Suppl. 1 2008 Measured tonss utilizing a goniometer provided an improved grade of truth, but consequences appear to be dependent on the clinician executing the measuring.
Richard l. Gajdosik Associate Professor Physical healers may accept most knee goniometric measurings as clinically valid, and the grounds indicates that most of these measurings are dependable.
6. KNEE SOCIETY SCORE:
Gil Scuderi, MD, President, Jim Benjamin, MD, Jess Lonner, MD, Bob Bourne, MD, and Norm Scott, MD, 2007, the Knee Society evaluation system ( KSS ) was foremost published in CORR in 1989 and has become a standard clinical rating, describing having the consequences of entire knee replacing.
John N. Insall, MD, Lawrence D. Dorr, Scott, MD The Knee Society has proposed this new evaluation system to be simple but more fastidious and more nonsubjective.
MD, Richard D. Scott, MD, and W. Norman It is hoped the articulatio genus society evaluation system will go universally recognized and will be adopted by all writers, even if they wish to describe consequences utilizing a customary marking method every bit good.
3. MATERIALS AND METHODOLOGY:
Knee society mark
Scope of gesture
Dynamic articulatio genus splint
( A ) Study design:
30 topics with flexure contracture following one-sided TKA assigned in two groups.
15 topics: Dynamic Splint Along With Conventional Physiotherapy.
15 topics: Conventional Physiotherapy.
( B ) Study scene:
This survey was carried out in the section of physical medical specialty and rehabilitation, Sri Ramakrishna infirmary, Coimbatore.
( C ) Study continuance:
This survey was carried out for a period of 6 months.
( D ) Sampling:
Age: 45 to 70 old ages.
Flexure contracture: 20 – 12 deg ( post operatively )
Reduced flexibleness in AROM of articulatio genus extension
Pain that is worsened by flexing over while legs are consecutive
Impaired pace form
Ability to understand informed consent and experiment duties
TKA & lt ; 2 months
Osteomyelitis or any orthopaedic infection
Extensor mechanism disfunction
Knee articulation neuropathy
Previous Stroke or Brain Injury
The information collected was analyzed utilizing independent t-test. The trial was carried out between two groups. Independent’t ‘ trial was used to compare the effectivity of intervention between the groups.
X1 = Difference between pretest and posttest values of Group I
X2 = Difference between pretest and posttest values of Group II
= Mean difference of Group I
= Mean difference of Group II
n1 = No. of samples in Group I
n2 = No. of samples in Group II
S = Combined criterion divergence
Dynamic articulatio genus Extension splint:
The Rebound Effect
53 % Average Reduction in Time and Cost Associated with ROM Rehabilitation
“ High strength, widening short-run distortion favours recoverable, elastic tissue, while the weak force, long continuance stretching enhances lasting fictile distortion. In the clinical scene, application of force has a high increased hazard holding hurting and possibly do tissue dislocation. Dynasplint Systems improve scope of gesture by making lasting remodeling, and non-traumatic tissue, which virtually eliminates the consequence of the kick scope frequently observed in the field clinician.
Features & A ; Benefits
LLPS ( Low-Load, Prolonged-Duration Stretch ) engineering has been proven to successfully handle joint stiffness and limited scope of gesture.
Early application can cut down clip and cost associated with scope of gesture rehabilitation
Simple, adjustable and consistent bilateral tensioning System
Available for rent or purchase
Comfortable to have on
Each Dynasplint System is recycled to cut down waste and assist the environment
A Dynasplint Systems adviser will suit your patients and oversee their intervention to guarantee the best possible consequences
Over a one-fourth of a million patients have been successfully treated with Dynasplint Systems
Handily labeled and easy to utilize
Patient Wearing Protocol
Please reexamine the tenseness your Dynasplint adviser set for you ab initio.
In the beginning, the splint should be worn for 2-4 hours.
Do non increase the tenseness until you can digest nightlong wear. Time is the most of import factor and your first end should be 6-8 hours of hurting free wear.
After accomplishing this clip end, when you take the splint off if you have less than 1 hr of post-wear stiffness, bend tenseness up by one on both sides.
However if you are unable to have on the splint for a drawn-out period of clip, diminish the tenseness by a half to one full bend.
During the procedure of recovering your scope of gesture, if you have any inquiry or concerns reach your Dynasplint adviser.
MODALITIES FOR PAIN CONTROL, EDEMA REDUCTION:
Functional electrical stimulation
Transdermal electrical stimulation
Position: patient seated
Posterior semivowel of shinbone on femur-grade 3 Oscillation with 30 2nd clasp, Repeated 5 times with patellar mobilisation of inferior semivowels ( 5 mins )
Position: patient prone with kneecap off of tabular array
Anterior semivowel of shinbone on femur- class 3 oscillation and inactive clasp ( 10 secs in 3 repeats ) with patellar mobilisation superior semivowels ( 5 mins )
Closed and unfastened kinetic concatenation strengthening exercisings
Proprioceptive/balance exercisings aiming the bole and lower appendage muscular structure
Partial organic structure weighted knee bends
Scope of gesture exercisings
Heel slide ( supine & A ; sitting )
Stretching ( prone/supine ) to increase articulatio genus extension ROM
Backward or Retro-Walking
Pushing or Pulling
Squating or Crouching
Upper organic structure exercising.
One-leg cycling, utilizing non-operative leg with opposition to gesture.
Lateral Stepping over/around objects
Closed Kinetic Chain Activities
Entire articulatio genus arthroplasty ( TKA ) is considered the intervention of pick for patients with intractable hurting and significant functional disablements who have non had acceptable alleviation and functional betterment after conservative intervention. Knee flexure contracture is a common pathology following TKA impacting up to 61 % of these patients.
The intent of the survey is to find the effectivity of dynamic splinting in handling patients with flexion contracture following Unilateral TKA.
Literature reexamine provinces that there is important difference between dynamic splinting and conventional physical therapy direction in cut downing flexure contracture following Unilateral TKA.
A sum of 30 patients with one-sided TKA were selected under inclusive standards and were indiscriminately allocated into an experimental group and control group as Group A and group B severally. In each group 15 Persons were allotted
In Group A, dynamic splint along with conventional physical therapy was given and in Group B, Conventional physical therapy entirely was given. Both Groups were treated for a period of 6 months and the pre trial and station trial values are taken on the 1st ( 2 months after TKA ) and at the terminal of 6th months. In between Follow up appraisals were done at regular interval of every two hebdomads to judge the forecast.
Statistical analysis performed between the Group A and Group B and the consequences showed the undermentioned result.
The scope of gesture and functional betterment among the patients following the intercession was evaluated by Goniometry and knee society mark severally.
“ T ” Value
“ Phosphorus ” Value
Scope of gesture
With goniometric measuring the scope of gesture showed a important betterment of about12.9 and 11.5 for Group A and Group B severally. “ T ” value for the independent T trial calculated between the Group is 2.82 which is important at the degree of 0.009 degree at 28 grades of freedom.
With knee society mark measurement the articulatio genus mark showed a important betterment of about18 and 13 for Group A and Group B severally. “ T ” value for the independent T trial calculated between the Group is 3.06 which is important at the degree of 0.005 degree at 28 grades of freedom.
With knee society mark measurement the map mark showed a important betterment of about35.6 and 30.1 for Group A and Group B severally. “ T ” value for the independent T trial calculated between the Group is 3.01 which is important at the degree of 0.005 degree at 28 grades of freedom.
From statistical analysis it is clear that there was a average decrease in flexure contracture of about 12.9 of Group A when compared to 11.5 with that of Group B. The calculated’t ‘ value was 2.82 which is greater than the table value at 28 grades of freedom
With knee society score it was apparent that the Group A ( articulatio genus mark and map mark ) showed a important average betterment of about 18 and 35.6 when compared to 13 and 30.1 with Group B ( knee mark and map mark ) severally. The calculated’t ‘ value was 3.06 which is greater than the table value at 28 grades of freedom.
Hence it is cleared that dynamic splinting reduces flexure contracture from 20-12deg ( two month after TKA ) to 5-0 deg ( after the application of dynamic splint )
So the statistical analysis infers us to reject void hypothesis and at that place by accepting the alternate hypothesis i.e. there is important difference in articulatio genus flexure contracture after the application of dynamic knee splint.
Hence it is suggested that supplying a dynamic splint is effectual in cut downing flexure contracture and bettering functional position in intervention of articulatio genus flexure contracture following one-sided TKA.
LIMITATION OF STUDY
Sample size is smaller.
It is a clip edge survey.
The survey was carried on with few nonsubjective parametric quantities in entering the efficaciousness of intervention.
The survey concentrated merely on one-sided TKA
The survey could hold been done with long term follow up and more figure of patients, to analyse the result.
The survey could hold employed some more parametric quantities to measure the clinical result more accurately and exactly
Further surveies can be done, to analyse the effects of dynamic splint in bilateral TKA.
Further surveies can be done, to compare the effects of dynamic splint in one-sided and bilateral TKA.