The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.