The role of electromyography in postoperative total knee arthroplasty: A systematic review

Nikita Golovachev; Kassem Ghayyad; Mustafa Hashimi; Ramakanth Yakkanti

doi:10.1016/j.jor.2025.05.007

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65 (); 216-226

doi:

10.1016/j.jor.2025.05.007

The role of electromyography in postoperative total knee arthroplasty: A systematic review

Nikita Golovachev, Kassem Ghayyad, Mustafa Hashimi, Ramakanth Yakkanti

Rothman Orthopaedics Florida at AdventHealth, 265 E. Rollins St, Orlando, FL, 32804, USA

⁎Corresponding author: Ramakanth Yakkanti. ramakanth.yakkanti@rothmanortho.com

Received: 2025-4-13, Accepted: 2025-5-3, Published: 2025-5-10

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Electromyography (EMG) measures electrical activity in muscle fibers during contractions after total knee arthroplasty (TKA), with higher amplitudes indicating stronger or compensatory muscle engagement. Despite increased TKA procedures, 10 % of patients report stiffness and mobility issues. In recent years, EMG has been increasingly used in physical therapy as biofeedback to enhance muscle strength and control by translating muscle activity into visual signals for patients.

This systematic review adhered to PRISMA guidelines, searching PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database for peer-reviewed original research articles in English that used EMG for post-operative assessment in TKA patients, excluding studies on other type of knee surgeries. Data extracted included study design, number of patients, and the reasons and outcomes of EMG use.

Fifty-three studies from 1999 to 2023 were analyzed. Findings varied widely, influenced by follow-up length, patient age, and exercise protocols. Limited trends were observed, and more randomized controlled trials are needed. Three randomized controlled trials indicated that EMG biofeedback can reduce pain shortly after surgery, particularly in older patients, but its impact on long-term functional outcomes varies. The effectiveness of EMG biofeedback depends on the patient's age, recovery goals, and intervention timing.

While EMG can enhance postoperative care by providing detailed insights into muscle recovery after TKA, its widespread application requires careful consideration. More research is needed to determine if biofeedback can effectively guide therapy.

Keywords

Electromyography

EMG

Total knee arthroplasty

TKA

Postoperative rehabilitation

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1 Introduction and background

Electromyography (EMG) is used in postoperative total knee arthroplasty (TKA) to measure electrical activity generated by muscle fibers during contractions.^1–3 The amplitude, measured in microvolts (μV), reflects muscle strength during tasks. Higher amplitudes suggest increased fiber engagement. EMG also evaluates activation timing, such as when muscles activate during walking, stair climbing, and co-contractions.² These metrics help identify compensatory responses to muscle weakness.

Over the last two decades, the annual TKA volume increased 156 %, with a projected yearly growth of 4.44 %.⁴ However, many patients report stiffness and mobility issues.⁵^,⁶ EMG biofeedback in physical therapy improves muscle strength and voluntary control by allowing patients to adjust engagement based on EMG signals.⁷^,⁸ This feedback translates electrical muscle activity into visual or auditory signals, giving patients immediate information to adjust their muscle engagement. By doing so, patients can enhance movement quality, target specific muscles, and improve strength and control. This method benefits recovering TKA patients in both static (e.g., sitting quadriceps exercises) and dynamic (e.g., gait analysis) testing see (Fig. 2).

Recent reviews highlight EMG's biofeedback effectiveness during postoperative knee surgery rehabilitation.⁹^,¹⁰ Argut et al. found biofeedback improves pain control and quadriceps strength, but effects on knee range of motion (ROM) are unclear.⁹ Xie et al. reported enhanced ROM but no superiority in reducing pain or improving function.¹⁰ As these reviews focus mainly on ACL reconstructions and meniscectomies, a research gap exists regarding EMG's effectiveness in TKA.

This systematic review is the first to analyze the use of EMG exclusively in postoperative TKA patients. It aims to explore the potential advantages of EMG in the postoperative period in patients who received a TKA, assess its effectiveness in patients who have undergone surgery, and evaluate its clinical relevance for monitoring patients postoperatively. Additionally, the review seeks to determine whether EMG can effectively compare the effect of various TKA surgical approaches and prosthesis designs on postoperative muscle function.

2 Material and methods

2.1

2.1 Study design

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹¹ The goal of this review was to identify all studies that utilized EMG in postoperative total knee arthroplasty patients, describe the reason for its use, and report the results.

2.2

2.2 Search strategy

This study was exempt from IRB approval. Two authors independently searched for clinical studies focusing on the use of EMG in patients who have undergone total knee arthroplasty in the following databases: PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Physiotherapy Evidence Database. The search was performed in September 2024, employing the following terms and Boolean operators: “((TKA) OR (total knee arthroplasty) OR (knee replacement) OR (joint replacement)) AND ((EMG) OR (electromyography) OR (EMG-biofeedback) OR (electromyography biofeedback) OR (electromyographic biofeedback))” and its iterations in (Appendix A).

2.3

2.3 Study selection & data extraction

Using our search terms, we identified 1213 articles. After removing duplicates, 735 articles remained. Two authors independently reviewed titles and abstracts, narrowing the selection to 146 articles meeting the inclusion criteria. Full-text evaluation and reference list exploration yielded 53 studies (Fig. 1). Inclusion criteria were peer-reviewed original research articles in English using EMG for post-op assessment in TKA patients. Exclusions included studies on non-TKA knee surgeries, preoperative/intraoperative EMG, case reports, systematic reviews, and meta-analyses. No restrictions were applied to publication dates. Authors were blinded during the selection process, and disagreements were resolved by the senior author. Extracted data included author, publication year, journal, study design, level of evidence, patient demographics, surgical approach, follow-up length, reasons for EMG use, and results. A third author independently verified the compiled data (Table 1).

Table 1 Description of articles & study demographics.

First Author	Year	Journal	Study Design	Level of Evidence	No. of Patients (Study/Control)	Mean Age (SD)	Sex (% Men)
Parentis	1999	Clinical Orthopaedics and Related Research	RCT	I	Vastus splitting approach: 21 kneesMedian parapatellar approach: 25 knees	Vastus splitting approach: 68.2Median parapatellar approach: 65.5	N/A
Benedetti	2003	Clin Biomech	Case series	IV	9/0	66.1 (5.2)	33
Catani	2003	Clin Biomech	Cross-sectional	IV	Mobile bearing: 10Fixed bearing: 10	Cohort: 68Control: 71	20
Fuchs	2003	Am J Phys Med Rehabil	Prospective cohort	II	17/11	Study: 62.5 (8.3)Control: 69.1 (5.5)	Cohort: 5.9Control: 55
Fuchs	2004	Clin Biomech	Prospective cohort	II	Bicondylar sledge: 15Constrained TKA: 15Control: 11	Bicondylar sledge: 67.4 (9.4)Constrained TKA: 68.1 (7.7)Control: 69.1 (5.5)	Bicondylar sledge: 33.3Constrained TKA: 20Control: 54.5
Fuchs	2005	Knee Surg Sports Traumatol Arthrosc	Prospective cohort	II	12/12	68.6 (8.5)	N/A
Fuchs	2005	Knee Surg Sports Traumatol Arthrosc	Prospective cohort	II	Operated & contralateral leg: 29Control: 11	Operated & contralateral leg: 66Control: 69.1	Operated & contralateral leg: 37.9Control: N/A
Fuchs	2005	Knee Surg Sports Traumatol Arthrosc	Prospective cohort	II	Unicondylar: 17Bicondylar: 15	Unicondylar: 62.5 (8.3)Bicondylar: 67.4 (9.4)	Unicondylar: 5.9Bicondylar: 33.3
Mouchnino	2005	BMC Musculoskelet Disord	Prospective cohort	II	Operated and nonoperated leg (Study): 9Control: 14	Cohort: 69Control: 72	Cohort: 45.5Control: 50
Gage	2007	Gait Posture	Cross-sectional	IV	8/9	Cohort: 62.9 (6)Control: 62.2 (5.6)	Cohort: 25Control: 55.6
Dalury	2008	J Arthroplasty	RCT	I	Median parapatellar: 10Mid-vastus: 10	67	30
Gage	2008	Gait Posture	Prospective cohort	II	8/9	Cohort: 62.9Control: 62.1	Cohort: 25Control: 55.6
Garling	2008	Knee Surg Sports Traumatol Arthrosc	Prospective cohort	IV	Mobile bearing: 5Fixed bearing: 4Control: 8	Mobile bearing: 64Fixed bearing: 67Control: 30	Mobile bearing: 20Fixed bearing: 50Control: 50
Callaghan	2009	Current orthopaedic practice	Prospective cohort	II	Sub-vastus: 8Mid-vastus: 10	Mid-vastus: 71 (4.5)Sub-vastus: 66 (5.1)	Mid-vastus: 40Sub-vastus: 37.5
Catani	2009	J Orthop Res	Prospective cohort	II	Operated leg: 16Contralateral leg: 16	68.2	25
Staehli	2010	J Electromyogr Kinesiol	Cross-sectional	IV	Preoperative: 10Postoperative: 20	Preoperative: 59.6 (6)Postoperative: 61.5 (5.3)	N/A
Stevens-Lapsley	2010	Clin Orthop Relat Res	Prospective cohort	II	Operated leg: 30Contralateral leg: 30Control: 15	Cohort: 64.3 (9.2)Control: 66.5 (6.5)	Cohort: 57Control: 60
Tibesku	2011	Knee Surg Sports Traumatol Arthrosc	RCT	I	Mobile-bearing: 16Fixed-bearing: 17	Mobile-bearing: 65 (9)Fixed-bearing: 66 (10)	N/A
Venema	2012	J Geriatr Phys Ther	Prospective cohort	II	10/10	Cohort: 65.5 (9.8)Control: 65.9 (9.7)	60
Davidson	2013	J Electromyogr Kinesiol	Prospective cohort	II	10/13	Cohort: 59.7 (9.1)Control: 63.9 (6.8)	Cohort: 30Control: 61.6
Lester	2013	J Arthroplasty	Prospective cohort	II	Operated leg: 7Contralateral leg: 7	72.9 (10.2)	57
McGinnis	2013	Clin Biomech	Cross-sectional	IV	Operated leg: 28Contralateral leg: 28Control: 18	Cohort: 69.9 (7.9)Control: 62.7 (6.6)	Cohort: 38Control: 52
Metcalfe	2013	Gait Posture	Prospective cohort	II	Operated leg: 14Contralateral leg: 14Control: 20	Cohort: 68.9Control: 68.3	Cohort: 36Control: 50
Yoshida	2013	Knee	Prospective cohort	II	21/14	Cohort: 63 (8.1)Control: 64.1 (6.5)	N/A
Aydogdu	2014	Knee Surg Sports Traumatol Arthrosc	RCT	I	Sub-vastus: 15Medial parapatellar: 11	40–80	Sub-vastus: 13.3Medial parapatellar: 18.1
Bjerke	2014	J Arthroplasty	Cross-sectional	IV	23/23	Cohort: 57.6 (5.8)Control: 54.7 (7.4)	Cohort: 48Control: 43
Huang	2014	Chinese Journal of Tissue Engineering Research	Prospective cohort	II	Operated leg: 25Contralateral leg: 25	69.6 (6.78)	12
Shanb	2014	Journal of Musculoskeletal Research	RCT	I	21/24	Cohort: 60.6 (5.08)Control: 60.0 (0.89)	Cohort: 38Control: 62.5
Thomas	2014	Knee	Prospective cohort	II	Operated leg: 10Contralateral leg: 10Control: 10	Cohort: 64.7 (7.9)Control: 60.6 (7.4)	Cohort: 40Control: 40
Astephen Wilson	2015	J Arthroplasty	Case series	IV	52/0	Women: 64.3 (6.5)Men: 65.1 (7.8)	46.15
Kuntze	2015	J Neurophysiol	Cross-sectional	IV	10/9	Cohort: 61.9 (8.8)Control: 61.4 (7.4)	0
Kuntze	2015	J Electromyogr Kinesiol	Cross-sectional	IV	10/9	Cohort: 61.9 (8.8)Control: 61.4 (7.4)	0
Wang	2015	Res Nurs Health	RCT	I	33/33	Study: 73.5 (9.5)Control: 71.7 (6.5)	Study: 36.4Control: 33.3
Mikkelsen	2016	Am J Phys Med Rehabil	Cross-sectional	IV	20/0	66 (9)	45
Pozzi	2016	Gait Posture	Cross-sectional	IV	19/19	Study: 70 (6)Cohort: 67 (8)	Study: 42.1Control: 47.4
Ardestani	2017	J Electromyogr Kinesiol	Cross-sectional	IV	High-functional: 13Low-functional: 13Control: 18	High-functional: 62 (5.1)Low-functional: 61.1 (8.4)Control: 54.6 (6.3)	High-functional: 38Low-functional: 38Control: 44
Husted	2017	Int J Sports Phys Ther	Randomized cross-over	III	23/0	66.5	43.5
Verdini	2017	Muscles Ligaments Tendons J	Cross-sectional	IV	TKA: 7Mobile bearing UKA: 7Fixed bearing UKA: 8Control: 12	TKA: 70Mobile bearing UKA: 68Fixed bearing UKA: 67Control: 67	TKA: 14.3Mobile bearing UKA: 28.6Fixed bearing UKA: 37.5Control: 75
Silva DCCM	2018	J Bodyw Mov Ther	Prospective cohort	II	33/0	68.2 (7.85)	33
Simon	2018	J Arthroplasty	Cross-sectional	IV	Bicruciate retaining: 12Posterior cruciate retaining: 15	Bicruciate retaining: 64 (11)Posterior cruciate retaining: 67 (7)	Bicruciate retaining: 33Posterior cruciate retaining: 40
Beach	2019	Knee	Prospective cohort	II	Medial pivot: 18Posterior stabilizing: 18Cruciate retaining: 18	Medial pivot: 66.7 (5.6)Posterior stabilizing: 69.1 (6.4)Cruciate retaining: 67.6 (4.6)	N/A
Di Benedetto	2019	Acta Biomedica	Prospective cohort	II	Journey 2 implant: 12Attune implant: 12	Journey 2 implant: 70.3Attune implant: 71.8	Journey 2 implant: 33.3Attune implant: 42.9
Jakobsen	2019	J Exp Orthop	Cross-sectional	IV	24/0	67 (8)	42
Moutzouri	2019	BMC Musculoskelet Disord	RCT	I	26/25	Cohort: 71.3 (5.3)Control: 72.3 (5.6)	N/A
Prusinowska	2019	Reumatologia	Prospective cohort	II	TKA: 10Getting 2nd TKA: 8Control: 16	TKA: 56.4Getting 2nd TKA: 62.1Control: 63.5	TKA: 20Getting 2nd TKA: 25Control: 19
Esposito	2020	Clin Biomech	Cross-sectional	IV	Medial pivot: 20Posterior stabilized: 20Control: 20	Medial pivot: 73.3 (3.5)Posterior stabilized: 70.5 (4.7)Control: 32.1 (6.7)	Medial pivot: 45Posterior stabilized: 60Control: 55
Hyodo	2020	Arthroplasty Today	Prospective cohort	II	Modern prosthesis: 12Conventional prosthesis: 12	Modern prosthesis: 69.4 (4.9)Conventional prosthesis: 70.0 (6.4)	Modern prosthesis: 16.7Conventional prosthesis: 33.3
Wang	2021	Medicine	Prospective cohort	II	Operated leg: 42Contralateral leg: 42	60.3	16.7
Koehn	2022	PLoS One	Prospective cohort	II	Pre-TKA: 306-months post-op: 2624 months post-op: 13Control: 10	Pre-TKA: 59.7 (7.8)6-months post-op: 60.3 (7.0)24 months post-op: 61.9 (6.9)Control: 63.5 (3.4)	Pre-TKA: 43.36-months post-op: 34.624 months post-op: 38.5Control: 50
Ruspi	2022	J Electromyogr Kinesiol	Prospective cohort	II	26/16	Cohort: 68.5 (9.3)Control: 65.7 (10.9)	Cohort: 53.8Control: 50
Sklempe Kokic	2022	J Clin Med	RCT	I	59/58	Cohort: 70Control: 69	Cohort: 28.9Control: 41.3
Yoshida	2022	J Bodyw Mov Ther	Prospective cohort	II	14/8	Cohort: 72.1 (6.5)Control: 66.1 (7.5)	Cohort: 0Control: 0
Rao	2023	Elife	Cross-sectional	IV	Unstable: 8Stable: 10	Unstable: 68.9 (8.3)Stable: 62.6 (6.8)	Unstable: 37.5Stable: 7

2.4

2.4 Quality assessment

Two authors independently evaluated the risk of bias in the individual studies. If disagreement occurred, they sought a resolution by consulting a third author. Due to the heterogeneity among the articles, a pooled analysis could not be performed.

3 Results

3.1

3.1 Study characteristics

This study analyzed 53 articles published from 1999 to 2024 that utilized EMG in postoperative TKA patients. Study designs included 9 randomized control trials (RCTs), 28 prospective cohort studies, 15 cross-sectional studies, and 1 case series study (Table 1). Patient demographics varied, though the mean age was predominantly over 60 (Table 1). Studies employed various surgical approaches for TKA, with follow-up periods ranging from the immediate postoperative phase to several years post-TKA. EMG was used to measure muscle amplitude and activation timing in static and dynamic conditions, compare muscle responses to surgical approaches and prosthesis designs, and as a tool for biofeedback in postoperative rehabilitation.

3.2

3.2 Dynamic muscle function – muscle activity as measured by EMG amplitude

3.2.1

3.2.1 Operated vs. non-operated leg

Seven studies examined dynamic muscle function amplitude, comparing operated versus non-operated legs across various follow-up intervals (Table 2). During the first year, studies highlighted reduced EMG activity in the operated leg across most muscles except for the biceps femoris (BF) during regular walking.¹² Quadriceps amplitude increased during sit-to-stand tasks relative to healthy controls,¹³ and EMG signal intensity in the tibialis anterior decreased compared to the opposite leg during gait.¹⁴ After one year, some studies observed increased EMG amplitude in the biceps femoris and quadriceps during walking,¹⁵^,¹⁶ with one study noting higher medial gastrocnemius amplitude in the operated leg versus the contralateral leg 1.

Table 2 Dynamic muscle function – individual muscle EMG results in TKA group.

First author	Year	Follow-up post-op	Quadriceps	Hamstrings	Others	Test performed
Benedetti	2003	6-, 12-, and 24-months	Prolonged activity of rectus femoris during stance phase throughout follow-up	Prolonged activity of hamstrings during stance phase throughout follow-up	Prolonged activity of tibialis anterior during stance phase throughout follow-up, and premature activation of gastrocnemius during gait at 6 months post-op	Gait analysis
Fuchs	2003	Mean 21.5 months	Nonsignificant	Lower hamstrings activity	Significantly lower EMG activity during walking and stair climbing in all other muscles except for tibialis anterior	Walking and stair climbing
Fuchs	2005	Mean 16.4 months	Nonsignificant	Significantly higher amplitude during walking	Nonsignificant	Gait analysis
Fuchs	2005	Mean 10.1 months	Lower compared to nonoperated leg and healthy controls	Nonsignificant	All muscle activity in operated leg was lower than in the nonoperated leg and in healthy controls.	Gait and balance analysis
Mouchnino	2005	12 months	Before TKA, activity of contralateral VL significantly surged before ground contact; after surgery, activity aligned more closely with the control group	N/A	N/A	Step-down task
Gage	2007	Mean 8 months	Nonsignificant	Nonsignificant	Nonsignificant	Rotational support surface perturbations
Gage	2008	Mean 8 months	Nonsignificant	Nonsignificant	Nonsignificant	Frontal plane support surface rotations
Catani	2009	6 months	Prolonged activity during stance phase; slightly prolonged and co-contracted in others	Prolonged activity during stance phase; slightly prolonged and co-contracted in others	Nonsignificant	Gait analysis
Davidson	2013	1 month	Increased quadriceps activity during the eccentric phase of the five-time-sit-to-stand task	Nonsignificant	Higher eccentric coactivation indices compared to healthy controls	Sit-to-stand task
Lester	2013	At least 2 years	Threefold increase in EMG amplitude for the operated knees compared to the non-operated knees during walking.	N/A	N/A	Gait analysis
McGinnis	2013	6 months	Nonsignificant	Nonsignificant	Nonsignificant	Gait analysis
Metcalfe	2013	Mean 14 months	Increased co-contraction of the quadriceps when walking on a flat surface; abnormal patterns approach normal levels a year after knee arthroplasty	Increased co-contraction of the hamstrings when walking on a flat surface; abnormal patterns approach normal levels a year after knee arthroplasty	N/A	Gait analysis
Yoshida	2013	3 months, 12 months	Weakness at 3 months post-op and increased co-contraction with hamstrings	Increased activity at 3 and 12 months post-op	N/A	Gait analysis
Bjerke	2014	19 months	Nonsignificant	Nonsignificant	N/A	Stair ascent
Huang	2014	Mean 19.3 months	Nonsignificant	Nonsignificant	Higher medial gastrocnemius amplitude on the replacement side	Gait analysis
Thomas	2014	Pre-op, then 1- and 6- months post-op	Co-activation was higher bilaterally compared to controls. Patients turned off quadriceps later during stance phase.	Co-activation was higher bilaterally compared to controls	N/A	Gait analysis
Astephen Wilson	2015	12 months	Women had higher quadriceps activity	Men had higher hamstrings activity	Women had higher gastrocnemius activity compared to men	Gait analysis
Kuntze	2015	Mean 19 months	Nonsignificant	Nonsignificant	Nonsignificant	Stair climbing
Kuntze	2015	Mean 19 months	Delayed peak activation in vastus medialis in early step phase, with prolonged activation during the middle of the step	Delayed peak activation in biceps femoris in early step phase, with prolonged activation during the middle of the step	TKA patients had a delayed peak muscle activation of the vastus medialis and biceps femoris in the early step phase, and prolonged activation during the middle of the step.	Gait analysis
Pozzi	2016	6 months	Nonsignificant	Nonsignificant	During the weight acceptance phase, the TKA group had significantly higher EMG in the lateral gastrocnemius muscle, but no significant differences in the soleus and medial gastrocnemius muscles.	Step up and over task
Ardestani	2017	Minimum 12 months	Variable activity in high-functional patients based on gait cycle	Variable activity in high-functional patients based on gait cycle	Low-functional TKA group used fewer numbers of neural commands to execute a gait cycle compared to the high-functional TKA and control groups. Stride-to-stride variability of muscles' response to the neural commands was reduced up to 15 % in the low-functional TKA group.	Gait analysis
Wang	2021	3 months	Nonsignificant	Nonsignificant	During gait, surface EMG signals of tibialis anterior muscle in the operated side were significantly decreased. The gluteus maximus and gastrocnemius revealed no significant difference.	Gait analysis
Koehn	2022	6 months & 24 months	N/A	N/A	A higher number of neuromuscular modules were related to better performance-based and patient-reported function before and 6-months after surgery. Participants with organization similar to healthy,age-matched controls trended toward better, though nonsignificant, function 24-months after surgery.	Gait analysis
Yoshida	2022	3, 12, & 24 weeks	Vastus lateralis activity during gait continued to decrease up to 12 weeks but then increased, equaling the control group at 24 weeks. Rectus femoris activity slightly increased at 3 weeks and remained steady thereafter.	N/A	Tensor fasciae latae activity kept decreasing post-op, eventually matching control levels.	Gait analysis
Rao	2023	>1 year	Nonsignificant between stable and unstable knees	Nonsignificant between stable and unstable knees	Nonsignificant between stable and unstable knees	Gait analysis, downhill walking, and stair descent

Overall, studies indicate reduced EMG activity in most muscles of the operated leg within the first year post-op, followed by increased amplitude in specific muscles, like the BF, quadriceps, and medial gastrocnemius during walking, after one year.

3.3

3.3 Comparison to controls

Three studies analyzed EMG amplitude in the operative leg versus healthy control legs (Table 2). Pozzi et al. observed a higher EMG amplitude in the lateral gastrocnemius during weight acceptance in TKA patients.¹⁷ Bjerke et al. found no notable difference in vastus lateralis (VL) and semitendinosus activity during stair climbing between TKA patients and controls.¹⁸ Yoshida et al. noted initial VL activity decline up to 12 weeks post-op, which later matched controls by 24 weeks.¹⁹ Fuchs et al. reported reduced EMG activity during walking and stair climbing in patients with unicondylar prostheses.²⁰

Overall, studies show varied outcomes in muscle activation post-TKA, with some muscles exhibiting increased EMG activity compared to healthy controls, while others show decreased activity or eventual improvement over time.

3.4

3.4 Dynamic muscle function - activation timing & Co-contraction

3.4.1

3.4.1 Operated vs. non-operated leg

Five studies compared activation timing in dynamic muscle function between the operated leg with the non-operated one (Table 3). The studies found no significant differences in peak or average knee co-contraction,²¹ that some patients exhibited extended quadriceps and hamstrings activity during the stance phase,²² and that a delayed activation of the quadriceps occurred in the surgical limb compared to the non-surgical limb one month post-TKA.²³ Yoshida et al. identified increased co-contraction of the quadriceps and hamstrings during the loading phase of walking at 3- and 12-month follow-up, which was linked to quadriceps weakness and increased hamstring muscle activity.²⁴ Metcalfe et al. noted that pre-surgery co-contraction abnormalities during flat-surface walking were resolved by an average of 14 months post-surgery.²⁵

Table 3 Static muscle function – individual muscle EMG results in TKA group.

First author	Year	Follow-up post-op	Quadriceps	Hamstrings	Others	Test performed
Staehli	2010	5–12 months	Intra-class correlation coefficients and coefficients of variation for muscle function during voluntary or electrically stimulated outcomes were very similar between pre-op and post-op patients, indicating good test-retest reliability.	N/A	N/A	Voluntary and electrically stimulated contractions
Stevens-Lapsley	2010	2 weeks, 1-, 3-, and 6-months	Weaker quadriceps compared to nonoperative leg	No hamstrings strength loss in operative leg compared to nonoperative	N/A	Maximal isometric quadriceps contraction
Venema	2012	Pre-op, then 3-, and 6-months post-op	Lower amplitude compared to controls	Lower amplitude compared to controls	N/A	Standard reaching task
Mikkelsen	2016	4–8 weeks	During a set of strength training, muscle activity and activation increases up until contraction failure.	N/A	N/A	Knee extensions to contraction failure
Husted	2017	4–8 weeks	Higher muscle activity during rapid knee-extensions compared to slow knee-extensions for vastus lateralis. No significant difference for vastus medialis between rapid and slow knee-extensions.	N/A	N/A	Slow and rapid knee extensions
Verdini	2017	1–3 years	Nonsignificant	Co-contractions of the quadriceps and biceps femoris were present from about 25 % of the descent phase up to 75 % of the ascent phase.	N/A	Unconstrained squat
Silva DCCM	2018	Up to 8 weeks	Nonsignificant	Statistically significant increase in EMG activity of the biceps femoris muscle after myofascial release.	N/A	Maximal voluntary isometric contractions
Jakobsen	2019	4–8 weeks	Knee extensions with an elastic band and one-legged squats showed significantly higher voluntary peak quadriceps muscle activity compared to machine-based exercises.	One-legged squats elicited higher hamstring muscle activity than leg press and sit-to-stand.	N/A	Six different strength training exercises
Moutzouri	2019	8 & 14 weeks	The sensorimotor training group showed significantly higher integrated EMG peak amplitude in the rectus femoris compared to the functional exercise group.	N/A	N/A	Maximal voluntary isometric contractions
Prusinowska	2019	10 days	Post-TKA, there was an increase in rectus femoris voltage compared to pre-surgery levels. However, there was a decrease in vastus medialis obliquus voltage after surgery.	N/A	N/A	Isometric tension
Ruspi	2022	3 days	Patients showed significantly lower rectus femoris activation during knee extension compared to hip flexion and hip flexion with extension, both before and after surgery, similar to controls. However, unlike controls, patients had higher vastus medialis and vastus lateralis activation during hip flexion compared to knee extension.	N/A	N/A	Maximal voluntary isometric contractions of knee extension, hip flexion, and hip flexion with contralateral hip extension

The studies collectively indicate that while pre-surgery co-contraction abnormalities and delayed muscle activation can persist shortly after TKA, improvements, particularly in muscle co-contraction during walking, tend to occur within 12–14 months post-surgery.

3.5

3.5 Comparison to controls

Eight studies analyzed dynamic muscle function activation timing in the operative leg compared to healthy control legs (Table 2). Within the first year, Gage et al. found similar muscle activation timing between TKA patients and controls during upright rotation and uphill rectus femoris onset.²⁶^,²⁷ Preoperatively, Mouchnino et al. observed increased VL activity in the non-arthritic leg, supporting more body weight, which normalized post-surgery to control levels, showing improvement.²⁸ Kuntze et al. found no significant muscle differences during stair climbing but delayed VM and BF peak activation in early stepping at 19 months post-op.²⁹^,³⁰ Two studies using non-negative matrix factorization showed patients with higher functional levels post-TKA had greater diversity in muscle synergies, reflecting adaptable motor control strategies.³¹^,³² This adaptability was linked to improved functional performance and outcomes at six months, with better muscle coordination resembling controls maintaining function two years post-surgery.³²

The studies reveal that post-TKA patients generally exhibit muscle activation patterns similar to healthy controls within a year, with trends indicating normalized muscle activity and adaptable motor control strategies correlating with improved functional performance and patient-reported outcomes.

3.6

3.6 Static muscle function – amplitude & activity

The use of EMG to examine static muscle amplitude and activity during various exercises after TKA was utilized in 9 studies (Table 3).^33–41 “Static” refers to patients focusing on specific contractions, such as sitting quadriceps exercises. Ruspi et al. found higher VMO and VL activation during hip flexion versus knee extension 1–3 days post-op, suggesting hip flexion benefits early rehabilitation.⁴¹ Prusinowska et al. observed increased RF voltage during isometric tension 10 days post-op but decreased VMO activity.³⁹ By 8 weeks post-op, Silva et al. reported increased BF activity after myofascial release, and Moutzouri et al. found superior RF outcomes with sensorimotor training versus functional exercises.³⁷^,³⁸ Mikkelsen et al. and Husted et al. observed increased VL activity during strength training, including rapid versus slow knee extensions.³⁴^,³⁵ Jakobsen et al. noted home-based exercises enhanced quadriceps and hamstring activity similarly to machine-based training.³⁶ Venema et al. found no significant EMG differences at 3- and 6-month follow-ups.³³ Between 5 and 12 months post-op, Staehli et al. observed comparable muscle function outcomes, emphasizing EMG's reliability in detecting VL and RF activity.⁴⁰

The studies reveal varied trends: hip flexion exercises increase VMO and VL activation early (1–3 days), RF activity rises at 10 days, strength and sensorimotor training boost muscle activity at 4–8 weeks, and muscle activity stabilizes by 3–6 months.

3.7

3.7 Static muscle function – activation timing & Co-contraction

Two studies employed EMG to analyze muscle activation timing during different exercises post-TKA (Table 3).⁴²^,⁴³ Stevens-Lapsley et al. observed prolonged hamstrings coactivation of the operated leg compared to the unoperated leg during maximal quadriceps contraction one month after surgery.⁴³ After 1–3 years post-TKA, Verdini et al. observed that patients with both mobile-bearing and fixed-bearing prostheses had co-contractions of the quadriceps and BF during 25 % of the descent phase and up to 75 % of the ascent phase.⁴²

3.8

3.8 Surgical approaches

Electromyographic outcomes comparing different TKA surgical approaches were assessed in 4 studies (Table 4).^44–47 Parentis et al. reported 43 % of midvastus approach patients experienced postoperative denervation over 2–12 weeks, compared to none in the median parapatellar group.⁴⁴ Dalury et al. found no significant VMO EMG differences between the median parapatellar and midvastus approaches at 12 weeks, concluding the midvastus approach does not harm the VMO.⁴⁵ Callaghan et al. observed no significant EMG differences between subvastus and midvastus approaches up to 3 months post-op.⁴⁶ Aydogdu et al. noted increased EMG amplitude 6 weeks post-op in the subvastus group versus the medial parapatellar group, suggesting quicker knee extensor recovery.⁴⁷

Table 4 Results of postoperative EMG use for comparing surgical approaches.

First author	Year	Surgical Approach	Follow-up post-op	Results of EMG	Test performed
Parentis	1999	Median parapatellar vs. mid-vastus approach	2-, 6-, and 12-weeks	No significant differences in EMG parameters after adding biofeedback training to standard exercise protocol.	Maximal voluntary isometric contraction
Dalury	2008	Median parapatellar vs. mid-vastus approach	12 weeks	The EMG biofeedback group reported significantly less pain elicited by continuous passive motion compared to the group without biofeedback.	Knee extension and hip flexion with contralateral hip extension
Callaghan	2009	Sub-vastus vs. mid-vastus	5 days, 6 weeks, & 3 months	Biofeedback did not significantly enhance functional outcomes compared to conventional rehabilitation after total knee arthroplasty; both biofeedback and non-biofeedback groups showed similar results.	Maximal voluntary isometric contraction and straight leg raise
Aydogdu	2014	Sub-vastus vs. medial parapatellar	6 weeks	Increase in EMG amplitude and number of the turns per second at a force of 30 % maximal contraction 6 weeks postoperatively in the sub-vastus group compared to the parapatellar group.	Maximal voluntary isometric contraction

Overall, studies show the midvastus approach causes postoperative denervation, unlike the median parapatellar approach, with no significant VMO EMG differences at 12 weeks. Subvastus and midvastus approaches show similar EMG results up to 3 months, but the subvastus approach increases EMG amplitude at 6 weeks, suggesting quicker knee extensor recovery.

3.9

3.9 Prosthesis designs

Ten studies examined EMG results between TKA prostheses (Table 5). Mobile-bearing and fixed-bearing implants caused prolonged RF and TA activation during stair climbing, but no differences in gait cycles or step-up tasks at 9.6- and 24-month follow-ups.²^,⁴⁸^,⁴⁹ Medial pivot implants showed lower VL and higher RF activity compared to cruciate-retaining and posterior stabilizing designs during specific tasks.⁵⁰^,⁵¹ Journey 2 implants demonstrated less BF and TA EMG reduction and lower VMO, RF, and VL activity during stance and swing phases than Attune and Legion implants.⁵²^,⁵³ No significant differences in co-contraction levels were noted during step-up tasks.⁴⁸ Bicondylar prostheses showed higher VL EMG activity than unicondylar prostheses.⁵⁴ Posterior cruciate-retaining prostheses exhibited lower VMO and RF activity than bicruciate-retaining designs,⁵⁵ with no significant differences between bicondylar sledge and constrained TKA prostheses.⁵⁶

Table 5 Results of postoperative EMG use for comparing prosthesis designs.

First author	Year	Type of Prosthesis	Follow-up	Results of EMG	Test performed
Tibesku	2011	Mobile bearing vs. fixed bearing	24 months	No significant differences during in EMG activity patterns during gait cycles between groups.	Gait analysis
Catani	2003	Mobile bearing vs. fixed bearing	Fixed bearing: 11 monthsMobile bearing: 20 months	Both groups exhibited abnormal prolonged activity in rectus femoris and tibialis anterior during stair climbing, with normal activity in biceps femoris and gastrocnemius.	Stair climbing
Garling	2008	Mobile bearing vs. fixed bearing	Mean 9.6 months	No difference in co-contraction levels during a step-up task between mobile bearing and fixed bearing groups.	Step-up task
Esposito	2020	Medial pivot vs. posterior stabilizing vs. control	12–18 months	The activation timing of the vastus medialis, biceps femoris, and rectus femoris was significantly greater in the patient groups during gait compared to the control group. The medial pivot group also had significantly increased activity of the rectus femoris in the stance phase compared to the posterior stabilizing group.	Gait analysis
Beach	2019	Medial pivot vs. posterior stabilizing vs. cruciate retaining	Minimum of 12 months	No significant differences between groups for any muscles, in any task, with one exception: the vastus lateralis, during the step-ascent task, was significantly lower in activity in the medial pivot group compared to the cruciate retaining group.	Step-ascent and gait analysis
Di Benedetto	2019	Journey 2 vs. Attune	3 months	Both groups showed general muscle activity reduction, with significant decreases in the rectus femoris and gastrocnemius lateralis during kinematic analysis. The Journey 2 implant group had less reduction in biceps femoris and tibialis anterior, while the Attune implant group showed less reduction in the vastus medialis.	Gait analysis
Hyodo	2020	Modern prosthesis (Journey 2) vs. conventional prosthesis (Legion)	Journey 2: 12Legion: 12	During the stance phase, the Journey 2 group had lower EMG activity in the vastus medialis, rectus femoris, and vastus lateralis muscles compared to the Legion group, but it was not statistically significant. The lower quadriceps muscle activity in the Journey 2 group persisted into the swing phase and included lower activity in the medial hamstring, lateral hamstring, and gluteus medius muscles.	Gait analysis
Fuchs	2005	Unicondylar vs.Bicondylar (medial and lateral uni)	Unicondylar: 21.5Bicondylar: 31.9	Significant EMG activity differences during gait were noted only in the vastus lateralis, with higher mean EMG in the bicondylar prosthesis group; no peak EMG differences were observed between groups.	Gait analysis
Fuchs	2004	Bicondylar sledge vs. constrained TKA	Bicondylar sledge: mean 31.9 months.Constrained TKA: mean 26.7 months	During walking and stair climbing, no significant EMG differences were found between arthroplasty groups.	Stair climbing and gait analysis
Simon	2018	Bicruciate retaining vs. posterior cruciate retaining	8–14 months	The EMG biofeedback group reported significantly less pain elicited by continuous passive motion compared to the group without biofeedback.	Level and downhill walking

In summary, mobile- and fixed-bearing implants showed abnormal RF and TA activation during stair climbing but no gait or step-up differences. Medial pivot designs had lower VL and higher RF activity than posterior stabilizing implants, while Journey 2 implants showed reduced EMG amplitude compared to Attune and Legion implants.

3.10

3.10 Biofeedback

EMG use for biofeedback in knee rehabilitation, reported in three separate RCT studies, was shown to have mixed outcomes (Table 6).³^,⁵⁷^,⁵⁸ Shanb et al. found no significant EMG changes when biofeedback was added to standard exercises in a patient group averaging 60 years old.⁵⁷ In a separate study, Wang et al. reported that the biofeedback group, with participants in their early 70's, experienced significantly less pain during the immediate postoperative period compared to those without biofeedback.⁵⁸ Finally, Sklempe Kokic et al. noted that biofeedback did not significantly enhance functional outcomes compared to conventional rehabilitation methods in the three weeks post-TKA.³

Table 6 Results of postoperative EMG use for biofeedback.

First author	Year	Follow-up post-op	Results of EMG	Test performed
Shanb	2014	4 months	No significant differences in EMG parameters after adding biofeedback training to standard exercise protocol.	Maximal voluntary isometric quadriceps contraction
Wang	2015	5 days	The EMG biofeedback group reported significantly less pain elicited by continuous passive motion compared to the group without biofeedback.	Muscle relaxation during continuous passive motion therapy
Sklempe Kokic	2022	21 days	Biofeedback did not significantly enhance functional outcomes compared to conventional rehabilitation after total knee arthroplasty; both biofeedback and non-biofeedback groups showed similar results.	Maximal voluntary isometric quadriceps contraction

Overall, EMG biofeedback in knee rehabilitation post-TKA appears to have limited effectiveness, with studies showing no significant EMG changes or enhanced functional outcomes compared to conventional methods, although it may reduce immediate postoperative pain in older patients.

4 Discussion

This systematic review encompassed 53 studies spanning 1999 to 2024 to assess EMG's application and effectiveness following TKA. The results show EMG can aid postoperative rehabilitation by offering insights into muscle function and recovery, identifying deficits to guide personalized plans, and potentially improving recovery, satisfaction, and complication prevention. However, its effectiveness varies depending on factors like patient age, surgical approach, and rehabilitation exercises.

Previous reviews have examined EMG's postoperative application, mainly focusing on biofeedback benefits.⁹^,¹⁰ Argut et al. found biofeedback controls pain and improves quadriceps strength, though its impact on knee range of motion (ROM) was unclear.⁹ Xie et al. showed enhanced ROM but no superiority in pain reduction or functional improvements.¹⁰ To date, no systematic review has exclusively analyzed EMG in TKA patients.

EMG biofeedback in postoperative TKA rehabilitation has shown varied effectiveness.³^,⁵⁷^,⁵⁸ Studies indicate it may significantly reduce pain in older patients during the immediate postoperative phase, but its impact on functional outcomes and muscle strength is inconsistent.³^,⁵⁷^,⁵⁸ Shanb et al. suggest longer-term use might enhance outcomes,⁵⁷ while Wang et al. highlight its non-invasive, cost-effective potential for pain management.⁵⁸ Conversely, Sklempe Kokic et al. found no additional benefits in their short-term study, underscoring the need for longer trials.³

Evaluating muscle activation across surgical approaches highlights mixed outcomes. Parentis et al. reported postoperative denervation with the midvastus approach,⁴⁴ while Dalury et al. and Callaghan et al. found no differences between approaches.⁴⁵^,⁴⁶ These findings suggest EMG alone may not determine the best approach but could complement other tools.

The integration of EMG in postoperative TKA care provides insights into dynamic and static muscle function, evaluating amplitude and activity during gait, stair climbing, and isometric contractions. This review observed reduced EMG activity in the operated leg, normalizing over time, indicating phased muscle recovery and adaptation.²^,¹⁴^,¹⁹^,²¹^,^25–27^,³³ This aligns with findings of significant quadriceps strength impairment at one-month post-op due to activation failure and atrophy, with strength improving to preoperative levels by three to six months.⁵⁹^,⁶⁰ Results highlight differential effects of exercise modalities, such as strength versus sensorimotor training and home-based versus machine-based exercises, emphasizing tailored rehabilitation protocols.³⁶^,³⁸ Another review suggests optimal outpatient physical therapy should combine strength training, aquatic therapy, and balance training tailored to patient progress.⁶¹

There were some limitations in this systematic review, including variability in study design and insufficient RCTs for thorough comparisons. Methodological differences in EMG measurements, such as electrode placement, further impacted result consistency. Future research is needed to address these gaps and refine EMG's role in postoperative care.

5 Conclusion

Although the use of EMG in postoperative rehabilitation depicts muscles lacking in recovery, its use should be selective and based on further studies to identify circumstances and patient groups that would benefit most. Routine incorporation of EMG after TKA should be approached cautiously. EMG provides important insights, but considering the need for specialized knowledge to interpret data and accessibility issues, its broad clinical application should be carefully evaluated. Where resources permit, EMG can improve care by providing a detailed understanding of recovery needs and progress. For general adoption, further studies are needed to assess its benefits, cost-effectiveness, and biofeedback potential.

Ethical statement

Not applicable.

Author contribution

All authors had equal contribution in conception, data collection, preparing ,manuscript and reviewing manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

Huang P., Liu Z.H., Qi J., Chen B., Xu J.Q., Deng L.F., . Surface electromyography of lower limb muscles in knee osteoarthritis patients undergoing knee joint replacement. Chin J Tissue Eng Res. 2014;18(13):2024-2030.
[Google Scholar]
Tibesku C.O., Daniilidis K., Skwara A., Dierkes T., Rosenbaum D., Fuchs-Winkelmann S., . Gait analysis and electromyography in fixed- and mobile-bearing total knee replacement: a prospective, comparative study. Knee Surg Sports Traumatol Arthrosc. 2011;19(12):2052-2059.
[Google Scholar]
Sklempe Kokic I., Vuksanic M., Kokic T., Peric I., Duvnjak I., . Effects of electromyographic biofeedback on functional recovery of patients two months after total knee arthroplasty: a randomized controlled trial. J Clin Med. 2022;11:11.
[Google Scholar]
Shichman I., Roof M., Askew N., et al . Projections and epidemiology of primary hip and knee arthroplasty in medicare patients to 2040-2060. JB JS Open Access. 2023;8:1.
[Google Scholar]
DeFrance M.J., Scuderi G.R., . Are 20% of patients actually dissatisfied following total knee arthroplasty? A systematic review of the literature. J Arthroplast. 2023;38(3):594-599.
[Google Scholar]
Parvizi J., Nunley R.M., Berend K.R., et al . High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res. 2014;472(1):133-137.
[Google Scholar]
Frank D.L., Khorshid L., Kiffer J.F., Moravec C.S., McKee M.G., . Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010;7(2):85-91.
[Google Scholar]
Giggins O.M., Persson U.M., Caulfield B., . Biofeedback in rehabilitation. J NeuroEng Rehabil. 2013;10(1):60.
[Google Scholar]
Karaborklu Argut S., Celik D., Yasacı Z., . Effectiveness of therapeutic electromyographic biofeedback after orthopedic knee surgeries: a systematic review. Disabil Rehabil. 2022;44(14):3364-3372.
[Google Scholar]
Xie Y.J., Wang S., Gong Q.J., et al . Effects of electromyography biofeedback for patients after knee surgery: a systematic review and meta-analysis. J Biomech. 2021;120
[Google Scholar]
Moher D., Liberati A., Tetzlaff J., Altman D.G., . Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. PLoS Med. 2009;6(7)
[Google Scholar]
Fuchs S., Rolauffs B., Plaumann T., Tibesku C.O., Rosenbaum D., . Clinical and functional results after the rehabilitation period in minimally-invasive unicondylar knee arthroplasty patients. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):179-186.
[Google Scholar]
Davidson B.S., Judd D.L., Thomas A.C., Mizner R.L., Eckhoff D.G., Stevens-Lapsley J.E., . Muscle activation and coactivation during five-time-sit-to-stand movement in patients undergoing total knee arthroplasty. J Electromyogr Kinesiol. 2013;23(6):1485-1493.
[Google Scholar]
Wang Z.H., Wang J.C., Zheng S., Xue P., Han F.J., . Three-dimensional gait characteristics of patients after unilateral total knee arthroplasty. Medicine (Baltim). 2021;100
[Google Scholar]
Fuchs S., Skwara A., Rosenbaum D., . Preliminary results after total knee arthroplasty without femoral trochlea: evaluation of clinical results, quality of life and gait function. Knee Surg Sports Traumatol Arthrosc. 2005;13(8):664-669.
[Google Scholar]
Lester D.K., Shantharam R., Zhang K., . Dynamic electromyography after cruciate-retaining total knee arthroplasty revealed a threefold quadriceps demand compared with the contralateral normal knee. J Arthroplast. 2013;28(4):557-562.
[Google Scholar]
Pozzi F., Marmon A.R., Snyder-Mackler L., Zeni J., . Lower leg compensatory strategies during performance of a step up and over task in patient six-months after total knee arthroplasty. Gait Posture. 2016;49:41-46.
[Google Scholar]
Bjerke J., Öhberg F., Nilsson K.G., Stensdotter A.K., . Compensatory strategies for muscle weakness during stair ascent in subjects with total knee arthroplasty. J Arthroplast. 2014;29(7):1499-1502.
[Google Scholar]
Yoshida T., Ebiko J., Sasaki K., Uchiyama E., Kura H., . Recovery process of the muscle activities during walking with efficient early quadriceps training and gait exercises after total knee arthroplasty. J Bodyw Mov Ther. 2022;29:49-53.
[Google Scholar]
Fuchs S., Tibesku C.O., Frisse D., Laass H., Rosenbaum D., . Quality of life and gait after unicondylar knee prosthesis are inferior to age-matched control subjects. Am J Phys Med Rehabil. 2003;82(6):441-446.
[Google Scholar]
McGinnis K., Snyder-Mackler L., Flowers P., Zeni J., . Dynamic joint stiffness and co-contraction in subjects after total knee arthroplasty. Clin Biomech. 2013;28(2):205-210.
[Google Scholar]
Catani F., Ensini A., Belvedere C., et al . In vivo kinematics and kinetics of a bi-cruciate substituting total knee arthroplasty: a combined fluoroscopic and gait analysis study. J Orthop Res. 2009;27(12):1569-1575.
[Google Scholar]
Thomas A.C., Judd D.L., Davidson B.S., Eckhoff D.G., Stevens-Lapsley J.E., . Quadriceps/hamstrings co-activation increases early after total knee arthroplasty. Knee. 2014;21(6):1115-1119.
[Google Scholar]
Yoshida Y., Mizner R.L., Snyder-Mackler L., . Association between long-term quadriceps weakness and early walking muscle co-contraction after total knee arthroplasty. Knee. 2013;20(6):426-431.
[Google Scholar]
Metcalfe A., Stewart C., Postans N., et al . Abnormal loading of the major joints in knee osteoarthritis and the response to knee replacement. Gait Posture. 2013;37(1):32-36.
[Google Scholar]
Gage W.H., Frank J.S., Prentice S.D., Stevenson P., . Organization of postural responses following a rotational support surface perturbation, after tka: sagittal plane rotations. Gait Posture. 2007;25(1):112-120.
[Google Scholar]
Gage W.H., Frank J.S., Prentice S.D., Stevenson P., . Postural responses following a rotational support surface perturbation, following knee joint replacement: frontal plane rotations. Gait Posture. 2008;27(2):286-293.
[Google Scholar]
Mouchnino L., Gueguen N., Blanchard C., et al . Sensori-motor adaptation to knee osteoarthritis during stepping-down before and after total knee replacement. BMC Muscoskelet Disord. 2005;6:21.
[Google Scholar]
Kuntze G., von Tscharner V., Hutchison C., Ronsky J.L., . Alterations in lower limb multimuscle activation patterns during stair climbing in female total knee arthroplasty patients. J Neurophysiol. 2015;114(5):2718-2725.
[Google Scholar]
Kuntze G., von Tscharner V., Hutchison C., Ronsky J.L., . Multi-muscle activation strategies during walking in female post-operative total joint replacement patients. J Electromyogr Kinesiol. 2015;25(4):715-721.
[Google Scholar]
Ardestani M.M., Malloy P., Nam D., Rosenberg A.G., Wimmer M.A., . Tka patients with unsatisfying knee function show changes in neuromotor synergy pattern but not joint biomechanics. J Electromyogr Kinesiol. 2017;37:90-100.
[Google Scholar]
Koehn R.R., Roelker S.A., Pan X., Schmitt L.C., Chaudhari A.M.W., Siston R.A., . Is modular control related to functional outcomes in individuals with knee osteoarthritis and following total knee arthroplasty? PLoS One. 2022;17
[Google Scholar]
Venema D.M., Karst G.M., . Individuals with total knee arthroplasty demonstrate altered anticipatory postural adjustments compared with healthy control subjects. J Geriatr Phys Ther. 2012;35(2):62-71.
[Google Scholar]
Mikkelsen E.K., Jakobsen T.L., Holsgaard-Larsen A., Andersen L.L., Bandholm T., . Strength training to contraction failure increases voluntary activation of the quadriceps muscle shortly after total knee arthroplasty: a cross-sectional study. Am J Phys Med Rehabil. 2016;95(3):194-203.
[Google Scholar]
Husted R.S., Wilquin L., Jakobsen T.L., Holsgaard-Larsen A., Bandholm T., . Rapid knee-extensions to increase quadriceps muscle activity in patients with total knee arthroplasty: a randomized cross-over study. Int J Sports Phys Ther. 2017;12(1):105-116.
[Google Scholar]
Jakobsen T.L., Jakobsen M.D., Andersen L.L., Husted H., Kehlet H., Bandholm T., . Quadriceps muscle activity during commonly used strength training exercises shortly after total knee arthroplasty: implications for home-based exercise-selection. J Exp Orthop. 2019;6(1):29.
[Google Scholar]
DCCM E.S., de Andrade Alexandre D.J., Silva J.G., . Immediate effect of myofascial release on range of motion, pain and biceps and rectus femoris muscle activity after total knee replacement. J Bodyw Mov Ther. 2018;22(4):930-936.
[Google Scholar]
Moutzouri M., Coutts F., Gliatis J., Billis E., Tsepis E., Gleeson N., . Early initiation of home-based sensori-motor training improves muscle strength, activation and size in patients after knee replacement: a secondary analysis of a controlled clinical trial. BMC Muscoskelet Disord. 2019;20(1):231.
[Google Scholar]
Prusinowska A., Komorowski A., Syrówka P., . The use of surface electromyography in rehabilitating rheumatic patients after knee arthroplasty (pilot study) Reumatologia. 2019;57(4):199-206.
[Google Scholar]
Staehli S., Glatthorn J.F., Casartelli N., Maffiuletti N.A., . Test-retest reliability of quadriceps muscle function outcomes in patients with knee osteoarthritis. J Electromyogr Kinesiol. 2010;20(6):1058-1065.
[Google Scholar]
Ruspi A., Temporiti F., Adamo P., Mina F., Traverso F., Gatti R., . Neuromuscular activation of quadriceps bellies during tasks performed in the same biomechanical condition in patients undergoing total knee arthroplasty. J Electromyogr Kinesiol. 2022;64
[Google Scholar]
Verdini F., Zara C., Leo T., Mengarelli A., Cardarelli S., Innocenti B., . Assessment of patient functional performance in different knee arthroplasty designs during unconstrained squat. Muscles Ligaments Tendons J. 2017;7(3):514-523.
[Google Scholar]
Stevens-Lapsley J.E., Balter J.E., Kohrt W.M., Eckhoff D.G., . Quadriceps and hamstrings muscle dysfunction after total knee arthroplasty. Clin Orthop Relat Res. 2010;468(9):2460-2468.
[Google Scholar]
Parentis M.A., Rumi M.N., Deol G.S., Kothari M., Parrish W.M., Pellegrini V.D., . A comparison of the vastus splitting and median parapatellar approaches in total knee arthroplasty. Clin Orthop Relat Res. 1999;367:107-116.
[Google Scholar]
Dalury D.F., Snow R.G., Adams M.J., . Electromyographic evaluation of the midvastus approach. J Arthroplast. 2008;23(1):136-140.
[Google Scholar]
Callaghan M.J., Babu V.L., Ellis D.J., Samarji R.A., . Electromyographic comparison of the mid-vastus and sub-vastus approaches to total knee arthroplasty. Current orthopaedic practice. 2009;20:4:442-447.
[Google Scholar]
Aydogdu S., Zileli B., Cullu E., Atamaz F.C., Sur H., Zileli M., . Increased turn/amplitude parameters following subvastus approach in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014;22(7):1632-1637.
[Google Scholar]
Garling E.H., Wolterbeek N., Velzeboer S., et al . Co-contraction in ra patients with a mobile bearing total knee prosthesis during a step-up task. Knee Surg Sports Traumatol Arthrosc. 2008;16(8):734-740.
[Google Scholar]
Catani F., Benedetti M.G., De Felice R., Buzzi R., Giannini S., Aglietti P., . Mobile and fixed bearing total knee prosthesis functional comparison during stair climbing. Clin Biomech. 2003;18(5):410-418.
[Google Scholar]
Esposito F., Freddolini M., Marcucci M., Latella L., Corvi A., . Biomechanical analysis on total knee replacement patients during gait: medial pivot or posterior stabilized design? Clin Biomech. 2020;78
[Google Scholar]
Beach A., Regazzola G., Neri T., Verheul R., Parker D., . The effect of knee prosthesis design on tibiofemoral biomechanics during extension tasks following total knee arthroplasty. Knee. 2019;26(5):1010-1019.
[Google Scholar]
Di Benedetto P., Vidi D., Colombo A., Buttironi M.M., Cainero V., Causero A., . Pre-operative and post-operative kinematic analysis in total knee arthroplasty. A pilot study. Acta Biomed. 2019;90:91-97.
[Google Scholar]
Hyodo K., Kanamori A., Kadone H., Takahashi T., Kajiwara M., Yamazaki M., . Gait analysis comparing kinematic, kinetic, and muscle activation data of modern and conventional total knee arthroplasty. Arthroplast Today. 2020;6(3):338-342.
[Google Scholar]
Fuchs S., Tibesku C.O., Frisse D., Genkinger M., Laass H., Rosenbaum D., . Clinical and functional comparison of uni- and bicondylar sledge prostheses. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):197-202.
[Google Scholar]
Simon J.C., Della Valle C.J., Wimmer M.A., . Level and downhill walking to assess implant functionality in bicruciate- and posterior cruciate-retaining total knee arthroplasty. J Arthroplast. 2018;33(9):2884-2889.
[Google Scholar]
Fuchs S., Tibesku C.O., Genkinger M., Volmer M., Laass H., Rosenbaum D., . Clinical and functional comparison of bicondylar sledge prostheses retaining all ligaments and constrained total knee replacement. Clin Biomech. 2004;19(3):263-269.
[Google Scholar]
Shanb A.-S.A., Youssef E.F., . Effects of adding biofeedback training to active exercises after total knee arthroplasty. J Muscoskel Res. 2014;17
[Google Scholar]
Wang T.J., Chang C.F., Lou M.F., et al . Biofeedback relaxation for pain associated with continuous passive motion in taiwanese patients after total knee arthroplasty. Res Nurs Health. 2015;38(1):39-50.
[Google Scholar]
Mizner R.L., Petterson S.C., Stevens J.E., Vandenborne K., Snyder-Mackler L., . Early quadriceps strength loss after total knee arthroplasty: the contributions of muscle atrophy and failure of voluntary muscle activation. JBJS. 2005;87:5.
[Google Scholar]
Judd D.L., Eckhoff D.G., Stevens-Lapsley J.E., . Muscle strength loss in the lower limb after total knee arthroplasty. Am J Phys Med Rehabil. 2012;91(3):220-226.
[Google Scholar]
Pozzi F., Snyder-Mackler L., Zeni J.A., . Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-892.
[Google Scholar]

Show Sections

[1] Huang P., Liu Z.H., Qi J., Chen B., Xu J.Q., Deng L.F., . Surface electromyography of lower limb muscles in knee osteoarthritis patients undergoing knee joint replacement. Chin J Tissue Eng Res. 2014;18(13):2024-2030.
[Google Scholar]

[2] Tibesku C.O., Daniilidis K., Skwara A., Dierkes T., Rosenbaum D., Fuchs-Winkelmann S., . Gait analysis and electromyography in fixed- and mobile-bearing total knee replacement: a prospective, comparative study. Knee Surg Sports Traumatol Arthrosc. 2011;19(12):2052-2059.
[Google Scholar]

[3] Sklempe Kokic I., Vuksanic M., Kokic T., Peric I., Duvnjak I., . Effects of electromyographic biofeedback on functional recovery of patients two months after total knee arthroplasty: a randomized controlled trial. J Clin Med. 2022;11:11.
[Google Scholar]

[4] Shichman I., Roof M., Askew N., et al . Projections and epidemiology of primary hip and knee arthroplasty in medicare patients to 2040-2060. JB JS Open Access. 2023;8:1.
[Google Scholar]

[5] DeFrance M.J., Scuderi G.R., . Are 20% of patients actually dissatisfied following total knee arthroplasty? A systematic review of the literature. J Arthroplast. 2023;38(3):594-599.
[Google Scholar]

[6] Parvizi J., Nunley R.M., Berend K.R., et al . High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res. 2014;472(1):133-137.
[Google Scholar]

[7] Frank D.L., Khorshid L., Kiffer J.F., Moravec C.S., McKee M.G., . Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010;7(2):85-91.
[Google Scholar]

[8] Giggins O.M., Persson U.M., Caulfield B., . Biofeedback in rehabilitation. J NeuroEng Rehabil. 2013;10(1):60.
[Google Scholar]

[9] Karaborklu Argut S., Celik D., Yasacı Z., . Effectiveness of therapeutic electromyographic biofeedback after orthopedic knee surgeries: a systematic review. Disabil Rehabil. 2022;44(14):3364-3372.
[Google Scholar]

[10] Xie Y.J., Wang S., Gong Q.J., et al . Effects of electromyography biofeedback for patients after knee surgery: a systematic review and meta-analysis. J Biomech. 2021;120
[Google Scholar]

[11] Moher D., Liberati A., Tetzlaff J., Altman D.G., . Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. PLoS Med. 2009;6(7)
[Google Scholar]

[12] Fuchs S., Rolauffs B., Plaumann T., Tibesku C.O., Rosenbaum D., . Clinical and functional results after the rehabilitation period in minimally-invasive unicondylar knee arthroplasty patients. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):179-186.
[Google Scholar]

[13] Davidson B.S., Judd D.L., Thomas A.C., Mizner R.L., Eckhoff D.G., Stevens-Lapsley J.E., . Muscle activation and coactivation during five-time-sit-to-stand movement in patients undergoing total knee arthroplasty. J Electromyogr Kinesiol. 2013;23(6):1485-1493.
[Google Scholar]

[14] Wang Z.H., Wang J.C., Zheng S., Xue P., Han F.J., . Three-dimensional gait characteristics of patients after unilateral total knee arthroplasty. Medicine (Baltim). 2021;100
[Google Scholar]

[15] Fuchs S., Skwara A., Rosenbaum D., . Preliminary results after total knee arthroplasty without femoral trochlea: evaluation of clinical results, quality of life and gait function. Knee Surg Sports Traumatol Arthrosc. 2005;13(8):664-669.
[Google Scholar]

[16] Lester D.K., Shantharam R., Zhang K., . Dynamic electromyography after cruciate-retaining total knee arthroplasty revealed a threefold quadriceps demand compared with the contralateral normal knee. J Arthroplast. 2013;28(4):557-562.
[Google Scholar]

[17] Pozzi F., Marmon A.R., Snyder-Mackler L., Zeni J., . Lower leg compensatory strategies during performance of a step up and over task in patient six-months after total knee arthroplasty. Gait Posture. 2016;49:41-46.
[Google Scholar]

[18] Bjerke J., Öhberg F., Nilsson K.G., Stensdotter A.K., . Compensatory strategies for muscle weakness during stair ascent in subjects with total knee arthroplasty. J Arthroplast. 2014;29(7):1499-1502.
[Google Scholar]

[19] Yoshida T., Ebiko J., Sasaki K., Uchiyama E., Kura H., . Recovery process of the muscle activities during walking with efficient early quadriceps training and gait exercises after total knee arthroplasty. J Bodyw Mov Ther. 2022;29:49-53.
[Google Scholar]

[20] Fuchs S., Tibesku C.O., Frisse D., Laass H., Rosenbaum D., . Quality of life and gait after unicondylar knee prosthesis are inferior to age-matched control subjects. Am J Phys Med Rehabil. 2003;82(6):441-446.
[Google Scholar]

[21] McGinnis K., Snyder-Mackler L., Flowers P., Zeni J., . Dynamic joint stiffness and co-contraction in subjects after total knee arthroplasty. Clin Biomech. 2013;28(2):205-210.
[Google Scholar]

[22] Catani F., Ensini A., Belvedere C., et al . In vivo kinematics and kinetics of a bi-cruciate substituting total knee arthroplasty: a combined fluoroscopic and gait analysis study. J Orthop Res. 2009;27(12):1569-1575.
[Google Scholar]

[23] Thomas A.C., Judd D.L., Davidson B.S., Eckhoff D.G., Stevens-Lapsley J.E., . Quadriceps/hamstrings co-activation increases early after total knee arthroplasty. Knee. 2014;21(6):1115-1119.
[Google Scholar]

[24] Yoshida Y., Mizner R.L., Snyder-Mackler L., . Association between long-term quadriceps weakness and early walking muscle co-contraction after total knee arthroplasty. Knee. 2013;20(6):426-431.
[Google Scholar]

[25] Metcalfe A., Stewart C., Postans N., et al . Abnormal loading of the major joints in knee osteoarthritis and the response to knee replacement. Gait Posture. 2013;37(1):32-36.
[Google Scholar]

[26] Gage W.H., Frank J.S., Prentice S.D., Stevenson P., . Organization of postural responses following a rotational support surface perturbation, after tka: sagittal plane rotations. Gait Posture. 2007;25(1):112-120.
[Google Scholar]

[27] Gage W.H., Frank J.S., Prentice S.D., Stevenson P., . Postural responses following a rotational support surface perturbation, following knee joint replacement: frontal plane rotations. Gait Posture. 2008;27(2):286-293.
[Google Scholar]

[28] Mouchnino L., Gueguen N., Blanchard C., et al . Sensori-motor adaptation to knee osteoarthritis during stepping-down before and after total knee replacement. BMC Muscoskelet Disord. 2005;6:21.
[Google Scholar]

[29] Kuntze G., von Tscharner V., Hutchison C., Ronsky J.L., . Alterations in lower limb multimuscle activation patterns during stair climbing in female total knee arthroplasty patients. J Neurophysiol. 2015;114(5):2718-2725.
[Google Scholar]

[30] Kuntze G., von Tscharner V., Hutchison C., Ronsky J.L., . Multi-muscle activation strategies during walking in female post-operative total joint replacement patients. J Electromyogr Kinesiol. 2015;25(4):715-721.
[Google Scholar]

[31] Ardestani M.M., Malloy P., Nam D., Rosenberg A.G., Wimmer M.A., . Tka patients with unsatisfying knee function show changes in neuromotor synergy pattern but not joint biomechanics. J Electromyogr Kinesiol. 2017;37:90-100.
[Google Scholar]

[32] Koehn R.R., Roelker S.A., Pan X., Schmitt L.C., Chaudhari A.M.W., Siston R.A., . Is modular control related to functional outcomes in individuals with knee osteoarthritis and following total knee arthroplasty? PLoS One. 2022;17
[Google Scholar]

[33] Venema D.M., Karst G.M., . Individuals with total knee arthroplasty demonstrate altered anticipatory postural adjustments compared with healthy control subjects. J Geriatr Phys Ther. 2012;35(2):62-71.
[Google Scholar]

[34] Mikkelsen E.K., Jakobsen T.L., Holsgaard-Larsen A., Andersen L.L., Bandholm T., . Strength training to contraction failure increases voluntary activation of the quadriceps muscle shortly after total knee arthroplasty: a cross-sectional study. Am J Phys Med Rehabil. 2016;95(3):194-203.
[Google Scholar]

[35] Husted R.S., Wilquin L., Jakobsen T.L., Holsgaard-Larsen A., Bandholm T., . Rapid knee-extensions to increase quadriceps muscle activity in patients with total knee arthroplasty: a randomized cross-over study. Int J Sports Phys Ther. 2017;12(1):105-116.
[Google Scholar]

[36] Jakobsen T.L., Jakobsen M.D., Andersen L.L., Husted H., Kehlet H., Bandholm T., . Quadriceps muscle activity during commonly used strength training exercises shortly after total knee arthroplasty: implications for home-based exercise-selection. J Exp Orthop. 2019;6(1):29.
[Google Scholar]

[37] DCCM E.S., de Andrade Alexandre D.J., Silva J.G., . Immediate effect of myofascial release on range of motion, pain and biceps and rectus femoris muscle activity after total knee replacement. J Bodyw Mov Ther. 2018;22(4):930-936.
[Google Scholar]

[38] Moutzouri M., Coutts F., Gliatis J., Billis E., Tsepis E., Gleeson N., . Early initiation of home-based sensori-motor training improves muscle strength, activation and size in patients after knee replacement: a secondary analysis of a controlled clinical trial. BMC Muscoskelet Disord. 2019;20(1):231.
[Google Scholar]

[39] Prusinowska A., Komorowski A., Syrówka P., . The use of surface electromyography in rehabilitating rheumatic patients after knee arthroplasty (pilot study) Reumatologia. 2019;57(4):199-206.
[Google Scholar]

[40] Staehli S., Glatthorn J.F., Casartelli N., Maffiuletti N.A., . Test-retest reliability of quadriceps muscle function outcomes in patients with knee osteoarthritis. J Electromyogr Kinesiol. 2010;20(6):1058-1065.
[Google Scholar]

[41] Ruspi A., Temporiti F., Adamo P., Mina F., Traverso F., Gatti R., . Neuromuscular activation of quadriceps bellies during tasks performed in the same biomechanical condition in patients undergoing total knee arthroplasty. J Electromyogr Kinesiol. 2022;64
[Google Scholar]

[42] Verdini F., Zara C., Leo T., Mengarelli A., Cardarelli S., Innocenti B., . Assessment of patient functional performance in different knee arthroplasty designs during unconstrained squat. Muscles Ligaments Tendons J. 2017;7(3):514-523.
[Google Scholar]

[43] Stevens-Lapsley J.E., Balter J.E., Kohrt W.M., Eckhoff D.G., . Quadriceps and hamstrings muscle dysfunction after total knee arthroplasty. Clin Orthop Relat Res. 2010;468(9):2460-2468.
[Google Scholar]

[44] Parentis M.A., Rumi M.N., Deol G.S., Kothari M., Parrish W.M., Pellegrini V.D., . A comparison of the vastus splitting and median parapatellar approaches in total knee arthroplasty. Clin Orthop Relat Res. 1999;367:107-116.
[Google Scholar]

[45] Dalury D.F., Snow R.G., Adams M.J., . Electromyographic evaluation of the midvastus approach. J Arthroplast. 2008;23(1):136-140.
[Google Scholar]

[46] Callaghan M.J., Babu V.L., Ellis D.J., Samarji R.A., . Electromyographic comparison of the mid-vastus and sub-vastus approaches to total knee arthroplasty. Current orthopaedic practice. 2009;20:4:442-447.
[Google Scholar]

[47] Aydogdu S., Zileli B., Cullu E., Atamaz F.C., Sur H., Zileli M., . Increased turn/amplitude parameters following subvastus approach in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014;22(7):1632-1637.
[Google Scholar]

[48] Garling E.H., Wolterbeek N., Velzeboer S., et al . Co-contraction in ra patients with a mobile bearing total knee prosthesis during a step-up task. Knee Surg Sports Traumatol Arthrosc. 2008;16(8):734-740.
[Google Scholar]

[49] Catani F., Benedetti M.G., De Felice R., Buzzi R., Giannini S., Aglietti P., . Mobile and fixed bearing total knee prosthesis functional comparison during stair climbing. Clin Biomech. 2003;18(5):410-418.
[Google Scholar]

[50] Esposito F., Freddolini M., Marcucci M., Latella L., Corvi A., . Biomechanical analysis on total knee replacement patients during gait: medial pivot or posterior stabilized design? Clin Biomech. 2020;78
[Google Scholar]

[51] Beach A., Regazzola G., Neri T., Verheul R., Parker D., . The effect of knee prosthesis design on tibiofemoral biomechanics during extension tasks following total knee arthroplasty. Knee. 2019;26(5):1010-1019.
[Google Scholar]

[52] Di Benedetto P., Vidi D., Colombo A., Buttironi M.M., Cainero V., Causero A., . Pre-operative and post-operative kinematic analysis in total knee arthroplasty. A pilot study. Acta Biomed. 2019;90:91-97.
[Google Scholar]

[53] Hyodo K., Kanamori A., Kadone H., Takahashi T., Kajiwara M., Yamazaki M., . Gait analysis comparing kinematic, kinetic, and muscle activation data of modern and conventional total knee arthroplasty. Arthroplast Today. 2020;6(3):338-342.
[Google Scholar]

[54] Fuchs S., Tibesku C.O., Frisse D., Genkinger M., Laass H., Rosenbaum D., . Clinical and functional comparison of uni- and bicondylar sledge prostheses. Knee Surg Sports Traumatol Arthrosc. 2005;13(3):197-202.
[Google Scholar]

[55] Simon J.C., Della Valle C.J., Wimmer M.A., . Level and downhill walking to assess implant functionality in bicruciate- and posterior cruciate-retaining total knee arthroplasty. J Arthroplast. 2018;33(9):2884-2889.
[Google Scholar]

[56] Fuchs S., Tibesku C.O., Genkinger M., Volmer M., Laass H., Rosenbaum D., . Clinical and functional comparison of bicondylar sledge prostheses retaining all ligaments and constrained total knee replacement. Clin Biomech. 2004;19(3):263-269.
[Google Scholar]

[57] Shanb A.-S.A., Youssef E.F., . Effects of adding biofeedback training to active exercises after total knee arthroplasty. J Muscoskel Res. 2014;17
[Google Scholar]

[58] Wang T.J., Chang C.F., Lou M.F., et al . Biofeedback relaxation for pain associated with continuous passive motion in taiwanese patients after total knee arthroplasty. Res Nurs Health. 2015;38(1):39-50.
[Google Scholar]

[59] Mizner R.L., Petterson S.C., Stevens J.E., Vandenborne K., Snyder-Mackler L., . Early quadriceps strength loss after total knee arthroplasty: the contributions of muscle atrophy and failure of voluntary muscle activation. JBJS. 2005;87:5.
[Google Scholar]

[60] Judd D.L., Eckhoff D.G., Stevens-Lapsley J.E., . Muscle strength loss in the lower limb after total knee arthroplasty. Am J Phys Med Rehabil. 2012;91(3):220-226.
[Google Scholar]

[61] Pozzi F., Snyder-Mackler L., Zeni J.A., . Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-892.
[Google Scholar]

The role of electromyography in postoperative total knee arthroplasty: A systematic review

Abstract