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Total Hip & Knee Arthroplasty & Rehabilitation Implications: Past, Present, & Future


Total Hip & Knee Arthroplasty & Rehabilitation Implications: Past, Present, & Future Celia Pechak, PT, MPH, PhD East Texas District TPTA April 26, 2008 – PowerPoint PPT presentation

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Title: Total Hip & Knee Arthroplasty & Rehabilitation Implications: Past, Present, & Future

Total Hip Knee Arthroplasty Rehabilitation
Implications Past, Present, Future
  • Celia Pechak, PT, MPH, PhD
  • East Texas District TPTA
  • April 26, 2008

Todays Objectives
  • Review the evidence related to standard
    minimally invasive
  • Encourage discussion related to participants
    clinical experiences with this patient population
  • Offer practical resources for accessing the
    evidence clinical expertise
  • Stimulate participants interest in accessing
    supporting clinical research in this area

Overview of Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
  • Currently 193,000 THAs are performed per year in
    the US
  • Currently 381,000 TKAs are performed per year in
    the US
  • 750,000 THA/TKAs per year are projected by 2030

Jones, Westby, et al., 2005
THATrip Down Memory Lane
  • 1970s
  • Admitted 1-2 days before surgery
  • Bedrest 2-3 days post-op
  • Partial weight bearing
  • LOS 17 days
  • Now
  • Admitted morning of surgery
  • Mobilize day of surgery or POD 1
  • Usually WBAT
  • LOS lt 5days
  • Ganz, 2004

And, the FUTURE is it already here???........
Charnley THA
  • Sir John Charnley introduced the
  • THA worldwide in 1960s
  • one of the most successful
  • surgical interventions ever developed.
  • 25-year follow-up of 1689 patients (2000
    arthroplasties) who had Charnley THA between 1969
    and 1971
  • 461 patients still living
  • 77.5 free of reoperation
  • 80.9 free of revision or removal of the implant
    for any reason
  • 86.5 free of revision or removal for aseptic
  • Berry et al., 2002
  • Image Charnley_foto.jpg

Standard THA
  • Standard total hip arthroplasty
  • Incision gt 10 cm
  • Posterior lateral
  • Anterior lateral
  • Direct lateral
  • Transtrochanteric

Pros Cons of Approaches
  • Posterolateral approach
  • Return to normal abductor strength and ambulation
    is faster in the posterolateral
  • Higher rates of dislocation than other approaches
  • Lateral transtrochanteric approaches
  • Higher rates of post op limp due to gluteal nerve
    injury or avulsion of gluteal flap
  • Wenz et al., 2002

Optimal Approach?
  • Cochrane Systematic Review was done to determine
    optimal approach for adults with OA
  • Insufficient data to reach firm conclusion

Jolles Bogoch, 2006
  • DVT (8 to 70)
  • Leg length discrepancy
  • Component malalignment
  • Infection
  • Improper implant fixation to surrounding bone
  • Nerve palsy
  • Prosthetic hip dislocation
  • Otto, 2005

Revisions with Charnley THA
  • Men had 2-fold higher rate of revision for
    aseptic loosening than women
  • Patients with inflammatory arthritis were at
    lower risk of needing revision compared to
    patients with osteoarthritis
  • Younger age at time of surgery, increased rate of
    acetabular gt femoral component failure
  • Berry et al., 2002

Nerve Palsy
  • Prevalence rate of 0.17 in one review of 27,000
  • Risk factors hip dysplasia, posttraumatic
    arthritis, posterior approach,
  • lengthening gt 1.1cm
  • 70 of patients with incomplete palsy recovered
  • 36 of patients with complete palsy recovered
    fully at a mean of 21 months

Huo et al., 2006
Cumulative Long-term Risk of Dislocation
  • Retrospective study
  • 5459 patients s/p Charnley THA between 1969 and
    1984 routinely followed until revision or death
  • 4.8 dislocated
  • Highest risk in first year s/p surgery
  • Patients at highest risk
  • females, those with dx of osteonecrosis of
    femoral head, acute fx, or nonunion of proximal
    part of femur

Berry et al., 2004
Late Dislocation
  • 15964 pts s/p THA between 1969 1995
  • 32 of the dislocated hips first dislocated 5 or
    more years after primary THA
  • (median 11.3 yrs)
  • Late dislocations associated with
  • long-standing problem with prosthesis, trauma,
    neurologic decline, polyethylene wear, or
  • Image image8/adihp1.jpg

Knoch et al., 2002
Are Hip Precautions Necessary?
  • 499 patients s/p THA via anterolateral approach
  • No post-operative restrictions
  • 3 dislocations within 6 weeks post-op (0.6)
  • Stable hip achieved after closed reduction
  • Low early dislocation rate can be achieved using
    anterolateral approach without restrictions

Talbot et al., 2002
Treatment of Dislocation
  • Cochrane Systematic Review was completed to
    determine the best methods of treatment of
    recurrent dislocation following THA
  • No studies met their search criteria
  • Recommended multi-center study

Khan et al., 2006
Comparing Cemented vs. Cementless
  • Cemented technique
  • 98 survivorship of implant at 10 years
  • 93 survivorship of implant at 25 years
  • Cementless technique
  • Similar to above numbers for femoral component,
    and better with acetabular component at 15 year
  • Cementless technique is now preferred method,
    especially in younger patients

Jones, Westby, et al., 2005
Weight Bearing with Cementless THA
  • In the ole days NWB /or PWB
  • Now WBAT/FWB
  • Rationale
  • NWB and TDWB produces greater joint pressure than
  • FWB does not adversely affect bone ingrowth or
    prosthetic stability

Jones, Westby et al., 2005
What Else Has Changed Since the Ole Days?
  • Trend towards less stiff more biologically
    inert metal alloys
  • Greater use of modularity
  • Different bearing surface options
  • Experiments with bioactive ceramic coatings that
    increase bone ingrowth

Jones, Westby et al., 2005
Evolution in Bearing Surfaces
  • Metal-on-polyethylene
  • Problems with debris osteolysis
  • Metal on cross-linked polyethylene
  • Greater wear resistance
  • Metal-on-metal
  • Low wear rates
  • Increasingly used in young, active patients
  • Ceramic on cross-linked polyethylene
  • Ceramic on ceramic
  • Low risk of ceramic bearing fracture

Jones, Westby et al., 2005
Impact of Analgesia Choice
  • Compared 45 patients undergoing classic THA (3
    groups of 15)
  • IV patient-controlled analgesia with morphine
  • Continuous femoral nerve sheath block (FNB)
  • Continuous epidural analgesia
  • All 3 provide similar pain relief allow similar
    hip rehab
  • FNB is associated with less side effects, so is
    recommended as first choice for analgesia

Singleyn et al., 2005
What is the Evidence Related to THA
Shift in Focus of Outcome Studies (THA TKA)
  • Past research focused on surgical/technical
    aspects of surgery
  • Recent research uses more patient-centered

Outcome Measures in the Literature for THA
  • Harris Hip Score
  • FIM
  • Oxford Hip Score
  • SF-12
  • HQ-12
  • Iowa Level of Assistance Scale
  • 12-Item Hip Questionnaire
  • Visual Analogue Scale

General Outcomes
  • Overall satisfaction with outcomes good to
  • Patients s/p THA had SF-36 scores closer to the
    norm than patients s/p TKA
  • Predictors of overall satisfaction with THA
    older age, not living alone, worse preoperative
    hip scale score, shorter LOS
  • Jones et al., 2005

What We Dont Know
  • No randomized controlled trials have been done to
    determine the most effective rehab protocol
  • No prospective studies have determined the
    advantage of inpatient rehab post THA
  • No specific data on the type and duration of ROM

What We Are Not Sure About
  • Role of pre-op education
  • Inconsistent outcomes, but the studies have
    generally reported decreased post-op pain,
    medication use, LOS, and fear/anxiety
  • Effect of pre-op exercise
  • Some evidence that pre-op exercise is of benefit

Jones, Westby et al., 2005
What We Are Not So Sure About
  • It has not been determined if inpatient,
    outpatient, or home-based rehabilitation provides
    better long-term results and patient satisfaction
  • But more studies are appearing

Jones, Westby et al., 2005
What We Do Know
  • Early transfer to inpatient rehabilitation is
    associated with faster achievement of goals
  • Very low hematocrit at inpatient rehabilitation
    admission is related to longer LOS greater
    hospital charges, but did not impede overall
    gains in function (THA TKA)

Munin et al. in Jones, Westby et al., 2005
Vincent Vincent, 2007
What We Do Know
  • Ongoing impairments and functional deficits for
    as long as 2 years post THA
  • Of 67 patients treated with unilateral THA
    (original and revised) who presented for rehab
    with problems
  • 6-9 weeks to one year post-op
  • 47 hip abductor weakness
  • 28 muscle contracture
  • 13 limb length difference
  • 12 malalignment
  • gt See article for treatment suggestions
  • Bhave et al., 2005

Jones, Westby et al., 2005
Home Programs
  • Jan et al., 2004
  • Patients s/p THA gt 1.5 years in the past
    underwent a 12-week home program that included
    hip flexion ROM, low resistance strengthening hip
    flex/ext/abd, and 30 min walking every day
  • Exercise-high compliance group showed greater
    improvement in strength on operated side, fast
    walking speed, and functional score on Harris Hip
    Score than exercise-low compliance and control
  • Recommend HEP 3x/week for training effect

Weight Bearing and Postural Stability Exercises
  • Trudelle-Jackson Smith, 2004
  • 34 subjects who had undergone THA 4-12 months
    previously 28 completed the study
  • 8 week intervention experimental group recd
    strength postural stability exercises control
    group recd basic isometric AROM
  • Exercise program emphasizing weight bearing
    postural stability significantly improved muscle
    strength, postural stability self-perceived

Study supported by the Texas Physical Therapy
Treadmill Training
  • Hesse et al., 2003 Treadmill training with
    Body-Weight Support is more effective than
    conventional PT at restoring symmetrical
    independent walking after hip replacement
  • White Lifeso, 2005 Treadmill walking program
    may help persons with a THA achieve more
    symmetric gait

Biomechanical Considerations Related to Rehab
  • Hip exercises (such as SLRs) are more stressful
    to hip than walking
  • Functional activities including descending
    stairs, getting out of a chair, and
    bending/lifting with bent knees put the most
    stress on hips and knees

Jones, Westby, et al., 2005
Issues Related to Sports Recreational
  • During daily activities, loads of 3-4 X body
    weight occur
  • 5-10 X in sports activities to 25X with weight
  • Increased speed of walking or running, increased
  • But slower than normal walking speed also
    increases joint forces

Kuster, 2002
Jones, Westby, et al., 2005
Risk vs Benefit of Inactivity?
  • Strong evidence exists that total joint in
    INACTIVE person will show less wear than that in
    an active person
  • But, exercise will decrease fall risk, increase
    bone density thus prosthesis fixation (amongst
    other benefits!!)
  • Kuster, 2002

Sports Activity Recommendations
  • Recommendations on athletic activities after
    joint replacement are based on opinions of
    orthopedic surgeons, not research
  • Consensus recommendations for patients s/p THA
    per 1999 Hip Society Survey
  • Recommended/allowed e.g., swimming, walking
  • Allowed with experience e.g., canoeing, hiking,
  • XC skiing
  • Not recommended e.g., high impact aerobics,
  • No conclusion e.g., speed walking, downhill
    skiing, weight machines, ice skating
  • Kuster, 2002

When Can Patients Resume Sexual Relations After
  • 67 254 surgeons surveyed recommended waiting 1
    to 3 mos. following THA
  • 30 would allow within first 4 weeks
  • 5 safe positions for men and 3 for women were
    approved by 90 surgeons

Dahm et al., 2004
Exercise Activity Recommendations
  • Patients should be advised to comply with their
    exercise programs for at least one year after
  • Avoid sporting activities that create high
    compressive or rotary forces or increase risk of
    injury to the new joint

Jones, Westby, et al., 2005
Minimally-invasive THA
  • General definition incision lt 10 cm
  • Strict definition incisions that do not involve
    cutting muscles or tendons
  • Single incision (1-MITHA)
  • Modification of old approach
  • E.g., top half of post-lat or ant-lat approach
  • May be less cutting of muscles/tendons, or not
  • Two incisions (2-MITHA)
  • New approach
  • Use intermuscular planes to access joint

2-MITHAAnterior incision over
femoral neck femoral head neck removed
acetabular component placedPosterior incision
in line with femoral canal femoral component
placed(Berry DJ et al., 2003 -

Enthusiasm vs. Skepticism
  • Potential for quicker recovery
  • Better cosmesis
  • Less perceived invasion of the body
  • M-I procedures work well for other surgeries
  • Patients are asking for MITHA
  • Potential for increased complications
  • Smaller visual field
  • Learning curve
  • Difficult to perform studies without observer or
    selection bias
  • Are short-term benefits worth increased risk?
  • Why fix what isnt broken? (classic THA is one of
    most successful operations invented)
  • Is it really minimally invasive?
  • Berry, 2005

Is MITHA ReallyMinimally Invasive?
  • Mardones et al., 2005
  • 2-MITHA posterior approach 1-MITHA performed on
    10 cadavers
  • Authors conclude that they cannot support 2-MITHA
    can be done reliably without substantial damage
    to abductor muscles, external rotator muscles or
  • Abductor muscle damage also occurred in every

Overview of 2-MITHAper Dr. Richard
Berger (surgeon-developer of 2-MITHA)
  • Best candidate thin woman with atrophic changes
  • Need specialized instruments
  • Fluoroscopy used during procedure
  • Computerized navigation systems might improve
  • Limited to cementless application
  • Surgery itself is more expensive, but shorter
    hospital stay rehab
  • Berger, 2004

Berger 2-MITHA
  • Berger et al., 2004
  • 100 patients received 2-MITHA with minimal soft
    tissue trauma, capsule incised not excised
  • Initiated WBAT on day of surgery with no
  • post-op precautions
  • All patients independent with transfer,
    ambulation w/ crutches, and stairs within 23
  • Mean age of 56 years old

Berger 2-MITHA
  • Mean of 6 days to discontinue crutch use, d/c
    narcotic pain meds, and start driving
  • Mean of 8 days to return to work
  • Mean of 9 days to d/c any assistive devices
  • Mean of 16 days to walk ½ mile
  • No readmissions, dislocations, reoperations by 3
    months follow-up

2-MITHA on the other hand
  • Pagnano et al., 2005
  • 80 patients treated with 2-MITHA, compared with
    standard posterior approach done in past
  • Modest early functional outcomes
  • 2.8 days in hospital vs. 5.2 in control
  • 90 d/cd home vs. 65 in control
  • But, there have been improvements in anesthesia
    and lifting of WB restrictions since control
    group operated on, and so these might have
    contributed to better outcomes

2-MITHA on the other hand
  • Pagnano et al., 2005
  • 14 complication rate
  • 5 required reoperation
  • Older, obese women at risk in particular
  • Unpredictable technical challenges
  • Complications not just related to learning curve
  • Mean age of 70 years old

  • Woolson et al., 2004
  • 50 patients with 1-MITHA compared with 85
    patients with standard incision
  • No significant differences in average surgical
    time, intraoperative blood loss, in-hospital
    transfusion rate, LOS, or disposition
  • 1-MITHA had significantly increased risk of wound
    complication, acetabular component malposition,
    and poor fit/fill of femoral components
  • No benefit except smaller scar

  • Advances in practice are ahead of the evidence
  • Much more research is needed

One More Surgical Option
  • Hip resurfacing
  • (standard vs. mini-incision)
  • http//

Time for TKAs!
TKA Another Trip Down Memory Lane
  • 1970s
  • Admitted 1-2 days before surgery
  • Bedrest 2-3 days post-op
  • Ambulation with knee splint begun POD 3
  • Knee ROM begun
  • POD 7
  • No discharge until knee flex 90
  • Now
  • Admitted morning of surgery
  • Mobilize day of surgery or POD 1
  • Usually WBAT
  • LOS lt 5days
  • CPMs placed in post-op

Ganz, 2004
Cemented TKA
  • Cemented TKA is current gold-standard
  • 10-14 year survival rate of 94-98
  • Cobalt-chromium alloy femur articulating with
    standard polyethylene tibial surface is most

Jones, Westby et al., 2005
Image http//
TKA Options
  • Not enough evidence to say whether keeping or
    removing PCL is best
  • Recent literature synthesis suggests that
    resurfacing the patella probably improves
    outcomes and pain-free function

Jacobs et al., 2007
Jones, Westby et al., 2005
Reducing Polyethylene Wear
  • Use of cross-linked polyethylene decreases wear
    but long-term effectiveness has not been
  • Use of rotating platform or mobile bearing knee
    implants are used to decrease contact stresses at
    implant interface
  • Mobile bearing knee implants provide about the
    same amount of ROM and pain relief as fixed
    bearing implants

Jones, Westby et al., 2005
Jacobs et al., 2001
What Is the Evidence Related to TKA
Outcome Measures in TKA Literature
  • FIM
  • Lower Extremity Functional Scale
  • Six-Minute Walk Test
  • SF-36
  • Knee Society Clinical Rating System

Patient Satisfaction Pain
  • 15 year follow-up study of 4606 primary TKAs
  • Men, patients with OA, and those requiring
    revision indicated least satisfaction
  • Older patients, females, and patients without
    revisions reported the least pain

Roberts et al., 2007
What We Dont Know
  • No randomized controlled trials have been done to
    determine the most effective rehabilitation
  • No studies have prospectively assessed benefit of
    inpatient rehab post-TKA

Jones, Westby et al., 2005
What We Are Not Sure About
  • Role of pre-op education
  • Inconsistent outcomes, but the studies have
    generally reported decreased post-op pain,
    medication use, LOS, and fear/anxiety
  • Pre-op exercise
  • Inconclusive studies
  • Improvement with pre-op function but not in
    post-op recovery, decrease of LOS or

Jones, Westby et al., 2005
What We Are Not So Sure About
  • It has not been determined if inpatient,
    outpatient, or home-based rehabilitation provides
    better long-term results and patient satisfaction
  • But more studies are appearing

Jones, Westby et al., 2005
What We Do Know
  • Significant long-term impairments and disability
    (including pain) can continue for one year or
    more post-TKA

Jones, Westby et al., 2005
Functional Activities
  • Systematic Review
  • Exercises based on functional activities may be
    more effective than traditional exercise programs
    (ROM isometrics)
  • Any benefits seen after treatment did not persist
    to one year follow up

Lowe et al., 2007
Rehab Progress Post TKA
  • Repeated measurements taken over one year period
    of patients post TKA who had received short-term
    inpatient rehab, HEP, and some had additional
    rehab in community
  • Greatest improvements found in first 12 weeks
  • Slower improvement 12-26 weeks
  • Little improvement post 26 weeks

Kennedy et al., 2008
Continuous Passive Motion
  • Cochrane Systematic Review
  • CPM PT significantly increased active knee
    flexion, decreased length of stay, and decreased
    the need for post-op manipulation (compared to PT
  • CPM may improve short-term rehabilitation
  • But CPM does not appear to offer long-term

Milne et al., 2007
Jones, Westby et al., 2005
Obesity TKA
  • Review of recent literature
  • Conflicting evidence as to whether obese patients
    have lower functional gains and higher
    complication rates

Thompson et al., 2008
Extensor Mechanism Disruption
  • 290 patients post TKA
  • 6 had extensor mechanism disruption
  • This group had overall worse functional outcomes,
    requiring intensive rehab

Schoderbek et al., 2006
Bilateral TKAs
  • Compared 12 patients with unilateral TKA to
    gender/age/BMI-matched patients with bilateral
  • Short-term and long-term outcomes were equal by
    12 weeks, except quad strength
  • Quad strength was equal by 52 weeks

Patterson Snyder-Mackler, 2006
Sports Activity Recommendations
  • Knee Society recommendations
  • Suitable cycling, swimming, low-resistance
    rowing, walking, hiking, low-resistance
    weight-lifting, ballroom dancing, square dancing
  • Suitable but more risky downhill skiiing,
    ice-skating, speed walking, hunting, low-impact
    aerobics, volleyball
  • Avoid Baseball, basketball, football, hockey,
    soccer, high-impact aerobics, jogging,
    parachuting, power-lifting

Minimally Invasive TKA
  • Shorter incision
  • Quadriceps sparing

Minimally Invasive TKA
  • Early, limited results
  • Better ROM
  • Less blood loss
  • Shorter LOS
  • No long-term studies yet

Jones, Westby et al., 2005
Image http//
Minimally Invasive TKA
  • First 100 MITKAs were compared to previous 50
    standard TKAs by one high volume surgeon
  • Longer operative time, less accuracy, more
    patellar tilt in first 25 MITKAs
  • Overall, shorter LOS, less need for inpatient
    rehab, less narcotic usage, and less need for
    assistive devices at 2 weeks post-op
  • Conclusion Learning curve may be too long for
    low-volume surgeon

King et al., 2007
Unicompartmental Arthroplasty
  • Partial knee replacement
  • Usually done with minimally
  • invasive technique

Image http//
Unicompartmental Arthroplasty
  • More rapid recovery
  • Minimal bone loss
  • Less pain
  • Shorter LOS
  • 10-15 year survival rates range from
  • 95-98

Jones, Westby et al., 2005
Conclusion - Key Points
  • Surgical techniques and subsequent rehabilitation
    of THA TKA patients continue to evolve
  • All minimally-invasive arthroplasties are not
  • Still much controversy amongst orthopedic
    surgeons as to whether benefits outweigh costs
    risks of minimally invasive arthroplasties
  • More research related to THAs/TKAs rehabilitation
    is needed!

Resources for Evidence-Based Practice Best
  • Open Door
  • Easy access to the literature
  • Find it in the Research section of
  • APTA Listservs
  • Geriatrics Section
  • Acute Care Section
  • gtgt Quick and easy access to faculty
    clinicians who can help answer your questions

  • Always use it!
  • Maybe do it?
  • Please support it!
  • Texas Physical Therapy Foundation
  • Foundation for Physical Therapy