Total Hip & Knee Arthroplasty
& Rehabilitation Implications:
Past, Present, & Future
Celia Pechak, PT, MPH, PhD
East Texas District TPTA
April 26, 2008
Today’s Objectives
• Review the evidence related to
standard & minimally invasive
THA & TKA
• 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
THA:
Trip 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 < 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 loosening
Berry et al., 2002
Image: www.totaljoints.info/ Charnley_foto.jpg
Standard THA

Standard total hip arthroplasty
• Incision > 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
Complications
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 > femoral component failure
Berry et al., 2002
Nerve Palsy

Prevalence rate of 0.17% in one review of 27,000
patients

Risk factors: hip dysplasia, posttraumatic arthritis,
posterior approach,
lengthening > 1.1cm

70% of patients with incomplete palsy recovered fully

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 combination
Knoch et al., 2002
Image: www.wheelessonline.com/ image8/adihp1.jpg
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 mark

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
• 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 & Rehabilitation?
Shift in Focus of Outcome Studies
(THA & TKA)

Past research focused on surgical/technical
aspects of surgery

Recent research uses more patient-centered
outcomes
Outcome Measures in the
Literature for THA
Harris Hip Score
FIM
Oxford Hip Score
WOMAC
SF-12
HQ-12
Iowa Level of Assistance Scale
12-Item Hip Questionnaire
Visual Analogue Scale
General Outcomes

Overall satisfaction with outcomes “good” to
“excellent”

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 Don’t 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 restrictions
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
Munin et al. in Jones, Westby et al., 2005

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)
Vincent & Vincent, 2007
What We Do Know

Ongoing impairments and functional deficits for
as long as 2 years post THA
Jones, Westby et al., 2005
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
> See article for treatment suggestions
Bhave et al., 2005
Home Programs

Jan et al., 2004:
• Patients s/p THA > 1.5 years in the past underwent a 12week 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 groups
• 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 rec’d strength &
postural stability exercises; control group rec’d basic
isometric & AROM
• Exercise program emphasizing weight bearing & postural
stability significantly improved muscle strength, postural
stability & self-perceived function
**Study supported by the Texas Physical Therapy Foundation
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 Activities

During daily activities, loads of 3-4 X body
weight occur

5-10 X in sports activities to 25X with weight
lifting

Increased speed of walking or running,
increased loads
Kuster, 2002

But slower than “normal walking speed” also
increases joint forces
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, jogging
• No conclusion – e.g., speed walking, downhill skiing,
weight machines, ice skating
Kuster, 2002
When Can Patients Resume
Sexual Relations After THA?

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 surgery

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 < 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-MITHA
Anterior incision: over femoral neck; femoral head & neck removed;
acetabular component placed
Posterior incision: in line with femoral canal; femoral component placed
(Berry DJ et al., 2003 - http://ezproxy.twu.edu:2754/cgi/content/full/85/11/2235)
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 isn’t broken?
(classic THA is one of most
successful operations invented)
Is it really minimally invasive?
Berry, 2005
Is MITHA Really
Minimally Invasive?

Mardones et al., 2005
• 2-MITHA & posterior approach 1-MITHA
performed on 10 cadavers
• Authors conclude that they cannot support 2MITHA can be done reliably without substantial
damage to abductor muscles, external rotator
muscles or both
• Abductor muscle damage also occurred in
every 1-MITHA
Overview of 2-MITHA
per 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 technique
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
hours
• 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/c’d 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
1-MITHA

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
MITHA

Advances in practice are ahead of the
evidence

Much more research is needed
One More Surgical Option

Hip resurfacing
(standard vs. mini-incision)
http://www.totaljoints.info/surface_hip_replace.htm
QUESTIONS
&
DISCUSSION
About THAs
Time for TKAs!
TKA:
Another Trip Down Memory Lane
1970s
 Admitted 1-2 days
before surgery
 Bedrest 2-3 days postop
 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 < 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 common
Image: http://www.nlm.nih.gov/medlineplus/kneereplacement.html
Jones, Westby et al., 2005
TKA Options

Not enough evidence to say whether
keeping or removing PCL is best
Jacobs et al., 2007

Recent literature synthesis suggests
that resurfacing the patella probably
improves outcomes and pain-free
function
Jones, Westby et al., 2005
Reducing Polyethylene Wear

Use of cross-linked polyethylene decreases
wear – but long-term effectiveness has not
been established
Jones, Westby et al., 2005

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
Jacobs et al., 2001
What Is the Evidence Related to
TKA & Rehabilitation?
Outcome Measures in
TKA Literature
FIM
 Lower Extremity Functional Scale
 Six-Minute Walk Test
 SF-36
 WOMAC
 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 Don’t Know

No randomized controlled trials have
been done to determine the most
effective rehabilitation protocol

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
complications
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 postTKA

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 alone)

CPM may improve short-term rehabilitation
Milne et al., 2007

But CPM does not appear to offer long-term
advantage
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 TKAs

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, iceskating, speed walking, hunting, low-impact
aerobics, volleyball
 Avoid: Baseball, basketball, football, hockey,
soccer, high-impact aerobics, jogging,
parachuting, power-lifting
http://www.kneesociety.org/index.asp/fuseaction/site.totalKnee
Minimally Invasive TKA
Shorter incision
 Quadriceps sparing

http://www.orthop.washington.edu/uw/tabID__3376/ItemID__25/mid__10357/wversion__Staging/index__False/DesktopModules/Pictures/PictureView.aspx
Minimally Invasive TKA

Early, limited results:
• Better ROM
• Less blood loss
• Shorter LOS
Jones, Westby et al., 2005

No long-term studies yet
Image: http://www.orthop.washington.edu/uw/tabID__3376/print__full/ItemID__68/mid__0/Articles/Default.aspx
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 lowvolume surgeon
King et al., 2007
Unicompartmental Arthroplasty
“Partial” knee replacement
 Usually done with minimally
invasive technique

Image: http://www.orthop.washington.edu/uw/minimallyinvasive/tabID __3376/ItemID__7/PageID__3/Articles/Default.aspx
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
QUESTIONS
&
DISCUSSION
About TKAs
Conclusion - Key Points

Surgical techniques and subsequent
rehabilitation of THA & TKA patients continue
to evolve
 All minimally-invasive arthroplasties are not
equal
 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 Practices

Open Door:
• Easy access to the literature
• Find it in the “Research” section of www.apta.org

APTA Listservs
– Geriatrics Section
– Acute Care Section
>> Quick and easy access to faculty & clinicians
who can help answer your questions
RESEARCH
Always use it!
Maybe do it?
Please support it!

Texas Physical Therapy Foundation

Foundation for Physical Therapy
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