Clinical Background

Arthritis of the hip can result from many causes, such as childhood sepsis, slipped capital epiphysis, and rheumatoid arthritis. About 30% of all patients with hip arthritis have a mild form of acetabular dysplasia (a shallow socket), and 30% have a retroverted socket. Both of these conditions reduce the contact area of the femoral head in the acetabulum, which increases the pressure and makes wear more likely. Approximately 30% of patients have no obvious risk factors.

Arthritis of the hip is marked by progressive loss of articular cartilage with joint space narrowing and pain. Stiffness encourages development of osteophyte formation (bone spurs), which in turn leads to further stiffness, making it difficult for the patient to put on socks and shoes. This eventually leads to the general picture of shortening, adduction deformity, and external rotation of the hip, often with a fixed flexion contracture. Bone loss usually occurs slowly, but with osteonecrosis occasionally it occurs precipitously.

General Features of Osteoarthritis

According to Dieppe (1984), the following are general features of osteoarthritis:

Primary Symptoms and Signs of Osteoarthritis

Classification of Hip Arthritis

The radiographic appearance of OA can be classified as (1) concentric, in which there is uniform loss of articular cartilage, (2) downward and medial migration of the femoral head, or (3) upward migration and superolateral migration of the femoral head. This is important if a corrective osteotomy is considered but is otherwise of no significance.

Diagnosis of Hip Arthritis

Hip pain can be simulated by referred pain from the spine, L3-4 sciatica, and stenosis of the internal iliac artery. Causes of referred pain must be ruled out. The classic clinical test for hip arthritis is internal rotation of the hip in flexion. With hip arthritis, this internal rotation is limited and painful.

Differential diagnoses include hip dislocation, hip fracture, pelvic fracture or disruption, entrapment of the lateral femoral cutaneous nerve, FAI or labral pathology, tendinitis of the piriformis or gluteus maximus or minimus tendons, trochanteric bursitis, L3-4 sciatica, spinal referred pain, internal iliac artery stenosis, and strain or contusion of the quadriceps or hamstring muscles.

Radiographic examination includes an anteroposterior (AP) view of the pelvis and AP and lateral views of the hip. The lateral view must be a modified frog-leg lateral or Lauenstein. A shoot-through lateral is of no value to the surgeon because it gives a distorted picture of the femur. Serologic investigations are seldom required. The only indication for further imaging studies such as bone scanning and magnetic resonance (MRI) is suspected osteonecrosis in the absence of radiographic findings.

The American College of Rheumatology lists several criteria for the diagnosis of OA of the hip.

Treatment of Hip Arthritis

Nonoperative Treatment

Nonoperative treatment is initially indicated for nearly all patients with hip osteoarthritis. This may include activity modifications, assistive devices, and medications. Although some high-impact activities, such as running and jumping, should be avoided, it is important to maintain as much activity and joint motion as possible. Swimming, cycling, and leisurely walking are all low-impact activities that can help maintain range of motion, strength, and function. Staying active also can help with weight loss, which is an important part of the management of hip arthritis. For patients who are overweight, losing 20 pounds or more may decrease pain and delay the need for surgery.

A cane in the opposite hand helps to unload the hip significantly (Fig. 6-1). A properly fitted cane should reach the top of the greater trochanter of the patient’s hip while wearing shoes. Doing stretching and strengthening exercises or joining a yoga class can be of surprising value in terms of regaining ROM because it is not uncommon that stiffness of periarticular structures (e.g., the inability to put on shoes and socks) rather than pain makes surgery necessary.

Figure 6-1 Use of a cane redirects the force across the hip. Without the cane, the resultant force across the hip is about three times body weight because the force of the abductors acts on the greater trochanter to offset body weight and levels the pelvis in single stance.

(Redrawn from Kyle RF. Fractures of the hip. In Gustilo RB, Kyle RF, Templeton D (eds.). Fractures and Dislocations. St. Louis: Mosby, 1993.)

Operative Options for Hip Arthritis

Osteotomies, such as pelvic and intertrochanteric osteotomies, were popular in the past, and they still may have a limited role in selected situations. Fusion still does have a role but in very early childhood only. The mainstay of surgical treatment is total hip replacement (Fig. 6-2). In general, for elderly patients with low activity demands, both the acetabular and the stem components can be cemented. For patients who are young and high demand, the current trend is to use noncemented implants. These are only general guidelines. In revisions with poor-quality bone, the surgeon makes fixation choices based on intraoperative findings.

Figure 6-2 Total hip replacement.

Weight-bearing restrictions are different after arthroplasty with cemented and cementless hip devices. Cement is as strong as it will ever be 15 minutes after insertion. Some surgeons believe that some weightbearing protection should be provided until the bone at the interface with the cement (which has been damaged by mechanical and thermal trauma) has reconstituted with the development of a peri-implant bone plate. This phenomenon takes 6 weeks. Most surgeons, however, believe that the initial stability achieved with cement fixation is adequate to allow immediate full weightbearing with a cane or walker.

With a noncemented hip prosthesis, the initial fixation is press-fit, and maximal implant fixation is unlikely to be achieved until some tissue ongrowth or ingrowth into the implant has been established. Stability is usually adequate by 6 weeks. However, maximal stability is probably not achieved until approximately 6 months with noncemented prostheses. For these reasons, many surgeons advocate toe-touch weightbearing for the first 6 weeks. Other surgeons believe that the initial stability achieved is adequate to allow weightbearing as tolerated immediately after surgery.

Straight-leg raises (SLR) can produce very large out-of-plane loads on the hip and should be avoided in the postoperative period after total hip arthroplasty. Side-leg-lifting in the lying position also produces large loads on the hip. Even vigorous isometric contractions of the hip abductors should be practiced with caution, especially if a trochanteric osteotomy has been done.

Initial rotational resistance of a noncemented hip may be low, and it may be preferable to protect the hip from large rotational forces for 6 weeks or more. The most common rotational load comes when arising from a sitting position, so pushing with hands from a chair is strongly recommended.

After full weightbearing is established, it is essential that the patient continue to use a cane in the contralateral hand until the limp stops. This helps prevent the development of a Trendelenburg gait, which may be difficult to eradicate at a later date. In some difficult revisions in which implant or bone stability has been difficult to establish, a patient may be advised to continue to use a cane indefinitely. In general, when a patient gets up and walks away, forgetting about the cane, this is an indicator that the cane may be safely discarded.

Preoperative Management

Patient education regarding postoperative pain management, restrictions, independent walking, and proper rehabilitation is an important first step in achieving satisfactory results after THR. Preoperative classes can facilitate patients’ understanding of reasonable expectations of recovery, increase their motivation, and help expedite the rehabilitation learning process(Giraduet-Le Quintrec et al. 2003). Vukomanovic et al. reported that patients who both performed the “postoperative” exercises and received preoperative education demonstrated the ability to perform functional activities significantly earlier than those who were randomly assigned to the control group. These functional activities included being able to walk up and down stairs earlier, use the toilet and chair sooner, transfer independently, and ambulate independently.

Patient education also has been shown to be directly related to faster postoperative ambulation, reductions in hospital length of stay, and less use of narcotic pain medications (Spaulding 1995). A major part of preoperative educational classes should be dedicated to prevention of postoperative dislocation by appropriate explanation of hip precautions.

Although several studies have shown that preoperative strengthening exercises have a significant correlation with longer postoperative walking distance and may improve early return to ambulatory function after THR (Gilbey et al. 2003; Wang et al. 2002; Whitney and Parkman 2002), others have shown that these exercises have no significant impact on the outcomes (Gocen et al. 2004; Rooks et al. 2006).

Surgical Approach

One of the factors influencing postoperative recovery and rehabilitation is the surgical approach. The patient’s gait may be compromised with approaches in which the hip abductors are altered (i.e., lateral or anterolateral approaches). Inadequate repair or weakness of the abductor muscles after these approaches may result in prolonged limping. The posterolateral approach spares the hip abductors but is associated with a slightly higher dislocation rate. This dislocation rate can be reduced with the use of larger femoral heads and proper repair of the posterior soft tissues (Pellicci et al. 1998; Woo and Morrey, 1982). The direct anterior approach, although theoretically appealing, is technically demanding and may require fracture table and intraoperative fluoroscopy (Peak et al. 2005). Minimally invasive THR has been widely marketed, but the claims of significantly reduced pain, less morbidity, better function, and improved patient satisfaction appear to be unfounded (Khan et al. 2009). Based on recent reports, minimally invasive THR does not appear to affect the short-term or intermediate-term outcomes after the THR (Howell et al. 2004; Inaba et al. 2005; Lawlor 2005). Complications of minimally invasive THR include wound-healing problems, component malposition, and increased risk of femoral fractures (Howell et al. 2004; Lawlor 2005).

Multimodal Pain Management

Severe pain after THR is one of the greatest fears patients have before surgery and is the leading cause of delayed discharge. Pain remains a poorly understood, complex phenomenon that plays a significant role in limiting patients’ functional recovery and participation in postoperative physical therapy (Ranawat and Ranawat 2007). Optimal pain control promotes earlier ambulation and faster return to normal gait (Singelyn et al. 1998). Decreased postoperative range of motion due to pain commonly contributes to arthrofibrosis and inferior results (Ryu et al. 1993). A multimodal pain regimen is a relatively new concept that has shown excellent results in terms of improving postoperative pain, reducing the need for narcotic medications and increasing patients’ motivation and participation in postoperative physical therapy (Brown et al. 2009; Busch et al. 2006; Hebl et al. 2005; Maheshwari et al. 2006; Peters et al. 2006). The key to multimodal pain control is the use of various pain medications with different mechanisms of action that results in superior pain control while minimizing their adverse side effects. Several postoperative pain control protocols exist, including patient-controlled anesthesia pumps (PCA), femoral nerve blocks (FNBs), continuous or one-time psoas compartment block (cPCB), and continuous lumbar plexus block (cLPB) (Becchi et al. 2008; Siddiqui et al. 2007). The use of local infiltration through an intra-articular catheter after THR has been shown to reduce the hospital stay and reduce the opioid-related side effects, such as nausea and vomiting, compared to continuous epidural infusion (Andersen et al. 2007). Local periarticular injections have also been used in a multimodal pain regimen that has been shown to reduce postoperative pain and improve patient satisfaction and functional recovery (Pagnano et al. 2006; Parvataneni et al. 2007).

Hip Precautions

Postoperative hip restrictions are used to protect the soft tissue repair after a posterior approach and thereby avoid hip dislocation (Masonis and Bourne 2002). Table 6-2 presents the common precautions associated with each surgical approach; however, variations may exist regionally. These precautions can be difficult to adhere to and may interfere with the postoperative rehabilitation process (Peak et al. 2005). Dislocation after THA through the posterior approach commonly occurs when the hip is adducted past midline, internally rotated, and flexed more than 90 degrees. To prevent this, an abduction pillow (Fig. 7-48 in Chapter 7) is placed between the patient’s knees while in bed or a small cushion can be situated between the thighs while sitting (Rao and Bronstein 1991). In some cases, especially in revisions or in patients who are noncompliant, it may be necessary to use knee immobilizers or hip abduction orthoses for 6 to 12 weeks postoperatively to restrict hip adduction and flexion (Venditolli et al. 2006).

Table 6-2 Precautions Associated with Total Hip Arthroplasty Surgical Approaches

After an anterior or anterolateral approach, extreme external rotation, adduction, and extension should be avoided. Several reports have shown that removal of hip precautions after the anterolateral approach results in a faster return to normal activities with higher patient satisfaction and no ill effects on short-term dislocation rates (Peak et al. 2005; Talbot et al. 2002).

Postoperative Total Hip Arthroplasty Rehabilitation Programs

Although a wide variety of exercise programs exist based on surgeon preference and geographic location, most protocols include quadriceps sets, gluteal sets, ankle pumps, and active hip flexion (heel slides) exercises (Enloe et al. 1996). Progressive hip abductor strengthening is also advocated, as the abductors maintain the pelvis level during the stance phase and prevent tilting of the contralateral hip during the swing phase (Enloe et al. 1996; Soderberg 1986). Most exercise programs address this issue initially by concentric hip abduction in a supine position and later through isometric hip abduction against resistance (Munin et al. 1995). The straight-leg raising exercise has been shown to apply a force of 1.5 to 1.8 times body weight and should be allowed only when partial or full weightbearing is permitted (Davy et al. 1988). If pain occurs, hip flexion and knee extension exercises can be done separately with placement of a bolster under the knee to minimize hip stress (Davy et al. 1988; Trudelle-Jackson et al. 2002). Several reports have shown persistent quadriceps atrophy or weak thigh flexors of the operated hip compared to the contralateral hip (Bertocci et al. 2004; Reardon et al. 2001; Shih et al. 1994).

Functional tasks of daily living targeted in the rehabilitation program include weight transfer to the nonoperated hip, gait training on both level and uneven surfaces, stair climbing, and lower extremity dressing. Transferring of weight to the uninvolved side is initiated by leading with the nonoperated limb both into and out of bed and then is progressed to both sides of the bed. This method is also used with stair climbing: Patients are instructed to lead with the uninvolved hip while ascending and lead with the operated hip while descending the stairs to optimize control of body weight through the uninvolved leg (Strickland et al. 1992).

Weightbearing

Weightbearing restrictions after hip replacement, such as toe-touch weightbearing (TTWB) or partial weightbearing (PWB), directly affect the level of functional independence after surgery. PWB refers to 30% to 50% of the body weight, but studies have shown that patients have difficulty estimating and maintaining this percentage and commonly violate the restricted weightbearing (Davy et al. 1988). In TTWB, no more than 10% of body weight should be applied. TTWB is preferred over nonweightbearing (NWB) because the latter may actually create greater pressures over the hip joint as a result of muscle forces maintaining the correct pelvic positioning (Davy et al. 1988). Full weightbearing (FWB) has been shown to promote faster recovery and shorter hospital stays (Kishida et al. 2001). This is a result of reduced reliance on the upper extremities for weightbearing, resulting in earlier strengthening of the operative hip abductors and improved functional outcomes.

Assistive devices such as walkers, crutches, and canes are used to unload the operated joint and provide support and balance (Holder et al. 1993; Strickland et al. 1992). Progression from one to another is dependent on several factors such as age, comorbidities, and weightbearing restrictions. Walkers are usually the first choice after THR and provide the greatest stability by increasing the patient’s base of support and unloading the affected leg (Davy et al. 1988). Because walkers require the use of both hands, carrying objects and performing self-care activities are challenging. In addition, walkers occasionally do not fit through doorways and are not recommended for use on stairs. Rolling walkers have higher self-selected walking speeds than standard walkers (Palmer and Toms 1992). Most patients advance easily from gait training with a walker to crutches or a cane. Axillary and forearm crutches are more appropriate for younger, more agile patients because they allow faster gait and yield better energy efficiency in NWB healthy subjects (Holder et al. 1993), but they have the least stability and require more control of the lower extremity and overall balance (Palmer et al. 1992). A potential complication of axillary crutches is axillary nerve compression injuries from incorrect use (O’Sullivan and Schmitz 1988). Canes are usually used on the contralateral side of the hip replacement and can transfer 10% to 20% of body weight by decreasing vertical hip contact forces (Brander et al. 1994; Deathe et al. 1993; Stineman et al. 1996). The basic function of a cane is to extend the base of support and to provide stability. Canes should be used only for patients who are fully weightbearing. Canes are inexpensive, allow a reciprocal walking pattern, can be used on stairs, and can be sized according to the patients’ height. The crook of the handle should be even with the radial styloid process when the elbow is flexed at 15 to 30 degrees (O’Sullivan and Schmitz 1988).

Levels of Rehabilitative Care

Different rehabilitation settings include acute hospital care, inpatient rehabilitation, skilled nursing facilities, and home or outpatient rehabilitation centers. Selecting the appropriate postoperative rehabilitation that best serves the patient is often confusing to both the patient and health care professionals. In acute hospital care, postoperative physical therapy is usually started on the same day of surgery or the next morning. The goals for the first physical therapy session are to assess the patient’s mobility status and to initiate therapeutic activities. With the patient lying supine in the bed, the physical therapist should observe the patient’s positioning, assess for signs of a deep vein thrombosis (DVT) (Table 6-3), note the state of the dressing, and record the ROM and strength of the uninvolved leg. If signs of a DVT are present or if there is excessive drainage noted on the dressing, the nursing staff should be immediately informed prior to continuing the treatment session.

Table 6-3 Signs Associated with a Deep Vein Thrombosis

Initial training includes strength assessments, sit-to-stand transfers, and gait and balance teaching. Transfers from bed to chair are usually done twice a day for half an hour at a time. Patient education further involves lower extremity dressing, bathing, and toilet transfers using appropriate equipment to maintain hip precautions. Transfers and gait training exercises are advanced depending on the patients’ weightbearing status, preoperative level of ambulation, age, and amount of improvement, progressing from simple walking to attempting curbs and ramps based on the patient’s needs. Medical management includes aggressive multimodal pain control, bowel regimens, DVT prophylaxis, and management of any comorbidities.

Therapeutic exercises initiated during the initial visit may consist of lower extremity isometrics (quadriceps, hamstring, gluteal sets) and ankle pumps. Initially, a patient may be able to tolerate only passive ROM; however, he or she should be able to demonstrate increased active ROM tolerance over the course of the inpatient stay. Therapeutic exercises frequently are added daily to the patient’s routine. Table 6-4 presents a sample therapeutic exercise progression during the first postoperative week.

Table 6-4 Sample Week 1 Total Hip Replacement Postoperative Exercise Program*

* This sample program is based on a posterior surgical approach (see also page 435).

Comprehensive inpatient rehabilitation is different from acute hospital care because it is more focused on physical therapy and interdisciplinary treatment in combination with intensive family training. Inpatient rehabilitation is reserved for patients who require more than a few days of continuous skilled care, are able to physically tolerate at least 3 hours of therapy per day, and have a good chance of returning home within a reasonable time frame (Stineman et al. 1996). Medical management is similar to the acute hospital care setting. Reports have shown that older patients without family support and patients with comorbid medical conditions usually need inpatient rehabilitation after THR (Munin et al. 1995; Weingarten et al. 1994). The subacute nursing facility (SNF) was developed as a complement to inpatient rehabilitation and has grown as an alternative to it. The SNF is reserved for patients who cannot tolerate the 3 hours of therapy per day required in an inpatient rehabilitation program and are not at risk for medical instability (Haffey and Welsh 1995).

Because of recent increasing pressure to discharge patients more quickly after surgery, it is important to assess if a patient can be safely discharged home. With improved surgical and pain management techniques, some patients may go home as early as the first postoperative day, whereas others with more comorbidities require longer lengths of hospital stay.

General criteria for home discharge include the following:

Management of Common Problems After Total Hip Replacement

Outpatient Total Hip Arthroplasty Physical Therapy Protocol

Typically, a patient should be either able to demonstrate or be working toward the following clinical goals:

Exercises to increase muscle strength include the following:

Progressive overload to the muscles can be applied manually by the application of ankle weights or with the use of elastic resistance bands. The initial exercise prescription should consist of one to three sets of 15 to 20 repetitions. This volume of training will help to improve muscular endurance while minimizing the risk of excessive postexercise muscular soreness or pain. As endurance capacity increases, strength training can be increased to volumes of two to four sets of 6 to 10 repetitions. Table 6-5 presents frequently prescribed therapeutic exercises that address muscular weakness. The exercises are grouped by the muscles trained and in the order of difficulty.

Table 6-5 Therapeutic Exercises Frequently Prescribed in the Outpatient Orthopedic Physical Therapy Setting

* Exercises are presented by their relative degree of difficulty.

Return to Sport After Total Hip Replacement

Physical activity levels may have an impact on the lifespan of the total hip replacement. Wear and tear on the replaced joint or a traumatic event may necessitate a revision surgery at a later date; however, having a hip replaced does not mean that one must end his or her recreational or sport pursuits. Exercise and activity are necessary for maintaining overall health. Instead of restricting activity, physicians have developed recommendations and guidelines for those who wish to return to activities that are more strenuous than walking. Table 6-6 presents examples of activities and sports, their associated levels of impact on the hip replacement, and recommendations as to the safety of performing and participating in a particular sport.

Table 6-6 Sport Participation Recommendations and Associated Levels of Impact on the Total Joint Replacement

From Clifford PE, Mallon WJ. Sports participation for patients with joint replacements based upon level of impact loading. Clin Sports Med 24(1):182, 2005. Table 1.

Table 6-7 provides a list of sports that are considered acceptable for participation, those that are possibly acceptable for participation, and those that are not recommended. Sports are designated “possibly acceptable” or “not recommended” based on the risk of falling or traumatic contact. Falling or experiencing traumatic forces may contribute to hip dislocation, hip fracture, or failure of the hip replacement.

Table 6-7 Sports Participation Recommendations for Patients with a Total Hip Replacement

Adapted from Clifford PE, Mallon WJ. Sports participation for patients with joint replacements based upon level of impact loading. Clin Sports Med 24(1):183, 2005. Table 2.

Sport-Specific Exercises for the Golfer with a Total Hip Replacement

It is generally agreed that golfing is an acceptable sport to return to and that it places a low degree of stress on the hip implant (see Fig. 7-62). Because of the multiplanar nature of the golf swing and the unique forces placed on the body (specifically the core), the rehabilitation and strength training program for the golfer who has had a total hip replacement should include sport-specific exercises once the patient’s physician has lifted hip precautions. Most sport-specific exercises should address core stability and multiplanar movement patterns.

Exercises to increase core endurance capacity include front plank with hip extension (see Fig. 7-63), the bird dog, and the side plank. With improved core endurance, the golfer should be prescribed multiplanar exercises such as the lunge with trunk rotation (see Fig. 7-64), kettle bell squats (Fig. 6-3), plyometric ball tosses (see Fig. 7-65), and proprioceptive neuromuscular facilitation chop and lift patterns performed against resistance (Fig. 6-4).

Figure 6-3 Kettle bell squat with rotation.

Figure 6-4 Proprioceptive neuromuscular facilitation chop and lift patterns with pulleys.

Classification

Arthritic deformities of the knee are classified as varus or valgus, with or without patellar involvement. Patellofemoral arthritis is common in an arthritic knee but seldom is the major source of symptoms. Articular surface damage is commonly classified according to severity: minimal, no radiologic narrowing is seen; mild, loss of one third of the joint space; moderate, two thirds of the joint space is narrowed; and severe, evidence of bone-on-bone contact.

Diagnosis

Examination of the knee for arthritis can be done by moving the joint under a load (e.g., to examine medial compartment, a varus strain is applied to the knee and for the lateral compartment a valgus load is applied as the knee is moved through a ROM). Crepitus can be felt under the hand applying the varus or valgus strain and pain will be reproduced. Both collateral and cruciate ligaments should be examined. A slight increase in varus/valgus motion may be produced in a patient with a significant amount of joint space narrowing as the buttress effect of the meniscus and articular cartilage may be lost. The presence of any fixed flexion deformity (e.g., lack of passive extension of the knee) should be noted. The patellar position (central or subluxed) is important, as is the presence of a rotator deformity of the tibia. When the patient stands, any genu varum or valgum should be noted.

A thorough history and examination of the arthritic knee should obtain the following information:

Radiographic Evaluation

Radiographic evaluation should always include a standing (weightbearing) anteroposterior view of the knee. If surgery is contemplated, a full-limb view should be obtained to detect any deformities or problems above and below the standard radiographic views (e.g., a valgus or varus deformity of the ankle). A lateral radiograph is required, as is a skyline (tangential) view of the patella. If the problem is on the lateral side of the joint, a standing posteroanterior view must be obtained with the knee in 30 degrees of flexion. This is important because articular cartilage loss in the medial compartment is in the distal femur and central tibia, but articular cartilage loss in the lateral compartment is in the posterior femur and posterior tibia.

Treatment Options

Operative Treatment

Arthroscopic débridement is of temporary if any value in arthritic knees, simply cleaning out the tags and meniscal tears and flushing from the joint fluid that contains pain-producing peptides. Cole and Harners’ (1999) article on the evaluation and management of knee arthritis provides an excellent overview on arthroscopy in patients with knee arthritis.

Livesley et al. (1991) compared the results in 37 painful arthritic knees treated with arthroscopic lavage by one surgeon against those in 24 knees treated with physical therapy alone by a second surgeon. The results suggested that there was better pain relief in the lavage group at 1 year. Edelson et al. (1995) reported that lavage alone had good or excellent results in 86% of their patients at 1 year and in 81% at 2 years using the Hospital for Special Surgery scale.

Jackson and Rouse (1982) reported on the results of arthroscopic lavage alone versus lavage combined with débridement, with 3-year followup. Of the 65 patients treated with lavage alone, 80% had initial improvement, but only 45% maintained improvement at follow-up. Of the 137 patients treated with lavage plus débridement, 88% showed initial improvement and 68% maintained improvement at follow-up. Gibson et al. (1992) demonstrated no statistically significant improvement with either method, even in the short term.

Patients who present with flexion deformities associated with pain or discomfort and osteophyte formation around the tibial spines may benefit from osteophyte removal and notchplasty, as demonstrated by Puddu et al. (1994).

The true efficacy of lavage with or without débridement is controversial. More recent randomized controlled studies performed by Kirkley et al. (2008) and Moseley et al. (2002) found no benefit to arthroscopic lavage in patients with moderate to severe arthritis of the knee.

General Considerations

Operative treatment frequently is required for disabling knee pain, particularly in patients with post-traumatic knee OA. Reconstruction options include osteotomy, arthrodesis, and arthroplasty. In general, corrective osteotomy is done in younger patients with single-compartment degenerative change and angular malalignment. Osteotomy that corrects the angular malalignment also unloads the arthritic compartment and can delay disease progression and the need for total knee arthroplasty. Relative contraindications to osteotomy include tricompartmental arthritis, symptomatic patellofemoral degenerative changes, inflammatory arthritis, and age older than 60 years (Bedi and Haidukewych 2009). A downside to osteotomy is that changing the joint-line orientation with the osteotomy increases the technical difficulty of ensuing total knee arthroplasty.

For large, isolated traumatic lesions in young patients, fresh osteochondral allografting has been done in conjunction with the unloading osteotomy, with about 85% graft survival at 10 years (Ghazavi et al. 1997, Gross et al. 2005). Arthrodesis can be effective in relieving pain, but the functional limitations are substantial and ipsilateral back and hip pain may develop because of increased stress on these joints. Conversion of knee arthrodesis to total knee arthroplasty is difficult, has a high complication rate, and produces less than excellent outcomes.

Total Knee Arthroplasty Rationale

Many surgeons use identical routines after total knee replacement, whether the implants are cemented or noncemented (Fig. 6-5). Their rationale is that the initial fixation of noncemented femoral and tibial components is in general so good that loosening is uncommon. The tibia is largely loaded in compression. The stability achieved with pegs, screws, and stems on modern implants is now adequate to allow full weightbearing. However, if the bone is exquisitely soft, weightbearing should be delayed. The progression to weightbearing, therefore, must be based solely on the surgeon’s discretion and intraoperative observations.

Figure 6-5 Total knee arthroplasty.

The guidelines for rehabilitation given here are general guidelines and should be tailored to individual patients. Concomitant osteotomies and significant structural bone grafting are indications for limited weightbearing until healing has been achieved. Similarly, if the bone is extremely osteoporotic, full weightbearing is delayed until the periimplant bone plate develops. Exposure problems requiring a tibial tubercle osteotomy or a quadriceps tendon division may require that straight leg raises be avoided until adequate healing has occurred, which typically takes 6 to 8 weeks.

Component design, fixation methods, bone quality, and operative techniques all affect perioperative rehabilitation. The implant choice no longer determines rehabilitation methods. It does not or should not make much difference whether the implant is unconstrained, semi-constrained, or fully constrained.

Postoperative return of 90 degrees of knee flexion is generally considered the minimal requirement for activities of daily living with an involvement of one knee. However, if both knees are replaced, it is essential that one knee reach more than 105 degrees of knee bend to allow the patient to rise from a normal low toilet seat. Furthermore, to descend stairs reciprocally, without hip or trunk substitution, requires 115 to 117 degrees of knee flexion.

Continuous passive motion (CPM) may be used after surgery, but there is a certain increase in wound problems with it. Furthermore, if the patient is left on it for long periods, a fixed flexion contracture of the knee tends to develop. If CPM is to be used, therefore, the patient must come off the machine for part of the day and work at achieving full extension. We limit aggressive or prolonged CPM use in patients with the potential for wound problems (such as those with diabetes or those who are obese).

Immediately after surgery, patients frequently have a flexion contracture because of hemarthrosis and irritation of the joint. These flexion contractures generally resolve with time and appropriate rehabilitation. However, patients who have been left with a fixed flexion contracture at the time of the surgery frequently are unable to achieve full extension. It is important, therefore, that full extension be achieved in the operating room.

Manipulation under anesthesia occasionally may be required. This is an individual decision on the part of the surgeon. Generally, it is preferable to carry out a full manipulation under anesthesia using muscle relaxant if the patient has not achieved greater than 70 degrees of flexion by 1 week. The usual area at which adhesions develop is the suprapatellar pouch. Many surgeons rarely perform any manipulations under anesthesia and believe that the patient will be able to work through the motion loss. Late manipulation under anesthesia (after 4 weeks) requires great force and risks serious injury to the knee. Alternatively, arthroscopic lysis of adhesions in the suprapatellar pouch can be done with an arthroscopy obturator or a small periosteal elevator.

Reflex sympathetic dystrophy syndrome (RSDS) of the knee is uncommon after total knee replacement and is usually diagnosed late. The hallmarks are chronic pain that is present 24 hours a day and allodynia or skin tenderness. Such patients usually fail to achieve a reasonable ROM and usually also develop a flexion contracture. If this is suspected, a lumbar sympathetic block may be of not only diagnostic but also therapeutic value and should be carried out as soon as possible.

Goals of Rehabilitation After Total Knee Arthroplasty

• Prevent hazards of bedrest (e.g., DVT, PE, pressure ulcers).

• Assist with adequate and functional ROM:

• Strengthen thigh musculature.

• Assist patient in achieving functional independent activities of daily living.

• Achieve independent ambulation with an assistive device.

Management of Rehabilitation Problems After Total Knee Arthroplasty

Recalcitrant Flexion Contracture (Difficulty Obtaining Full Knee Extension)

• Initiate backward walking.

• Perform passive extension with the patient lying prone with the knee off the table, with and without weight placed across the ankle. This should be avoided if contraindicated by the PCL status of the arthroplasty.

• Perform eccentric extension. The therapist passively extends the leg and then holds the leg as the patient attempts to lower it slowly.

• With the patient standing, flex and extend the involved knee. Sports cord or rubber bands can be used for resistance.

• Use electric stimulation and VMO biofeedback for muscle re-education if problem is active extension.

• Passive extension is also performed with a towel roll placed under the ankle and the patient pushing downward on the femur (or with weight on top of the femur) (Fig. 6-6).

Figure 6-6 Passive range of motion exercises for knee extension. The patient places a towel under the foot. Use a slow, sustained push with the hands downward on the quadriceps.

Delayed Knee Flexion

• Passive stretching into flexion by therapist.

• Wall slides for gravity assistance.

• Stationary bicycle. If patient lacks enough motion to bicycle with saddle high, then begin cycling backward, then forward, until able to make a revolution. Typically, this can be done first in a backward fashion.