Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Advanced Techniques for Rehabilitation after Total Hip and Knee Arthroplasty 17 articles


Evaluation of a Custom Device for the Treatment of Flexion Contractures after Total Knee Arthroplasty

Mike S. McGrath MD, Michael A. Mont MD, Junaed A. Siddiqui, Erin Baker PT, Anil Bhave PT Knee flexion contractures can severely impair function after total knee arthroplasties. We evaluated the use of a custom-molded knee device to treat 47 patients who had knee flexion contractures (mean, 22°; range, 10°–40°) after primary or revision total knee arthroplasties and who had failed conventional therapeutic methods. The device was used for 30 to 45 minutes per session two to three times per day in conjunction with standard physical therapy modalities two to three times per week. Twenty-seven of 29 patients who underwent primary total knee arthroplasty and 13 of 18 patients who underwent revisions achieved full extension after a mean treatment time of 9 weeks (range, 6–16 weeks). Full knee extension was maintained at a minimum followup of 18 months (mean, 24 months; range, 18–36 months). The mean Knee Society knee and functional scores improved from 50 points and 34 points to 91 points and 89 points, respectively. This protocol had comparable rates of improvement in knee extension with less treatment time when compared with other nonoperative treatments reported in the literature. The custom knee device may be a useful adjunct to a physical therapy regimen for knee flexion contractures after total knee arthroplasty.,[object Object]

Reversing Muscle and Mobility Deficits 1 to 4 Years after TKA: A Pilot Study

Paul C. LaStayo PhD, PT, Whitney Meier DPT, OCS, Robin L. Marcus PhD, PT, OCS, Ryan Mizner PhD, MPT, Lee Dibble PhD, PT, ATC, Christopher Peters MD Muscle and mobility deficits can persist for years after a total knee arthroplasty (TKA). The purposes of this study were (1) to determine if 12 weeks of rehabilitation with resistance exercise induces increases in muscle size, strength, and mobility in individuals 1 to 4 years after a TKA; and (2) to compare the muscle and mobility outcomes of a traditional resistance exercise rehabilitation program with a rehabilitation program focused on eccentric resistance exercise. Seventeen individuals (13 women, four men; mean age, 68 years; age range, 55–80 years) with either a unilateral or bilateral TKA (total of 24 knees) were included in this matched and randomized repeated-measures rehabilitation pilot trial. Increases in quadriceps muscle volume and knee extension strength followed 12 weeks of eccentric exercise. Improvements were also noted in four mobility tests. Similar improvements were noted in the traditional group in two mobility tests. An increase in muscle size and strength and an improvement in levels of mobility can occur after 12 weeks of resistance exercise in older individuals 1 to 4 years after TKA. When the exercise mode focuses on eccentric resistance, the muscle growth response is greater as is the improvement in important mobility tasks.,[object Object]

Gait and Stair Function in Total and Resurfacing Hip Arthroplasty: A Pilot Study

M. Wade Shrader MD, Manoshi Bhowmik-Stoker MS, Marc C. Jacofsky MA, David J. Jacofsky MD Standard total hip arthroplasty (THA) is the established surgical treatment for patients older than 65 years with progressive osteoarthritis but survivorship curves wane in patients younger than 50. Resurfacing hip arthroplasty (RHA) is an alternative for younger, active patients reportedly providing superior range of motion. Quantitative investigation of functional recovery following arthroplasty may elucidate limitations that aid in device selection. Although limited long-term kinematic data are available, the early rate of recovery and gait compensations are not well described. This information may aid in refining rehabilitation protocols based on limitations specific to the implant. We presumed hip motion and forces for subjects receiving RHA are more similar to age-matched controls during physically demanding tasks, such as stair negotiation, at early time points than those for THA. In a pilot study, we quantified walking and stair negotiation preoperatively and 3 months postoperatively for seven patients with RHA (mean age, 49 years), seven patients with standard THA (mean age, 52 years), and seven age-matched control subjects (mean age, 56 years). Although both treatment groups demonstrated trends toward functional recovery, the RHA group had greater improvements in hip extension and abduction moment indicating typical loading of the hip. Further investigation is needed to determine if differences persist long term or are clinically meaningful.

THA with a Minimally Invasive Technique, Multi-modal Anesthesia, and Home Rehabilitation: Factors Associated with Early Discharge?

Dana Christopher Mears MD, PhD, Simon C. Mears MD, PhD, Jacques E. Chelly MD, PhD, MBA, Feng Dai PhD, Katie L. Vulakovich Multimodal anesthetic and pain regimens with minimally invasive surgical approaches and rapid rehabilitation protocols are thought to decrease length of stay after hip replacement. We asked whether a program including these three elements could achieve 23-hour discharge in a group of 665 patients and whether the length of hospital stay was influenced by patient age, gender, body mass index, change in hemoglobin or estimated blood loss, duration of surgery (≤ 90 or > 90 minutes), or American Society of Anesthesiologists physical status classification. Of the 665 patients, 259 (38.9%) were discharged home with indwelling peripheral nerve catheters. Hospital discharge in less than 24 hours was achieved in 295 (44.4%) of the 665 patients. After discharge, 73.5% of patients required no home or outpatient nursing care or physical therapy. Eighteen (2.7%) dislocations, eight (1.2%) femoral fractures requiring surgery, and thirteen (2.0%) revision procedures occurred within 90 days. Female gender, increasing age, increasing estimated blood loss, and American Association of Anesthesiologists classification 3 or 4 increased length of stay. Additional study is needed to confirm these factors and develop prospective prediction rules to allow for an outpatient approach to joint arthroplasty.,[object Object]

Pilates Training for Use in Rehabilitation after Total Hip and Knee Arthroplasty: A Preliminary Report

Brett Levine MS, MD, Beth Kaplanek RN, William L. Jaffe MD Recently, a strong emphasis has been placed on establishing rehabilitation protocols after primary total hip and knee arthroplasty in an attempt to shorten, improve, and standardize the postoperative period of recovery. Less invasive surgical techniques, patient demands, and the pressure of insurance regulations have forced postoperative rehabilitation to be placed on an expedited scale. With these concerns in mind, we introduce a pre- and postarthroplasty program involving the Pilates method. Modified exercises have been developed to account for the postoperative precautions and needs of total hip and knee arthroplasty patients. A patient-driven interest in the use of Pilates for postoperative rehabilitation has led to the development of our programs following total hip or knee arthroplasty. In reviewing our early observations of a small series of patients, it appears this technique can be utilized without early complications; however, further studies are necessary to confirm its utility and safety.,[object Object]

Factors Influencing Early Rehabilitation After THA: A Systematic Review

Vivek Sharma MD, Patrick M. Morgan MD, Edward Y. Cheng MD A wide variation exists in rehabilitation after total hip arthroplasty (THA) in part due to a paucity of evidence-based literature. We asked whether a minimally invasive surgical approach, a multimodal approach to pain control with revised anesthesia protocols, hip restrictions, or preoperative physiotherapy achieved a faster rehabilitation and improved immediate short-term outcome. We conducted a systematic review of 16 level I and II studies after a strategy-based search of English literature on OVID Medline, PubMed, CINAHL, Cochrane, and EMBASE databases. We defined the endpoint of assessment as independent ambulation and ability to perform activities of daily living. Literature supports the use of a multimodal pain control to improve patient compliance in accelerated rehabilitation. Multimodal pain control with revised anesthesia protocols and accelerated rehabilitation speeds recovery after minimally invasive THA compared to the standard approach THA, but a smaller incision length or minimally invasive approach does not demonstrably improve the short-term outcome. Available studies justify no hip restrictions following an anterolateral approach but none have examined the question for a posterior approach. Preoperative physiotherapy may facilitate faster postoperative functional recovery but multicenter and well-designed prospective randomized studies with outcome measures are necessary to confirm its efficacy.,[object Object]

Newer Anesthesia and Rehabilitation Protocols Enable Outpatient Hip Replacement in Selected Patients

Richard A. Berger MD, Sheila A. Sanders RN, Elizabeth S. Thill RN, Scott M. Sporer MD, Craig Della Valle MD Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consectutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consectutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement.,[object Object]

The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty

Richard A. Berger MD, Sharat K. Kusuma MD, Sheila A. Sanders RN, Elizabeth S. Thill RN, Scott M. Sporer MD The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standard-length hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization.,[object Object]

Perioperative Dexamethasone Does Not Affect Functional Outcome in Total Hip Arthroplasty

Stephane G. Bergeron MD, Kenneth J. Kardash MD, Olga L. Huk MD, MSc, David J. Zukor MD, John Antoniou MD, PhD Current trends in orthopaedic surgery have explored different forms of adjuvant treatments to minimize postoperative pain and the risk of nausea and vomiting. A small single preoperative dose of dexamethasone, as part of a comprehensive multimodal analgesic regimen in low-risk patients undergoing total hip arthroplasty (THA), provides antiemetic and opioid-sparing effects but the longer-term effects on pain, complications, or function are not known. We therefore asked whether such a routine would affect longer-term pain, complications, or function. Fifty patients undergoing elective primary THA using spinal anesthesia were initially randomized to receive either dexamethasone (40 mg intravenous) or saline placebo. The patients, anesthesiologists, nurses, and research coordinators were blinded to the study arms. The functional outcome was measured using the Harris hip score. Outcomes were assessed 6 weeks and 1 year postoperatively. We observed no difference in resting pain between the two groups at either time period. Both groups had similar functional outcome scores for the total Harris hip score and individual scoring items at each followup interval. There were no wound complications, deep infections, or osteonecrosis in the contralateral hip at 1-year followup. We recommend the addition of a small single preoperative dose of dexamethasone to a comprehensive multimodal analgesic regimen in low-risk patients given its immediate antiemetic and opioid-sparing effects, and absence of subsequent effects.,[object Object]

Functional Outcome of Femoral versus Obturator Nerve Block after Total Knee Arthroplasty

Stephane G. Bergeron MD, Kenneth J. Kardash MD, Olga L. Huk MD, MSc, David J. Zukor MD, John Antoniou MD, PhD Patients undergoing total knee arthroplasty often experience substantial postoperative pain, which may delay functional recovery and hospital discharge. We recently reported the short-term analgesic efficacy of a single-injection femoral nerve block after spinal anesthesia in total knee arthroplasty. We have now followed 30 patients a minimum of 1 year to determine the functional outcome and pain relief after femoral and obturator nerve block after total knee arthroplasty. Patients undergoing primary unilateral total knee arthroplasty were randomized to one of three treatment groups: (1) femoral nerve block; (2) obturator nerve block; or (3) placebo (sham block). At 6 weeks and 1 year, all three groups had similar total Hospital for Special Surgery knee scores and similar subscores such as range of motion, daily function, and resting and dynamic pain. The data support the usefulness of a peripheral nerve blockade in the context of a multimodal analgesic regimen and a tailored rehabilitation program to individual patients and institutions.,[object Object]

Is Recovery Faster for Mobile-bearing Unicompartmental than Total Knee Arthroplasty?

Adolph V. Lombardi MD, Keith R. Berend MD, Christopher A. Walter DO, Jorge Aziz-Jacobo MD, Nicholas A. Cheney DO How does unicompartmental compare with total knee arthroplasty in durability, incidence of complications and manipulations, recovery, postoperative function, and return to sport and work? We matched 103 patients (115 knees) treated with a mobile-bearing unicompartmental device through July 2005 to a selected group of 103 patients (115 knees) treated with cruciate retaining total knee arthroplasty for bilaterality, age, gender and body mass index. Patients who underwent a unicompartmental surgery had better range of motion at discharge and shorter hospital stay than those who had a total knee arthroplasty (77° versus 67° and 1.4 versus 2.2 days). At 6 weeks, Knee Society functional scores and range of motion were higher for unicompartmental than total knees (63 versus 55 and 115° versus 110°). Patient-perceived Oxford scores were similar between groups (unicompartmental 5.4 versus total 4.1). Average times to return to work and sport were similar for both groups. Minimally invasive unicompartmental knee arthroplasty demonstrated better early ROM, shorter hospital stays, and improved functional scores. No advantage was seen in terms of return to work, return to sport, or Oxford scores. The data suggest minimally invasive unicompartmental arthroplasty using a rapid recovery protocol allows patients a faster return to a more functional level than total knee arthroplasty.,[object Object]

Comparison of Outpatient versus Inpatient Total Knee Arthroplasty

Frank R. Kolisek MD, Mike S. McGrath MD, Nenette M. Jessup MPH, Eric A. Monesmith MD, Michael A. Mont MD New protocols have been designed for outpatient total knee arthroplasty procedures, but concerns exist about the potential for increased complication rates. We compared the results of two selected matched cohorts of 64 patients who underwent total knee arthroplasty during the same time period. One cohort of patients, who had no severe medical conditions, lived within one hour of the office, and had help at home, followed an accelerated pathway in which they were discharged within 23 hours of surgery, and the other cohort followed a standard inpatient protocol, with a mean hospital stay of 2.3 days (range, 2–4 days). There were no perioperative complications in either cohort, and none of the patients who followed the outpatient protocol returned to the hospital for any reason. At a mean followup of 24 months (range, 12–41 months), the mean Knee Society knee scores of the outpatient and inpatient cohorts were 96 points (range, 67–100 points) and 95 points (range, 78–100 points), respectively. The mean Knee Society function scores were 89 points (range, 50–100 points) and 90 points (range, 60–100 points), respectively. We believe outpatient total knee arthroplasty may be a safe procedure in certain selected patients, with similar outcomes to a traditional protocol.,[object Object]

Early Discharge and Recovery with Three Minimally Invasive Total Hip Arthroplasty Approaches: A Preliminary Study

R. Michael Meneghini MD, Shelly A. Smits RN Purported advantages of THA performed with minimally invasive surgical approaches include less muscle damage and faster recovery. The purpose of this preliminary investigation was to determine if differences existed between minimally invasive approaches in hospital discharge and early functional recovery in THA patients with a rapid rehabilitation protocol. Twenty-four consecutive patients were randomized to one of three minimally invasive surgical approaches (two-incision, mini-posterior, and mini-anterolateral) and enrolled in an aggressive postoperative rehabilitation program. Hospital discharge, early functional milestone recovery, and validated outcome measures (SF-36, WOMAC, Harris hip score, lower extremity activity scale) were collected. All patients met hospital discharge criteria no later than the first postoperative day. There was no difference in hospital discharge, functional milestone recovery, or validated outcome measures during the first year after surgery with the numbers available. There were no complications directly related to early hospital discharge or the aggressive rehabilitation protocol. While the data suggest earlier hospital discharge and rapid rehabilitation protocols may be implemented successfully we found no difference between the three minimally invasive approaches in early hospital discharge or early functional recovery utilizing a rapid rehabilitation protocol.,[object Object]

Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

Aditya V. Maheshwari MD, Yossef C. Blum MD, Laghvendu Shekhar MD, Amar S. Ranawat MD, Chitranjan S. Ranawat MD Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function.,[object Object]