Exploring

Advances in THA
&
Hip Resurfacing
Bridgit Finley, PT, DPT, M.Ed., OCS
579-1600
bfinley@ptcentral.org
www.ptcentral.org
facebook
Objectives
Course Objective:
The course participants will be able to:
 Understand the surgical procedures for a total
hip arthroplasty and hip resurfacing.
 Implement the use of outcome measures for
patient’s that have had hip surgery.
 Utilize the APTA web site to access information
in regards to evidence based practice.
 Effectively progress patients through the
rehabilitation protocol.
American Physical Therapy
Association
 Consumers
 Professional Development
 Advocacy
 Reimbursement
 Research
 Hooked on Evidence
– Database current research
– Earn CEU’s
– http://www.hookedonevidence.org/?CFID=441964
36&CFTOKEN=55727326
JOSPT
 Searched
– Hip Arthritis
 http://www.jospt.org/aboutus/su
bscribe.asp
 20 Abstracts
 Full Text Articles
NAJSPT
 SPTS
 Hip Arthritis
 http://www.spts.org/NAJSPT/Arch
ived%20Issues/November%2020
07.aspx
Overview of
the Hip
OSTEOARTHRITIS
 In US, 100 Billion Health Care $
by 2020
 Progressive loss of articular
cartilage with variable
subchondral bone loss.
 Prevalence – 7 to 25% in adults
age 55 and older.
 21 Million people in US
 Standard of care is THA
American College of
Rheumatology
Classification Hip OA
– Cluster 1
 Pain in the hip
 < 115 hip flexion
 < 15 IR
– Cluster 2
 Pain with IR
 < 60 minutes
Current guidelines focus morning stiffness
on pharmacological and
 > 50 yrs. old
surgical management
X-Ray
 Demonstrate
loss of joint
space,
osteophytes and
sclerosis.
 Dysplasia
– tears are more
common in
individuals with
acetabular
dysplasia.
 In US, between 1990
and 2002, THA rose
from 119,000 to
193,000 annually.
62% increase

193,000
THA Procedures
Performed Annually
Total Hip Arthroplasty
 The first joint replacement, a total
hip arthroplasty, was performed
in 1936.
 Most widely performed orthopedic
procedure performed on adults.
 In 2007, the average hospital and
physician charge for a THA totaled
$ 28,000.
Health Care Costs
 Physical Therapy  THR
 12 visits  $28,000
 Manual Therapy  Surgery,
and exercise hospitalization
 $1,200 and
rehabilitation
Subjective History
DJD (> 50)
 Usually no specific mechanism of
injury
 Groin pain; behind greater
trochanter, anterior thigh to knee
 Stiffness in the morning
 Loss of ROM (Flexion, IR)
 Increased pain with WB (bony)
Functional Limitations
 Walking
 Stair climbing
 Putting on shoes
 Shaving legs
 Rising from a chair
Causes of Hip OA
 Congenital Dysplasia
– Genetics
 Disease Process
 Trauma
 Compensation
– Leg length, lumbar pathology
 X-Ray
 Gold Standard

– Joint Space
Narrowing

– Osteophytes

– Subchondral
Bony Change
 Recent
Developments
Clinical Prediction Rule
Childs September 2008
 Loss of IR Twenty-one (29%) of the
72 subjects had
– < 15 degrees radiographic evidence of
hip OA.
 Loss of Flexion  A clinical prediction rule
consisting of 5 examination
– < 115 degrees variables was identified.
 If at least 4 of 5 variables
 (+) Scour Test were present, the positive LR
was equal to 24.3
 (+) Patrick’s  95% confidence interval: 4.4-
142.1, increasing
Test  the probability of hip OA to
91%.
 (+) Hip Flexion
Test
1975 Management THA
 Phase I – immobilization. If unstable
will use hip spica cast x 3 weeks. (2-5
days)
 Phase II – mobilization. Isometric,
isotonic (AAROM, AROM). Trochanter
detached and transplanted distally. 2-3
week and D/C to home. Crutches x 8
weeks. Walk day 7 - WBAT
 ROM goals
– Flexion 90, ER 15, Abd 15, IR 0, Add 0
2009 THA Management
 Hospital 1-3 days/Out-patient
 Ambulate day 1 – FWB
– AROM day 1
– Isotonic week 1
– C-V by day 10
 ROM goals
– Flexion 125, Add. 30, ER 40, IR 30
by week 12
Muscles
Gluteus Medius
 Gluteus Medius –
main hip
abductor
 Primary
stabilizer of hip
and pelvis
 Trendelenburg
sign
Gluteus Maximus
 TFL envelops the
muscles of the
thigh
 Counteracts the
backward pull of
the gluteus
maximums of the
ITB.
 Hip extensors are 3
times as strong as
the flexors
Psoas
 Iliopsoas bursa –
present in 98%
of adults.
 Lies under the
psoas tendon
 Overuse and
impingement
syndromes
Hip External Rotators
 Hip capsule is
cut and the ER
are retracted so
that the joint can
be exposed.
 THA – now most
repair the
capsule
Surgical Incisions
Metal-on-Metal
Hip Resurfacing
Arthroplasty
Resurfacing
 Main advantage is bone
conservation for younger patients
 Early resurfacing failed because of
polyethylene
 5 year follow-up excellent results
 Complication
– Femoral neck fracture
– Osteonecrosis
High Failure Rate
 1970, materials available at the
time had insufficient wear
resistance
 Incorrect patient selection
 1999, re-introduced
 Same revision rate as THA at 4
years
– Women 2 x than men
Design
 Metal on Metal
– Cause release of inflammatory
cytokines
– Metal allergy
 Large ball – decrease wear rate
 Cemented
 THA - Cementless acetabular
fixation – bony in growth
Patient Selection
 Young and active
 Isolated hip disease
 Excellent bone quality
 Normal kidney function

Contra-indicated
 Severe acetabular dysplasia
Surgery
 High learning curve
– Posterior approach
– Capsulotomy – preserve lateral
muscles but sacrifice medial
circumflex artery
– Implant positioning
– Limited candidates
Outcomes
 94-99% survival rates at 5 years
 446 hips, patients < 55 yrs old
 Primary diagnosis of OA
 No difference in ROM
 Gait analysis – no difference THA
 Hip impingement
Biomechanics
Ball and Socket Joint
 Rolls anterior
Flexion to 110-120
glides posterior
 Rolls
Extension
posterior
10-15glides anterior
 Rolls laterally
 Rolls
Abduction
medially
30-50
 Spins
Adduction
anteriorly
25-30and laterally
 Spins
ER 30-45
posteriorly and medially

 IR 20-35
Mobilization
 Posterior / Inferior Glide
Flexion
 Anterior Glide
 Lateral
Extension
Glide
 Lateral
Adduction
Glide
 Internal Rotation
Capsular Pattern
Cyriax  Flexion < 115
 IR  IR < 15
 Flexion
 Abduction
Resting Closed Packed
 Extension
Flexion 30 degrees
 Adduction
Abduction 30 degrees
 Internal
External Rotation
Rotation 10-15 degrees

Stable position of the joint

Tighten capsule
Muscle Imbalances
Weakness
Tightness
 Glut
PsoasMaximus
 Glut
Adductors
Medius
 Quads
Piriformis
 Hip ER
 Core Muslces
– Abs
– Errector spinae
Outcome
Measures
Hip Outcomes Measures
 Validity  Harris Hip Score
 Reliability  Charnley Score
 Includes  Oxford Hip Score
– Pain  The Hip
– ROM Disability and
– Function Osteoarthritis
 Surgeon & Outcome Score
Patient disagree
on outcomes
Patient Based Scales
 Site Specific  Oxford
– Oxford Hip Scale – 12 item
 Health Status questionnaire
– Designed for RA – THR
– 20 Tasks – Validated against
– SF-12 SF-36
– Short, practical
 Disease-Specific
and valid
– Hip & Knee OA
– WOMAC
Rehabilitation Protocol
 Age
 Health Status
– Control pain and swelling
 Body Weight
 Body Build -
Week 2-3
 Goals
– Patient Education
– Decrease Edema
– Incision Healing
– Independent HEP
– ROM: flexion 90, abduction 35, ER
35, IR 20, adduction 20
Treatment
 Modalities
 MFR/ Massage
 PROM
 Transfer and gait training
 Rhythmic Stabilization
 MET / Manual Stretching
Modalities
 US
– At incision and piriformis/ITB
 NMS
– Glut Medius with isometric ABD.
 IFC & CP
– Control swelling and pain
– At the end of treatment
Manual Therapy
 MFR
– ITB
– Piriformis
– Psoas
Hip PROM
 Watch for
compensation at
the pelvis.
 Capsular
pattern?
 End-feel?
 Pain?
PROM
Hip Rotation
 PROM of left hip
 Loss of IR > loss
of hip ER
 End-feel usually
empty and
painful.
MET – manual stretching
 Soft tissue and
capsular
tightness
 Have not moved
hip though this
motion in years
Gait
 Hip extension
– 15-20 degrees
 Pelvic
– Rotation
– Side bending
Rhythmic Stabilization
 Neutral Position
– Manual
resistance in ER
and IR
Muscle Energy Technique
 Hamstrings
 Psoas
 Lumbar Spine
Exercises
 Exercise Pro Handout Week 2-3
Week 5-6
 Hip Flexion 100-110, add. 40, ER
40, IR 30
 Quad/Ham strength 70%
 (-) Trendelenburg
 Initiate Hip PRE
 Neutral alignment lumbar spine
Treatment
 Myofascial Release
– Psoas
– Posterior Hip Capsule
 PROM/Jt. Mobilization
 Core Stabilization
Thomas Test
 Psoas Stretch
– Thigh off the
table
– Tight iliopsoas
and rectus
femoris muscle
(knee flexion)
Mobilization
 Leg traction – inferior glide
 Distraction – inferior or caudal
glide.
 Mobilization with movement
– Belt
– MET to restore IR/ER or hip flexion
Joint Mobilization
Whitman & Cleland
September 2007
 Hip OA when treated with manual
therapy (mobilization)
– 5 PT sessions
– Total PROM increases 82 degrees
– Harris Hip Score 25 points
 Case Report JOSPT Dec. 2007
Vol. 37, Num. 12

 73 yo female with THA revision

 2 yrs s/p revision admitted to
hospital 10/10 hip pain after
lifting her foot to put on her shoe
 X-ray normal d/c
 PT – manual therapy – 4 PT visits
 4 year follow up
Proprioception
 Arthritic hips lose input secondary
to loss of articular cartilage.
 THR – no input from the hip joint.
Must retrain neuromuscular
system.
 Balance activities.
Therapeutic Exercise
 THA Protocol Exercise Pro
Handout
 Week 5-6
Week 6-12
 Walk 1 mile
 C-V Endurance 20-40 minutes
 Pain Free
 Equal strength
 Flexion 130, ER 45, IR 35
Treatment
 D/C all modalities
 Manual techniques if necessary

 Exercise Pro Week 6-12

10 days S/P 12 Weeks
 Home exercises. Exercises
were commenced following
manual physical therapy in the
Contraindications clinic
• Recumbent Bike
• SLR  Upright bicycle: 10 min
•  Gluteus medius clamshell exercises: 3
sets of 12
 Hip abduction in sidelying: 3 sets of
12
 Core transverse abdominus: 2 sets of
20 in supine with hips flexed to 45°
 Bridge with straight leg raise: 3 sets
of 10
 Hip flexor stretch kneeling or
sidelying: 30 sec × 3
 Single leg balance: up to 60 sec
 Tandem stance eyes open or closed:
up to 60 sec
Questions