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 Now
 Admitted 1-2 days  Admitted morning of
before surgery surgery
 Bedrest 2-3 days  Mobilize day of
post-op surgery or POD 1
 Partial weight  Usually WBAT
bearing  LOS < 5days
 LOS 17 days
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

Image: www.wheelessonline.com/ image8/adihp1.jpg

Knoch et al., 2002

Are Hip Precautions Necessary?

 499 patients s/p THA via anterolateral approach

 No post-operative restrictions

 3 dislocations within 6 weeks post-op (0.6%)

 Stable hip achieved after closed reduction

 Low early dislocation rate can be achieved using

anterolateral approach without restrictions
Talbot et al., 2002
 Treatment of Dislocation
 Cochrane Systematic Review was
completed to determine the best
methods of treatment of recurrent
dislocation following THA

 No studies met their search criteria

 Recommended multi-center study

Khan et al., 2006
 Comparing
Cemented vs. Cementless

 Cemented technique:
• 98% survivorship of implant at 10 years
• 93% survivorship of implant at 25 years

 Cementless technique:
• Similar to above numbers for femoral
component, and better with acetabular
component at 15 year 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 12-
week home program that included hip flexion ROM, low
resistance strengthening hip flex/ext/abd, and 30 min
walking every day

• Exercise-high compliance group showed greater

improvement in strength on operated side, fast walking
speed, and functional score on Harris Hip Score than
exercise-low compliance and control 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 2-
MITHA 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 Now
 Admitted 1-2 days  Admitted morning of
before surgery surgery
 Bedrest 2-3 days post-  Mobilize day of surgery
op or POD 1
 Ambulation with knee  Usually WBAT
splint begun POD 3  LOS < 5days
 Knee ROM begun
 CPMs placed in post-op
POD 7
 No discharge until knee
flex = 90

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 post-

TKA

 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, ice-
skating, 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 low-

volume 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
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 Foundation for Physical Therapy

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