Fracture

Fracture

INTRODUCTION

DEFINITION OF TERMS
Types of Knee Arthroplasty
Number of Compartments Replaced
Unicompartmental: only medial or
lateral joint surfaces replaced
Bicompartmental; entire femoral and
tibial surfaces replaced
Tricompartmental; femoral, tibial
and patellar surfaces replaced
Implant Design
Degree of constraint
o Unconstrained: no inherent
stability in the implant design;
used
primarily
with
unicompartmental arthroplasty
o Semiconstrained:
provides
some degree of stability with
little compromise of mobility;
most common design used for
total knee arthroplasty
o Fully constrained: significant
congruency of components;
most inherent stability but
considerable
limitation
of
motion
Fixed bearing or mobile-bearing
design
Cruciate-retainingexcising/
substituting
Surgical Approach
Standard/ traditional or minimally
invasive
Quadriceps-splitting or quadricepssparing
Implant Fixation
Cemented
Uncemented
Hybrid
o

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EPIDEMIOLOGY

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ANATOMY/PHYSIOLOGY/KINESIOLOGY

ETIOLOGY
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PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY

CLINICAL SIGNS & SYMPTOMS/PHYSICAL DISABILITIES/IMPAIRMENTS

Indications for Surgery The following are
common
indications
for
total
hip
arthroplasty (THA), sometimes referred to
as total hip replacement.
Severe hip pain with motion and weight
bearing and marked limitation of motion
as the result of joint deterioration and loss
of articular cartilage associated with
osteoarthritis, rheumatoid or traumatic
arthritis,
ankylosing
spondylitis,
or
osteonecrosis (avascular necrosis), leading
to impaired function and health-related
quality of life

Nonunion
fracture,
deformity of the hip

instability

Gaucher's disease
Hemoglobinopathies (sickle cell disease)
Hemophilia
Hereditary disorders
Legg-Calve-Perthes disease
(LCPD)
Osteomyelitis (remote, not active)
Hematogenous
Postoperative
Osteotomy
Renal disease
Cortisone induced
Alcoholism
Slipped capital femoral epiphysis
Tuberculosis

or

Bone tumors
Failure of conservative management or
previous joint reconstruction procedures
(osteotomy,
resurfacing
arthroplasty,
femoral stem hemiarthroplasty, primary
THA)

Contraindications to Total Hip Arthroplasty

Absolute

Disorders of the Hip Joint for Which Total

Hip Arthroplasty May Be Indicated
Arthritis
Rheumatoid
Juvenile rheumatoid
(Still's disease)
Pyogenic
Ankylosing spondylitis
Avascular necrosis
Postfracture or dislocation
Idiopathic
Bone tumor
Cassion disease
Degenerative joint disease
Osteoarthritis
Developmental dysplasia of the hip
Failed hip reconstruction
Cup arthroplasty
Femoral head prosthesis
Girdlestone procedure
Resurfacing arthroplasty
Total hip replacement
Fracture or dislocation
Acetabulum
Proximal femur
Fusion or pseudarthrosis of hip

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Active joint infection

Systemic infection or sepsis
Chronic osteomyelitis
Significant loss of bone after
resection of a malignant tumor or
inadequate
bone
stock
that
prevents sufficient implant fixation
Neuropathic hip joint
Severe paralysis of the muscles
surrounding the joint Relative

Relative

Localized infection, such as bladder

or skin
Insufficient function of the gluteus
medius muscle
Progressive neurological disorder
Highly
compromised/insufficient
femoral or acetabular bone stock
associated with progressive bone
disease
Patients requiring extensive dental
workdental surgery should be
completed before arthroplasty
Young patients who must or are
most likely to participate in highdemand (high-load, high-impact)
activities

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PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY

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DIAGNOSTIC TOOLS/TEST

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DIFFERENTIAL DIAGNOSIS

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MANAGEMENTS

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PHARMACOLOGICAL MANAGEMENT

MEDICAL AND SURGICAL MANAGEMENT

Total Knee Arthroplasty

Total Hip Arthroplasty

Indications for Surgery

Indications for Surgery

The following are common indications for

TKA.

The following are common indications for

total hip arthroplasty (THA), also referred
to as total hip replacement (THR).

Severe joint pain with weight

bearing
or
motion
that
compromises functional abilities
Extensive destruction of articular
cartilage of the knee secondary to
advanced arthritis
Marked deformity of the knee such
as genu varum or valgum
Gross instability or limitation of
motion
Failure
of
nonoperative
management or a previous surgical
procedure

Features of Standard and Minimally

Invasive Surgical Approaches for Knee
Arthroplasty
Standard Approach
Anteromedial parapatellar vertical or
curved incision from the distal aspect
of the femoral shaft, running medial of
the patella to just medial of the tibial
tubercle, ranging from 8-12 cm or 1315 cm in length
Necessary soft tissue releases prior
to eversion of the patella
Anterior capsule release
Dislocation of the tibiofemoral joint
prior to bone cuts and implantation of
components
Minimally Invasive Approach
Reduced length of anteromedial skin
incision 6-9 cm in length
No patellar eversion
Anterior capsule release
No tibiofemoral dislocation
In situ bone cuts
In situ Implantation of components
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Severe hip pain with motion and

weight
bearing
and
marked
limitation of motion as the result of
joint deterioration and loss of
articular cartilage associated with
osteoarthritis,
rheumatoid
or
traumatic
arthritis,
ankylosing
spondylitis,
or
osteonecrosis
(avascular necrosis) leading to
impaired function and health-related
quality of life
Nonunion fracture, instability or
deformity of the hip
Bone tumors
Failure of conservative management
or previous joint reconstruction
procedures (osteotomy, resurfacing
arthroplasty,
femoral
stem
hemiarthroplasty,
total
hip
replacement)

Features of Minimally
Total Hip Arthroplasty

Invasive

Length of incison: 10 cm,

depending on the location of the
approach and the size of the patient
Most if not all muscles and tendons
left intact Single-incision or twoincision approach
Single incision: usually posterior or
anterior, or occasionally lateral.
Two-incision: approach: two 4- to 5cm incisions, one anterior for insertion
of acetabular component and one
posterior for placement of femoral
component.
Incision
disturbed

location

and

muscles

 Posterior approach a 7- to 10-cm

posterior incision extending mostly
distal to the greater trochanter
between the gluteus medius and
piriformis muscles; short external
rotators may or may not be incised
(later repaired), but the abductor
mechanism consistently is left intact.
Anterior approach: approximately a
10 cm incision beginning just lateral
and distal of the anterior superior iliac
spine extending in a distal and slightly
posterior direction along the belly of
the tensor fasciae latae (TFL); sartorius
and rectus femoris retracted medially
and the TFL laterally leaves all muscles
intact; no postopertive precautions.
Lateral approach: least commonly
used; splits the middle-third of the
gluteus medius; anterolateral incision
into the capsule leaves the posterior
capsule intact, eliminating the need to
postoperative precautions

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PHYSICAL THERAPY MANAGEMENT

Exercise Precautions Following TKA
Postpone straight-leg raises (SLRs) in
side-lying positions for 2 weeks after
cemented arthroplasty and for 4 to 6
weeks
after
cementless/hybrid
arthroplasty to avoid varus and valgus
stresses to the operated knee.
Monitor the integrity of the surgical
incision during knee flexion exercises.
Watch for signs of excessive tension on
the wound, such as drainage or skin
blanching.
Check with the surgeon to determine
when it is permissible to initiate exercises
against low-intensity resistance. It may be
as early as 2 weeks or as late as 3 months
postoperatively.20

Tibiofemoral
joint
mobilization
techniques to increase knee flexion or
extension may or may not be appropriate,
depending on the design of the prosthetic
components. It is advisable to discuss the
use of these techniques with the surgeon
before initiating them.
Postpone unsupported or unassisted
weight-bearing activities until strength in
the quadriceps and hamstrings is sufficient
to stabilize the knee.

Weight bearing as tolerated with

cemented prosthesis, delayed with
uncemented or hybrid
Key examination procedures

Pain (010 scale)

Monitor for hemarthosis
ROM
Patellar mobility
Muscle control
Soft tissue palpation
Goals

Control postoperative swelling

Minimize pain
ROM 090
3/5 to 4/5 muscle strength
Ambulate with or without assistive
device
Establish home exercise program
Interventions

Pain modulation modalities

Compression wrap to control effusion
Ankle pumps to minimize risk of DVT
A-AROM and AROM
Muscle setting quadriceps, hamstrings,
and adductors (may augment with Estim)
Patellar mobilization (grades I and II)
Flexibility program hamstrings, calf, IT
band
Trunk/pelvis strengthening
Gait training

GOALS AND EXERCISE INTERVENTIONS

Maximum Protection Phase: Weeks 14

Prevent vascular
complications.

Patient presentation

Ankle pumping exercises with the leg

elevated immediately after surgery to
prevent a DVT or pulmonary embolism

Patient enters rehabilitation 12 days

postoperatively

Deep breathing exercises

Postoperative compression dressing

Postop pain controlled
ROM 1060

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and

pulmonary

Prevent reflex inhibition or loss of

strength
of
knee
and
hip
musculature.

Muscle-setting
exercises
of
the
quadriceps
(preferably
coupled
with
neuromuscular
electrical
stimulation),

hamstrings,
adductors.

and

hip

extensors

and

Assisted progression to active SLRs in

supine and prone positions the first day or
two after surgery, postponing SLRs in sidelying positions for 2 weeks after cemented
TKA and for 4 to 6 weeks after cementless/
hybrid replacement to avoid varus or
valgus stresses to the operated knee.

Active
assisted
ROM
(A-AROM)
progressing to assisted ROM (AROM) of the
knee while seated and standing for
gravity-resisted
knee
extension
and
flexion, respectively.
As weight bearing on the operated lower
extremity permits, wall slides in a standing
position, mini-squats, and partial lunges to
develop control of the knee extensors and
reduce the risk of an extensor lag.
Regain knee ROM.
Heel-slides in a supine position or while
seated with the foot on the floor to
increase knee flexion.
Neuromuscular facilitation and inhibition
technique, such as the agonist-contraction
technique , to decrease muscle guarding,
particularly in the quadriceps, and
increase knee flexion.
Gravity-assisted knee flexion by having
the patient sit and dangle the lower leg
over the side of a bed.
Gravity-assisted knee extension in the
supine position by periodically placing a
rolled towel under the ankle and leaving
the knee unsupported or in a seated
position with the heel on the floor and
pressing downward just above the knee
with both hands.
Gentle inferior and superior patellar
gliding techniques to prevent restricted
mobility.
P R E C A U T I O N : Avoid placing a pillow
under the knee while lying supine or while
seated with the operated leg elevated to

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reduce the risk of developing a knee

flexion contracture.
Moderate Protection Phases: Weeks 48
Patient presentation
Minimum pain
Full weight bearing except with
uncemented or hybrid
ROM 090
Joint effusion controlled

Key examination procedures

Pain assessment
Joint effusiongirth
ROM
Patellar mobility
Gait analysis

Goals

Reduce swelling
ROM 0110 or more
Full weight bearing
4/5 to 5/5 strength
Unrestricted ADL function
Adherence to home exercise program

Interventions

Patellar mobilization
LE stretching program
Closed-chain strengthening
Limited range PRE
Tibiofemoral joint mobilization, if
appropriate and needed
Proprioceptive training
Stabilization exercises
Gait training
Protected
aerobic
exercise
swimming, cycling or walking

The emphasis of the moderate protection

phase of rehabilitation, which begins at
about 4 weeks and extends to 8 to 12
weeks postoperatively, is to achieve
approximately 110 knee flexion and active
knee extension to 0 and gradually to

regain lower extremity strength, muscular

endurance, and balance. By 4 to 6 weeks
postoperatively
if
nearly
full
knee
extension has been achieved and the
strength of the quadriceps is sufficient,
most patients transition to using a cane
during ambulation activities. This makes it
possible to focus on improving the
patients gait pattern and the speed and
duration of walking. The goals and
exercise interventions for this phase of
rehabilitation are the following.
Increase
strength
and
endurance of knee and hip.

muscular

Multiple-angle isometrics and lowintensity dynamic resistance exercises of

the quadriceps and hamstrings against a
light grade of elastic resistance or a cuff
weight around the ankle. Perform in a
variety of positions to strengthen knee and
hip musculature.
Resisted SLRs in various positions to
increase the strength of hip musculature,
with emphasis on the hip extensors and
abductors.
As weight bearing allows, continue or
begin closedchain exercises including wall
slides, mini-squats, and partial lunges. Add
forward and backward, progressing to
lateral step-ups and step-downs (initially
using a low block or stool and progressing
the height of the block) and scooting
forward and backward on a wheeled stool
to improve functional control of the knee.
Stationary cycling with the seat
positioned as high as possible to
emphasize knee extension.
Continue to increase knee ROM.
Low-intensity self-stretching using a
prolonged stretch or holdrelax exercises
to increase knee flexion and extension if
limitation persists. Flexibility of the hip
flexors, hamstrings, and calf muscles also
may need to be increased for standing and
ambulation activities.

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Stationary cycling with seat lowered to

increase knee flexion.
Grade III inferior or superior patellar
mobilization techniques to increase knee
flexion or extension, respectively, if
insufficient patellar mobility is restricting
ROM.
Improve standing balance.
Proprioceptive and balance training
progressing from bilateral to unilateral
stance on stable surface, then to balance
activities on an unstable surface.
Functional reaching
standing, stooping.

activities

Heel-toe walking; ambulation

variety of surfaces and inclines.

while
on

Stepping over small objects.

Minimum Protection/Return
Phases: Beyond Week 8

to

Function

Patient presentation

Muscle function: 70% of noninvolved

extremity
No symptoms of pain or swelling
during previous phase

Key examination procedures

Pain assessment
Muscular strength
Patellar alignment/stability
Functional status

Goals

Develop maintenance program and

educate patient on importance of
adherence including methods of joint
protection

Improve
cardiopulmonary
endurance/aerobic fitness

Interventions

Continue as previous phase; advance

as appropriate
Implement
exercise
specific
to
functional tasks

From the 8th to 12th week and beyond

after
surgery,
the
emphasis
of
rehabilitation
is
on
task-specific
strengthening exercises, proprioceptive
training,
and
cardiopulmonary
conditioning so the patient develops the
strength,
balance,
and
endurance
needed to return to a full level of
functional activities. However, patients
often are discharged from supervised
therapy 2 to 3 months postoperatively
after attaining functional ROM of the
knee and the ability to ambulate
independently with an assistive device
despite persistent strength deficits and
functional limitations. These deficits
have been shown to persist for a year or
more after surgery.
It is likely that some patients,
especially those living in the community,
could benefit from an intensive exercise
program during the late phases of
rehabilitation to perform demanding
physical activities more efficiently, such
as ascending and descending stairs and
returning
to
selected
recreational
activities.

Golf (preferably with golf cart)

Ballroom or square dancing
Table tennis
Recommended
TKA**

If

Experienced

Before

Road cycling
Speed/power walking
Low-impact aerobics
Cross-country skiing (machine or
outdoor)
Table tennis
Doubles tennis
Rowing
Bowling, canoeing
Not Recommended***
Jogging, running
Basketball
Volleyball
Singles tennis
Baseball, softball
High-impact aerobics
Stair-climbing machine
Handball, racquetball, squash
Football, soccer

RECOMMENDATIONS FOR PARTICIPATION

IN PHYSICAL ACTIVITIES FOLLOWING TKA

Gymnastics, tumbling
Water-skiing

Highly Recommended*
Stationary cycling
Swimming, water aerobics
Walking

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TOTAL HIP ARTHROPLASTY

Early Postoperative Motion

After Total Hip Arthroplasty*

Precautions

ADL
Do not cross the legs.

Posterior/Posterolateral Approaches

During early ambulation, step to, rather than

past, the operated hip to avoid hyperextension.

ROM
Avoid hip flexion 80 to 90 and adduction and
internal rotation beyond neutral.
ADL

Avoid activities that involve standing on the

operated extremity and rotating away from the
involved side.

Transfer to the sound side from bed to chair or

chair to bed.
Do not cross the legs.

Maximum Protection Phase After

Keep the knees slightly lower than the hips

when sitting.

Traditional THA

Avoid sitting in low, soft chairs.

If the bed at home is low, raise it on blocks.

Goals and interventions.

Use a raised toilet seat.

The following goals and interventions

apply to the initial postoperative days
while
the
patient
is
hospitalized,
continuing through the first few weeks
after surgery when the patient is at home
or in another health care facility. Prevent
vascular and pulmonary complications.

Avoid bending the trunk over the legs when

rising from or sitting down in a chair or dressing
or undressing.
For bathing, take showers or use a shower chair
in the bathtub.
When ascending stairs, lead with the sound leg.
When descending, lead with the operated leg.
Pivot on the sound lower extremity.
Avoid standing activities that involve rotating
the body toward the operated extremity.
Sleep in supine position with an abduction
pillow; avoid sleeping or resting in a side-lying
position.
Anterior/Anterolateral and Direct Lateral
Approaches With or Without Trochanteric
Osteotomy
ROM
Avoid flexion 90.
Avoid hip extension, adduction, and external
rotation past neutral.
Avoid the combined motion
abduction, and external rotation.

of

flexion,

If the gluteus medius was incised and repaired

or a trochanteric osteotomy was done, do not
perform active, antigravity hip abduction for at
least 6 to 8 weeks or until approved by the
surgeon.

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Ankle pumping exercise to prevent

venous stasis, thrombus formation, and
the potential for pulmonary embolism.
Deep breathing exercise and bronchial
hygiene
to
prevent
postoperative
atelectasis or pneumonia continued until
the patient is up and about on a regular
basis. Prevent postoperative dislocation or
subluxation of the operated hip.
Patient and caregiver education about
motion restrictions, safe bed mobility,
transfers, and precautions during other
ADL
Monitor the patient for signs and
symptoms
of
dislocation,
such
as
shortening of the operated lower extremity
not previously present.
Achieve independent functional
mobility prior to discharge
Bed mobility and transfer training,
integrating weightbearing and motion
restrictions.

 Ambulation with an assistive device

(usually a walker or two crutches)
immediately after surgery, adhering to
weight-bearing restrictions and gaitrelated ADL precautions.
N O T E : Arising from a low chair imposes
particularly high loads across the hip joint,
producing loads approximately eight times
body weight.97 If the posterior capsule
was incised during surgery, this places the
involved hip at a high risk of posterior
dislocation until soft tissues around the hip
joint have healed sufficiently (at least 6
weeks) or until the surgeon indicates that
unrestricted
functional
activities
are
permissible.
Maintain
a
functional
level
of
strength and muscular endurance in
the upper extremities and unoperated
lower extremity.
Active-resistive exercises in functional
movement patterns, targeting muscle
groups
used
during
transfers
and
ambulation with assistive devices.
Prevent reflex inhibition and atrophy
of musculature in the operated limb.
Submaximal muscle-setting exercises of
the quadriceps, hip extensor, and hip
abductor musclesjust enough to elicit a
muscle contraction.
P R E C A U T I O N : If a trochanteric
osteotomy was performed, avoid even
low-intensity isometric contractions of the
hip
abductors
during
the
early
postoperative
phase
unless
initially
approved by the surgeon and performed
strictly at a minimum intensity. (See Box
20.7 for additional precautions after
trochanteric osteotomy.)
Regain active mobility and control of
the operated extremity.
While in bed, active-assistive (A-AROM)
exercises of the hip within protected
ranges.

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Active knee flexion and extension

exercises while seated in a chair,
emphasizing
terminal
extension
progressing to active hip and knee flexion
(heel
slides),
gravity-eliminated
hip
abduction (if permissible) by sliding the
leg on a low-friction surface, and active
rotation between external rotation or
internal rotation to neutral depending on
the surgical approach. Do these exercises
while lying supine in bed.
Active hip exercises in the standing
position with the knee flexed and
extended with hands on a stable surface
to maintain balance.
Closed-chain hip flexion and extension,
placing only the allowable amount of
weight on the operated extremity.
Prevent a flexion contracture of the
operated hip.
Avoid use of a pillow under the knee of
the operated extremity.
Moderate
Phases

and

Minimum

Protection

Goals and interventions.

The following are the goals and
interventions during the intermediate and
advanced phases of rehabilitation.
Regain
strength
endurance.

and

muscular

Open-chain
exercises within
the
permissible ranges in the operated leg
against
light
resistance.
Emphasize
increasing the number of repetitions
rather than the resistance to improve
muscular endurance.
Bilateral closed-chain exercises such as
mini-squats against light-grade elastic
resistance or while holding light weights in
both hands when unsupported standing is
permitted.

 Unilateral closed-chain exercises such as

forward and lateral step-ups (to a low
step) and partial lunges with the involved
foot forward when full weight bearing is
permitted on the operated lower extremity.
Resistive exercises to other involved
areas in order to improve function.
Improve cardiopulmonary endurance.

Nonimpact
aerobic
conditioning
program, such as progressive stationary
cycling, swimming, or water aerobics.
Reduce contractures while adhering
to motion precautions.
Gravity-assisted supine stretch to neutral
in the Thomas test position. Pull the
uninvolved knee to the chest while
relaxing the operated hip. (At least 10 of
hip extension beyond neutral is needed for
a normal gait pattern.)
Resting in a prone position for a
prolonged passive stretch of the hip flexor
muscles when rolling to prone-lying is
permissible and is also tolerable.
Integrate gained ROM into functional
activities.
P R E C A U T I O N : Check with the
surgeon before initiating a stretch of the
hip
flexors
to
neutral
or
into
hyperextension
if
the
patient
has
undergone an anterolateral approach.
Improve postural stability, balance,
and gait.
Emphasize use of a cane (in the hand
contralateral to the operated hip) and
progressive weight bearing on the
operated limb.
While using a cane, walk over uneven
and soft surfaces to challenge the balance
system.
Integrate posture training during
ambulation, emphasizing an erect trunk,
vertical alignment, equal step lengths, and
a neutral symmetrical position of the legs.

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Continue cane use until weight-bearing

restrictions are discontinued or if the
patient exhibits gait deviations, such as a
positive Trendelenburg sign on the
operated lower extremity, indicating
gluteus medius weakness. Cane use is also
recommended during extended periods of
ambulation to decrease muscle fatigue.
Prepare for a full level of functional
activities.
Integrate strength, endurance, and
balance exercises into functional activities
but continue to avoid applying high loads
during exercise. When weight-bearing
restrictions have been discontinued,
strengthen hip and knee musculature with
functional activities such as ascending and
descending stairs step over step.
Progressively increase the length of time
and distance of a low-intensity walking
program 2 to 4 days a week.
When walking and carrying a heavy
object in one hand, suggest that the
patient hold it on the same side as the
operated hip. Theoretically, this reduces
the amount of stress imposed over time on
the prosthetic hip replacement.
Through patient education reinforce the
importance of selecting activities that
reduce or minimize the forces and
demands placed on the prosthetic hip.

Accelerated Rehabilitation
After Minimally Invasive THA

Preoperative activities.
Prior to surgery, educate the patient
about
the
surgical
procedure
and
postoperative
rehabilitation
program,
wound care, and the home exercise
program. Initiate gait training (weight
bearing as tolerated) using crutches and a
cane.

Immediate postoperative therapy.

Approximately 5 to 6 hours after surgery,
if the patient is medically stable, begin the
following activities.

Postoperative bed and chair transfers

(weight bearing as tolerated)
Ambulation with crutches, progressing
to a cane as tolerated
Ascending and descending stairs, one
step at a time

Criteria for hospital discharge.

The patient is discharged from the
hospital to home when able to perform the
following tasks independently while using
an ambulation aid.

Transfer in and out of bed

Stand up from and sit down in a
standard, firm chair
Walk 100 feet
Ascend and descend a flight of stairs
.

Home-based and outpatient therapy

Patients participate in a home-based
therapy program followed by outpatient
therapy once able to drive. There are no
specific positioning or ROM precautions or
weight-bearing restrictions.

Progress to ambulation with a cane as

soon as possible.
Continue cane use until able to
ambulate with a symmetrical gait
pattern and no noticable limp.

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REFFERENCES