Arthroplasty

DEFINITION OF TERMS
ARTHROPLASTY

Total hip replacement (THR)

Arthroplasty, the surgical refashioning of a

joint, aims to relieve pain and to retain or
restore movement. The following are the
main varieties

Excision arthroplasty

Sufficient bone is excised from the

articulating parts of the joint to create
a gap at which movement can occur
(e.g. Girdlestones hip arthroplasty).
This movement is limited and occurs
through intervening fibrous tissue,
which forms in the gap. In some
situations, e.g. after excising the
trapezium, a shaped spacer can be
inserted; this is often tendon harvested
from nearby.

(Essential
Physical
Rehabilitation)

One articulating part only is replaced

(e.g. a femoral prosthesis for a
fractured femoral neck, without an
acetabular
component);
or
one
compartment of a joint is replaced (e.g.
the medial or lateral half of the
tibiofemoral joint). The prosthesis is
kept in position either by acrylic
cement or by a press-fit between
implant and bone.

Replacement

Both the articulating parts are replaced

by
prosthetic
implants;
for
biomechanical reasons, the convex
component is usually metal and the
concave high-density polyethylene.
Metal-onmetal replacements are also
becoming more common. Irrespective
of type, these components are fixed to
the host bone, either with acrylic
cement or by a cementless press-fit
technique. Using hip replacement as an
example, the rationale, indications and
complications of total joint replacement

(Apleys System Of Orthopaedic And

Fractures 9th Edition By Luis Solomon)

Arthroplasty

Medicine

and

Total Hip Arthroplasy

Partial replacement

is surgically replacing the femoral head

and acetabular surface of the hip.
Hemiarthroplasty
refers
to
the
replacement of the femoral head only.
The father of the modern-day hip
replacement is Sir John Charnley, who,
in 1961, developed the first low-friction
arthroplasty. His success spawned the
widespread use of hip replacements in
the 1970s.

One of the most widely performed

surgical interventions for advanced
arthritis of the hip joint is total hip
arthroplasty. Osteoarthritis is the
underlying pathology that accounts for
most primary total hip procedures.
(Therapeutic Exercise Foundations and
Techniques Sixth Edition by Kisner &
Colby)

Types of hip replacement

Broadly speaking there are three main

types:
Total hip replacement

the femoral head is replaced with a

prosthetic ball and the acetabulum is
relined with a prosthetic cup.

Resurfacing

a technique in which the patients

femoral head is preserved and
resurfaced with a metal shell. The
acetabulum is relined in the same way
as a THR. Originally developed for
younger patients, the preservation of
bone made potential future revision

easier. Unfortunately the system was

very sensitive to errors of placement,
and even small deviations from
perfect positioning resulted in femoral
neck fracture, rapid wear of bearings
and generation of excess metal debris.
As a result failure rates were high and
this technique has largely fallen out of
favour.

an open bowl; cement placed in canal

by hand; no canal lavage or drying;
pressure provided by surgeon's thumb
Second-generation techniques: plug,
injecting doughy cement, cement gun
Third-generation techniques: porosity
reduction, pressurization, pulsatile
lavage

Cementless femoral components

Hemiarthroplasty

replacement of the femoral head only,

without addressing the acetabulum.
Used for treatment of femoral neck
fractures

Design features/implant shapeStem

designs include tapered, cylindrical,
and anatomic.

Tapered stems have a proximal-todistal taper that is designed to

interlock in the metaphysis with no
diaphyseal fixation. Proximal porous
coating or plasma spray macrotexturing is used to impart stability and
allow for bone ingrowth. The implant is
usually collarless, which allows the
prosthesis to be wedged into the bony
metaphysis, providing for optimal fit
and bone ingrowth. The tapered design
allows subsidence into a tight fit and
optimizes proximal load sharing of the
implant, thereby optimizing bone
ingrowth
and
minimizing
stress
shielding.

Cylindrical stems usually have a

circumferential
porous
coating.
Proximal and distal coating optimizes
the surface area for maximum bone
ingrowth. Initial stability is dependent
on a tight diaphyseal fit. The tubular
diaphysis
can
be
reproducibly
machined to allow bone ingrowth and a
tight fit.

Anatomic stems fill the metaphyseal

region in both the coronal and sagittal
planes.
Adequate
fill
of
the
metaphyseal region in both the coronal
and sagittal plains is crucial. There is
little advantage to matching the
implant shape to the anatomy of the
femur; high rates of thigh pain have
been reported

IMPLANT SELECTION IN THA

Cemented implants

Cemented stems embrace two broad

concepts: a taper-slip or force-closed
design, and a composite beam or
shape-closed design. The taper slip is a
highly polished tapered stem designed
to settle within the cement mantle and
reengage the taper. This connects
shear stresses to radial hoop stresses,
thus optimizing the load distribution to
the surrounding bone and cement.
Taper slip stems, such as the Exeter
prosthesis, have gained increasing
popularity among cemented implants.
Cement is a grout, not a glue, and
fixation is achieved by a mechanical
interlock in the bony interstices.
The cement is pressurized into an
acetabulum that has been cleaned and
dried.
Cemented total hip replacements are
indicated for older, less active patients,
although very good results have also
been reported in the younger patient.

Cement techniques

First-generation
femoral
cement
techniques: cement mixed by hand in

Arthroplasty

Uncemented implants

The surface of these implants was

often textured (with porous beads or
titanium mesh) to enhance bone
fixation by osseointegration. It is
important to have initial press-fit
stability to allow bone on- or ingrowth
into the textured surface. More recently
bioactive surface coatings such as
hydroxyapatite have been applied to
accelerate bone ongrowth and improve
the extent of the osseointegration.
Well-fixed uncemented hips provide a
durable biological fixation which is
cyclically renewed with time.
Early uncemented implants which
were often extensively textured were
cylindrical distally and gained fixation
in the diaphysis. As these stems were
often large, this led to thigh pain in up
to 40 per cent of patients and stress
protection in the proximal femur with
associated loss of bone.
Subsequently tapered stems were
designed in which the surface texturing
was limited to the metaphyseal region
to promote proximal cancellous bone
ingrowth
Failures of these implants were often
attributable to malfunction of the
locking mechanism of the polyethylene
liner and to accelerated wear of the
thinner polyethylene liner.
A combination of a cemented stem and
an uncemented cup the so-called
hybrid hip

BEARING SURFACES

Highly
(XLPE)

cross-linked

polyethylene

Gamma irradiation of polyethylene

causes cross-linking, which greatly
improves
the
wear
resistance
compared
to
conventional
polyethylene. However, this comes at
a price, as the dose of irradiation is

Arthroplasty

inversely proportional to the fracture

toughness. Encouraging clinical results
with markedly reduced wear have
been reported with XLPE. It should be
noted that none of the commercially
available XLPEs are the same and
the clinical performance is therefore
likely to differ.
Ceramic-on-ceramic

Alumina ceramics were introduced as

a bearing material in the 1970s. They
are wettable, have very low wear
rates, are scratch-resistant and their
particulate debris is not biologically
very active. However, ceramics are
brittle and are susceptible to fractures.
Modern
ceramics
have
been
strengthened
and
have
much
improved
fracture
toughness.
Excellent results have been reported
with
ceramicceramic
couples;
however, because of their brittle
nature it is still not possible to make
safe ceramic liners with an inner
diameter greater than 86 mm.

Metal-on-metal

Metal bearing surfaces have very low

wear rates and are self-polishing,
which allows for selfhealing of surface
scratches. Metal is not brittle, unlike
ceramic, and components therefore do
not have to be as thick as their
ceramic counterparts. Thus large head
diameters can be combined with
monolithic cups. This gives a greater
range of motion to impingement, and
thus greater mobility and greater
stability. The wear of these larger
heads is dictated by the lubrication
regimen,
which
is
favourably
influenced by increasing the head size
(thus increasing the entrainment
velocity of the lubricating fluid), and
optimizing the diametrical clearance
and the sphericity of the head. These
durable couples allow patients to
return
to
vigorous
recreational
activities, and are known as high
performance bearings.

(Apleys System Of Orthopaedic And

Fractures
9th
Edition
By
Luis
Solomon)
Features of Traditional (Conventional) Surgical Approaches for THA and
Potential Impact on Postoperative Function
Surgical Approach
Posterior
Posterolateral

Direct Lateral

Anterolateral

Arthroplasty

Involvement
of
Hip Impact
on
Muscles
and
Other Postoperative
Soft Tissues Function
or
Gluteus maximus
Possible
earlier
divided in line with
recovery
of
a
its fibers with a
normal gait pattern
posterior approach
because
gluteus
medius
and
TFL left
Interval
between
intact
the
gluteus
Highest
risk
of
maximus
and
medius divided in a
dislocation
or
posterolateral
subluxation
of
approach
prosthetic hip
Short
external
rotators
and
piriformis released
and repaired
Gluteus maximus
tendon
possibly
released
from
femur; repaired at
conclusion
Posterior
capsule
incised
and
repaired
Gluteus
medius
and TFL left intact
Longitudinal
Weakness of the
division of the TFL
hip abductors
Release of up to
Possible
pelvic
one-half
of
the
obliquity
proximal insertion
Delayed recovery
of
the
gluteus
of symmetrical gait
medius
and
minimus;
reattached prior to
closure
Longitudinal
splitting
of
the
vastus lateralis
Capsulotomy and
repair
Incision
centered
Weakness of the
over the greater
hip abductors

Direct Anterior

Transtrochanteric

trochanter
and
lateral to the TFL
Anterior one-third
of
the
gluteus
medius
and
minimus
and
sometimes
the
vastus
lateralis
released;
reattached prior to
closure
External
rotators
usually
remain
intact
Anterior
capsulotomy
and
repair
Incision
made
anterior and distal
to the ASIS, slightly
anterior
to
the
greater trochanter,
and medial to the
TFL
No muscles incised
or detached, but
rectus femoris and
sartorius retracted
medially to access
the joint
Anterior
capsulotomy
and
repair
Osteotomy of the
greater trochanter
at the insertion of
the gluteus medius
and minimus
Anterior
capsulotomy
and
dislocation
Greater trochanter
reattached
and
wired in place prior
to closure

Delayed recovery
of gait symmetry
Lower incidence of
hip dislocation than
posterior approach

Weight bearing as
tolerated
immediately after
surgery
More
rapid
recovery
of
hip
muscle
strength
and normal gait
pattern compared
with anterolateral
approach

Extended period of
nonweight bearing
on the operated
extremity
Necessity
for
abduction
precautions
Possible pain due
to irritation of soft
tissues
from
internal
fixation
device

Features of Minimally Invasive Total Hip Arthroplasty

Length of incision: < 10 cm, depending on the location of the approach and
the size of the patient
Most, if not all, muscles and tendons left intact

Arthroplasty

Single-incision or two-incision surgical approach

Single incision: posterior, anterior or occasionally lateral.
Two-incision: two 4- to 5-cm incisions, one anterior for insertion of
acetabular component and one posterior for placement of femoral
component.
Incision location and muscles disturbed
Posterior approach: an 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); abductor
mechanism consistently is left intact.
Anterior approach: an 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 postoperative precautions.
Lateral approach: least commonly used; splits the middlethird of the
gluteus medius; anterolateral incision into the capsule leaves the posterior
capsule intact, eliminating the need to observe postoperative precautions
for prevention of posterior dislocation.
hinge, but rather the femoral condyles
The rationale for minimally
roll and glide on the tibia with multiple
invasive THA (as opposed to
instant
centers
of
rotation.
traditional THA through one of the
Approximately 200,000 TKRs are
aforementioned
conventional
performed annually in the United
surgical approaches) is that the use
States alone.
of smaller incisions and musclesparing techniques reduces soft
(Essential
Physical
Medicine
and
tissue trauma during surgery and
Rehabilitation)
potentially improve and accelerate
a patients postoperative recovery.
Types
of
knee
arthroplasty.
Benefits cited by advocates of
Contemporary
knee
replacement
minimally invasive THA are:
procedures can be divided into several
o Decreased blood loss.
categories based on component design,
o Reduced postoperative pain.
surgical approach, and type of fixation.
o Shorter length of hospital
Total Knee Arthroplasty: Design,
stay and lower cost of
Surgical Approach, Fixation
hospitalization.
Number of Compartments Replaced
o More rapid recovery of
Unicompartmental: only medial or
functional mobility.
lateral joint surfaces replaced
o Better cosmetic appearance
Bicompartmental: entire femoral
of the surgical scar.
and tibial surfaces replaced
Tricompartmental: femoral, tibial,
(Therapeutic Exercise Foundations and
and patellar surfaces replaced
Techniques Sixth Edition by Kisner &
Implant Design
Colby)
Degree of constraint
Total knee replacements (TKRs)
o Unconstrained: no inherent
stability in the implant
are one of the most common
design; used primarily with
procedures performed in orthopedic
unicompartmental
surgery today. TKR was introduced in
arthroplasty
the 1960s by Gunston, who realized
o Semiconstrained:
provides
the knee was not a single axis like a

Arthroplasty

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-retaining
or
cruciateexcising/substituting
Surgical Approach
Standard/traditional or minimally
invasive
Quadriceps-splitting or quadricepssparing
Implant Fixation
Cemented
Uncemented
Hybrid

arthroplasty) - Replacement only

of the medial or lateral tibiofemoral
compartment of the knee (see the
image below)
Cemented joint replacement
(cemented joint arthroplasty) - A
procedure in which bone cement or
polymethylmethacrylate (PMMA) is
used to fix the prosthesis in place in
the joint
Ingrowth, or cementless, joint
replacement (ingrowth, or
cementless, arthroplasty) - A
procedure that does not involve bone
cement to fix the prosthesis in place;
an anatomic or press fit with bone
ingrowth into the surface of the
prosthesis leads to a stable fixation;
this procedure is based on a fracturehealing model
Primary joint replacement (primary
joint arthroplasty) - A patient's first
replacement surgery
Revision - A patient's second or
succeeding surgery; it is usually
performed for an unstable, loose, or
painful joint replacement

Arthroplasty

EPIDEMIOLOGY

OTHER TERMS

Total hip replacement (THR) or

total hip arthroplasty (THA) Replacement of the femoral head
and the acetabular articular surface

Hemiarthroplasty - Replacement
of only the femoral head

Bipolar hemiarthroplasty - A
specific form of hemiarthroplasty in
which a femoral prosthesis is used
with an articulating acetabular
component; the acetabular cartilage
is not replaced; the principle of this
procedure is to decrease the
frictional wear between the femoral
head prosthesis and the cartilage of
the acetabulum

Total knee replacement (TKR)

or total knee arthroplasty (TKA)
- Replacement of the articular
surfaces of the femoral condyles,
tibial plateau, and patella; the
anterior cruciate ligament is excised,
but the posterior cruciate ligament
may be saved in cruciate-retaining
systems (see the image below)

Unicompartmental knee
replacement (unicompartmental

TOTAL HIP ARTHROPLASTY

Mortality rate: 1-2% Incidence:

The annual incidence increased from 43

to 133 per 100,000 people, an increase
by 3-fold.
The annual incidence of THA for primary
osteoarthritis per 100,000 increased 68 in
1982-86 to 114 in 1992-1996.
Annual incidence of revision THA
increased from 2.5 per 100,000 in 1982 to
25 per 100,000 in 1996
In a population-based study in
Denmark, the incidence rates of primary
and revision THA increased by 30% (101
to 131 per 100,000) by 10% (19.2 to 20.7
per 100,000) from 1996 to 2002. Age: 13% of the older adult population (those
65 years and older) will undergo THA at

some point, with the average age being

66.
Gender:

Race/Ethnicity:

Higher among women than men.

In a Danish study, the increase in THA
incidence rates from 1996 to 2002 were
similar in men and women.
In a study of nationally representative
sample of 7,100 people aged 60 years
from England, similar rates of existing
knee or hip joint replacement were
reported for women (6%) and men (5%).
In a study using the Hospital Episode
System in England, rate of THA was
estimated at 87/100,000 in 1996, slightly
higher in women (109/100,000) than men
(64/100,000).
Projection of time-trend revealed that a
40% increase in THA rates would be
noted by year 2030, with higher increase
in men (51%) than women (33%).
Ethnicity: Higher among whites compared
to blacks Economic Status: Higher in
those with a higher income level
Complications:
Nerve injuries incidence is 0.7% to .5%
in primary arthroplasties and 7.5%
incidence of nerve palsies after revision
procedures.
Vascular injuries occurs 0.2 to 0.3%.
Bladder infection is the most common
complication involving the urinary tract
and occurs 7 to 14%.
3% is the average
dislocation after THA.

incidence

of

Thromboembolism is responsible for

50% of postoperative mortality
TOTAL KNEE ARTHROPLASTY Ages:
In a U.S. study of Medicare recipients
comparing the rates of TKA between 2000
and 2006, rates in patients aged 65-74,
75-84 and 85 years (all rates per 1,000

Arthroplasty

population) were 5.4, 6.6 and 2.6 in 2000;

and 9.1, 10.2 and 4.0 in 2006,
respectively

In a U.S. study, Caucasians had TKA

rates of 5.7 and 9.2 per 1,000.
African-Americans had rates of 3.6 and
5.6 per 1,000, respectively.
The TKA rates were 37% lower among
blacks than whites in 2000 and 39% lower
in 2006.
In both years, the ethnic/racial disparity
was lower among women (23% and 28%)
than among men (63% and 60%).
Caucasians had the highest annual agestandardized rates of THA in San
Francisco residents in a study from 198488.
Blacks, Japanese, Hispanics, Chinese
and Filipino had lower rates in decreasing
order compared to Caucasians.
Gender:
Three studies reported similar increase
in utilization rates between men and
women undergoing arthroplasty.
In a U.S. study using the NIS, the
increase was noted both for women and
men at a similar rate.
In a U.S. Medicare study, women had
TKA utilization rates of 6.1 and 9.9 in
2000 and 2006; respective rates in men
were 4.6 and 7.3, respectively.
In a national study from South Korea,
women had more severe knee disease,
higher BMI and were 7-8 times more likely
to undergo TKA than men.
Region:

 A study from England found lower

prevalence of existing knee or hip joint
replacement for Northern compared to
Southern region, although the need was
significantly greater in North compared to
South.
In the same study, the need was
greater in women and increased from
wealthiest to poorest quintile, but receipt
did not differ by sex or socio-economic
group.

ANATOMY/PHYSIOLOGY/KINESIOLOGY
HIP
Structure and Function
The pelvic girdle links the lower
extremity to the trunk and plays a
significant role in the function of
the hip as well as the spinal joints.
The proximal femur and the pelvis
comprise the hip joint. The unique
characteristics of the pelvis and
femur that affect hip function are
reviewed in this section.
Anatomical Characteristics
Boney Structures
The structure of the pelvis and
femur are designed for weight
bearing and transmitting forces
through the hip joint.
Pelvis
Each innominate bone of the pelvis
is formed by the union of the ilium,
ischium, and pubic bones and
therefore, is a structural unit. The
right and left innominate bones
articulate anteriorly with each
other at the pubic symphysis and
posteriorly with the sacrum at the
sacroiliac joints. Slight motion
occurs at these three joints to
attenuate forces as they are
transmitted through the pelvic
region, but the pelvis basically

Arthroplasty

functions as a unit in a closed

chain.
Femur
The shape of the femur is designed
to bear body weight and to
transmit ground reaction forces
through the long bone, neck, and
head to the acetabulum of the
pelvis. In the frontal plane, there is
an angle of inclination (normally
125) between the axis of the
femoral neck and the shaft of the
femur. The angle of torsion formed
by the transverse axis of the
femoral condyles and the axis of
the neck of the femur ranges from
8 to 25, with an average angle of
12. There is also slight bowing of
the shaft in the sagittal plane.
Hip
Joint
Characteristics
and
Arthrokinematics
Characteristics
The hip is a ball-and-socket
(spheroidal) triaxial joint made up
of the head of the femur and
acetabulum of the pelvis. It is
supported by a strong articular
capsule that is reinforced by the
iliofemoral,
pubofemoral,
and
ischiofemoral ligaments. The two
hip joints are linked to each other
through the boney pelvis and to
the vertebral column through the
sacroiliac and lumbosacral joints.
Articular Surfaces
The concave boney partner of the
hip joint, the acetabulum, is
located in the lateral aspect of the
pelvis
and
faces
laterally,
anteriorly, and inferiorly. The
acetabulum is deepened by a ring
of fibrocartilage, the acetabular
labrum. The articular cartilage is
horseshoe-shaped and thicker in
the lateral region, where the major
weight-bearing
forces
are
transmitted. The central portion of
the acetabular surface is non
articular.
The convex boney partner is the
spherical head of the femur, which

is attached to the femoral neck. It

projects anteriorly, medially, and
superiorly.
The shapes of the articulating
surfaces of the hip joint and the
reinforcing
properties
of
the
capsule and ligaments, as well as
the hip musculature, lend mobility
coupled with stability for functional
tasks that require wide ranges of
combined movements, such as
squatting,
tying
shoes
while
seated, standing up from a chair, or
walking.
Ligaments
Three ligaments reinforce the joint
capsule:
- The
iliofemoral
and
pubofemoral
ligaments
are
situated anteriorly, and the
ischiofemoral
ligament
is
located posteriorly.

There is general agreement in the

literature that these three capsular
ligaments limit excessive extension of
the hip, and the iliofemoral ligament,
also known as the Y ligament of
Bigelow, is the strongest of the hip
ligaments. There is, however, some
dispute as to the functions of each of
these ligaments on an individual basis.
The
iliofemoral
ligament,
which
reinforces the anterior portion of the
capsule, also is thought to limit
external rotation of the hip. Lending
support to the inferior as well as
anterior portion of the capsule, the
pubofemoral ligament is believed to
limit
abduction.
Lastly,
the
ischiofemoral
ligament,
although
reinforcing the posterior aspect of the
capsule, may also limit internal
rotation and may limit adduction when
the hip is flexed.

Arthrokinematics of the Hip Joint

Motions of the femur
Physiological Motions of Roll
the Femur
Flexion
Anterior

Arthroplasty

Extension
Abduction
Adduction
Internal Rotation
External Rotation

Posterior
Lateral
Medial
Medial
Lateral

Motions of pelvis
When the lower extremity is stabilized
(fixated) distally, as when standing or
during the stance phase of gait, the
concave acetabulum moves on the
convex
femoral
head,
so
the
acetabulum slides in the same
direction as the pelvis. The pelvis is a
link in a closed chain; therefore, when
the pelvis moves, there is motion at
both hip joints as well as at the lumbar
spine.
Influence of the Hip Joint on Balance
and Posture Control
The joint capsule is richly supplied
with mechanoreceptors that respond
to variations in position, stress, and
movement for control of posture,
balance,
and
movement.
Reflex
muscle contractions of the entire
kinematic chain, known as balance
strategies, occur in a predictable
sequence when standing balance is
disturbed
and
regained.
Joint
pathologies, restricted motion, or
muscle weakness can impair balance
and postural control.
Functional Relationships in the Hip
Region
The hip functions in both nonweightbearing and weightbearing activities,
requiring the muscles to move the
femur or control the femur and pelvis
as outside forces are imposed on the
region.
Motions of the Femur and Muscle
Function Motions of the femur and
muscle actions are typically described
as occurring in the three primary
planes: flexion/ extension in the
sagittal plane, abduction/adduction in
the frontal plane, and internal/external
rotation in the transverse plane. Most

of the muscles function in several

planes.
Muscles of the Hip: Open-Chain (Nonweight-Bearing) Function
Action
Prime Movers
Secondary Movers (action
depends on hip joint position)
Flexion
Iliopsoas
Pectineus
Rectus
femoris
(also Adductor longus
extends knee)
Adductor magnus
Tensor fasciae latae (also Gracilis
abducts and internally
rotates hip and maintains
tension in iliotibial band)
Sartorius (also abducts
and externally rotates
hip
and
flexes
and
internally rotates knee)
Extension
Gluteus
maximus
Gluteus
medius
(also
externally
(posterior fibers)
rotates hip; superior
Adductor magnus
fibers
insert
into
Piriformis
iliotibial band)
Hamstrings:
long
head
of
biceps
femoris,
semitendinosus,
semimembranosus
(also flex knee)
Abduction
Gluteus medius
Piriformis
Gluteus minimus
Sartorius
Tensor fasciae latae
Rectus femoris
(also flexes hip)
Adduction
Adductor magnus
Biceps femoris (long
head)
Adductor longus

Gluteus
maximus
Adductor brevis
(posterior fibers)
Gracilis

Quadratus femoris
Pectineus
Obturator externus
External
(Lateral)
Obturator
internus
Gluteus
medius
Rotation
and externus
(posterior fibers)
Gemellus
superior
Gluteus
minimus
and inferior
(posterior fibers)
Quadratus femoris
Sartorius
Piriformis
Biceps femoris (long
head)
Gluteus maximus
Internal (Medial)

Arthroplasty

Rotation

No prime movers

Motions of the Pelvis and Muscle

Function
The pelvis is the connecting link
between
the
spine
and
lower
extremities. Movement of the pelvis
causes motion at the hip joints and
lumbar spine articulations. Contraction
of the hip musculature causes pelvic
motion
through
reverse
action;
therefore, to prevent excessive pelvic
motion when moving the femur at the
hip joint, the pelvis must be stabilized
by the trunk musculature.
Anterior Pelvic Tilt
The anterior superior iliac spines of
the pelvis move anteriorly and
inferiorly and thus closer to the
anterior aspect of the femur as the
pelvis rotates forward around the
transverse axis of the hip joints. This
results in hip flexion and increased
lumbar spine extension.
- Muscles causing this motion are the
hip flexors and back extensors.
- When hip flexion is the desired
motion, the pelvis must be stabilized
by the abdominals to prevent anterior
pelvic tilting.
- During standing, the line of gravity of
the trunk falls anterior to the axis of
the hip joints; the effect is an anterior
pelvic tilt moment. Stability is
provided by the abdominal muscles
and hip extensor muscles.
Posterior Pelvic Tilt

Arthroplasty

Gluteus
medius
(anterior fibers)
Gluteus
minimus
(anterior fibers)
Tensor fasciae latae
Adductor longus and
brevis
Adductor
magnus
(posterior fibers)
Pectineus
The posterior superior iliac spines of
the pelvis move posteriorly and
inferiorly, thus closer to the posterior
aspect of the femur as the pelvis
rotates backward around the axis of
the hip joints. This results in hip
extension and lumbar spine flexion.
- Muscles causing this motion are the
hip extensors and trunk flexors.
- When hip extension is the desired
motion,
the
lumbar
extensors
contract to stabilize the pelvis.
- During standing when the line of
gravity of the trunk falls posterior to
the axis of the hip joints, the effect is
a posterior pelvic tilt moment.
Dynamic stability is provided by the
hip flexors and back extensors and
passive stability by the iliofemoral
ligament.
Pelvic Shifting
During standing, a forward translatory
shifting of the pelvis results in
extension of the hip and extension of
the lower lumbar spinal segments.
There is a compensatory posterior
shifting of the thorax on the upper
lumbar spine with increased flexion of
these spinal segments. This is often
seen with slouched or relaxed
postures.
Lateral Pelvic Tilt
Frontal plane pelvic motion results in
opposite motions at each hip joint.
Pelvic motion is defined by what is
occurring to the iliac crest of the pelvis
that is opposite the weight-bearing
extremity (that is, the side of the
pelvis that is moving). When the pelvis
elevates, it is called hip hiking; when it

lowers, it is called hip or pelvic drop.

On the side that is elevated, there is
hip adduction; on the side that is
lowered, there is hip abduction. During
standing, the lumbar spine laterally
flexes toward the side of the elevated
pelvis (convexity of the lateral curve is
toward the lowered side)

externally,
opposite
-

Muscles causing lateral pelvic tilting

include the quadratus lumborum on
the side of the elevated pelvis and
reverse muscle pull of the gluteus
medius on the side of the lowered
pelvis.
When hip abduction is the desired
motion, the pelvis must be stabilized
by the lateral abdominals (internal and
external obliques) on the side of the
moving femur to prevent the pelvis
from tilting downward.
With
an
asymmetrical
slouched
posture, the person shifts the trunk
weight onto one lower extremity and
allows the pelvis to drop on the other
side. Passive support comes from the
iliofemoral ligament and iliotibial band
on the elevated side (stance leg).
When standing on one leg, there is an
adduction moment at the hip, tending
to cause the pelvis to drop on the
unsupported side (hip or pelvic drop).
This is prevented by the gluteus
medius stabilizing the pelvis on the
stance side.

Pelvic Rotation
Rotation occurs around one lower
extremity that is fixed on the ground.
The unsupported lower extremity
swings forward or backward along with
the pelvis. When the unsupported side
of the pelvis moves forward, it is
called forward rotation of the pelvis.
The trunk concurrently rotates in the
opposite direction, and the femur on
the stabilized side concurrently rotates
internally. When the unsupported side
of the pelvis moves backward, it is
called posterior rotation; the femur on
the stabilized side concurrently rotates

Arthroplasty

and

the

trunk

rotates

Muscles causing pelvic rotation are

the hip rotators working in synergy
with the oblique abdominal muscles,
the transversus abdominis, and the
multifidus.
When hip rotation is the desired
motion, the pelvis must be stabilized
by the trunk musculature.

Pelvifemoral Motion
A
combined
movement
occurs
between the lumbar spine and pelvis
during maximum forward bending of
the trunk as when reaching toward the
floor or the toes.
This motion is also known as
lumbopelvic rhythm.
Although
there
is
considerable
variability in the participation of each
of the joints, the motion typically is
described as beginning with forward
bending of the head.
As the head and upper trunk initiate
flexion, the pelvis shifts posteriorly to
maintain the center of gravity over the
base of support.
The trunk continues to forward-bend,
controlled by the extensor muscles of
the spine, until at approximately 45.
At this point for an individual with
relatively
normal
flexibility,
the
posterior ligaments become taut, and
the facets of the zygapophyseal joints
approximate. Both of these factors
provide stability for the intervertebral
joints, and the muscles relax.
Once all of the vertebral segments are
at the end of the range and stabilized
by the posterior ligaments and facets,
the pelvis begins to rotate forward
(anterior pelvic tilt), controlled by the
gluteus maximus and hamstring
muscles.
The pelvis continues to rotate forward
until the full length of the muscles is
reached. Final range of motion (ROM)
in forward bending is dictated by the
flexibility of the various back extensor

muscles and fasciae as well as hip

extensor muscles.

KNEE

The knee joint is designed for

mobility
and
stability;
it
functionally lengthens and shortens
the lower extremity to raise and
lower the body or to move the foot
in space. Along with the hip and
ankle, it supports the body when
standing, and it is a primary
functional unit in walking, climbing,
and sitting activities.

STRUCTURE AND FUNCTION OF THE

KNEE
The bones of the knee joint consist
of the distal femur with its two
condyles, the proximal tibia with its
two tibial plateaus, and the large
sesamoid bone in the quadriceps
tendon, the patella. It is a complex
joint
both
anatomically
and
biomechanically.
The proximal tibiofibular joint is
anatomically close to the knee but
is enclosed in a separate joint
capsule and functions with the
ankle.
JOINTS OF THE KNEE COMPLEX
A lax joint capsule encloses two
articulations: the tibiofemoral and the
patellofemoral joints. Recesses from
the capsule form the suprapatellar,
subpopliteal,
and
gastrocnemius
bursae. Folds or thickenings in the
synovium persist from embryologic
tissue in up to 60% of individuals and
may become symptomatic with
microtrauma or macrotrauma.
Tibiofemoral Joint
Characteristics.
the knee joint is a biaxial, modified
hinge joint with two interposed
menisci supported by ligaments
and
muscles.
Anteroposterior
stability is provided by the cruciate
ligaments; mediolateral stability is
provided by the medial (tibial) and

Arthroplasty

lateral
(fibular)
collateral
ligaments, respectively.
The convex bony partner is
composed of two asymmetrical
condyles on the distal end of the
femur. The medial condyle is longer
than the lateral condyle, which
contributes
to
the
locking
mechanism at the knee.
The concave bony partner is
composed of two tibial plateaus on
the proximal tibia with their
respective
fibrocartilaginous
menisci. The medial plateau is
larger than the lateral plateau.
The
menisci
improve
the
congruency of the articulating
surfaces. They are connected to the
tibial condyles and capsule by the
coronary ligaments, to each other
by the transverse ligament, and to
the patella via the patellomeniscal
ligaments. The medial meniscus is
firmly attached to the joint capsule
as well as to the medial collateral
ligament, anterior and posterior
cruciate
ligaments,
and
semimembranosus
muscle.
The
lateral meniscus attaches to the
posterior cruciate ligament and the
tendon of the popliteus muscle
through
capsular
connections.
Because of the relatively secure
attachment of the medial meniscus
compared to the lateral meniscus, it
has a greater chance of sustaining a
tear when there is a lateral blow to
the knee.

Arthrokinematics of the Knee Joint

Screw-home mechanism
The rotation that occurs between
the femoral condyles and the tibia
during
the
final degrees of
extension is called the locking, or
screw-home, mechanism. When the
tibia is fixed with the foot on the
ground (closed kinematic chain),
terminal extension results in the
femur rotating internally (the
medial condyle slides farther

posteriorly
than
the
lateral
condyle). Concurrently, the hip
moves into extension. Tautness in
the iliofemoral ligament, which
occurs
with
hip
extension,
reinforces the medial rotation of
the femur. As the knee is unlocked,
the
femur
rotates
laterally.
Unlocking of the knee occurs
indirectly with hip flexion and
directly from action of the popliteus
muscle. An individual who lacks full
hip
extenson
(hip
flexion
contracture) cannot stand upright
and lock the knee, thus lacking this
passive stabilizing function.
Patellofemoral Joint
Characteristics

The patella is a sesamoid bone in

the quadriceps tendon. It articulates
with the intercondylar (trochlear)
groove on the anterior aspect of the
distal portion of the femur. Its
articulating surface is covered with
smooth hyaline cartilage. The
patella is embedded in the anterior
portion of the joint capsule and is
connected to the tibia by the
ligamentum patellae. Many bursae
surround the patella.
Mechanics
As the knee flexes, the patella enters
the intercondylar groove with its
inferior margin making first contact
and then slides caudally along the
groove. With extension, the patella
slides superiorly. If patellar movement
is restricted, it interferes with the
range of knee flexion and may
contribute to an extensor lag with
active knee extension.
PATELLAR FUNCTION
The primary function of the patella is
to increase the moment arm of the
quadriceps muscle in its function to
extend the knee. It also redirects the
forces exerted by the quadriceps.
Patellar Alignment

Arthroplasty

The alignment of the patella in the

frontal plane is influenced by the line
of pull of the quadriceps muscle
group and by its attachment to the
tubial tubercle via the patellar
tendon. The result of these two forces
is a bowstring effect on the patella,
causing it to track laterally. One
method of describing the bowstring
effect is to measure the Q-angle.
The Q-angle is the angle formed by
two intersecting lines: one from the
anterior superior iliac spine to the
midpatella, the other from the tibial
tubercle through the midpatella. A
normal Q-angle, which tends to be
greater in women than men, is 10O to
15O.

Forces Maintaining Alignment

In addition to the bony restraints of
the trochlear groove (femoral
sulcus), the patella is stabilized by
passive and dynamic (muscular)
restraints. The superficial portion of
the extensor retinaculum, to which
the vastus medialis and vastus
lateralis
muscles
have
an
attachment,
provides
dynamic
stability in the transverse plane.
The
medial
and
lateral
patellofemoral ligaments, which
attach to the adductor tubercle
medially and iliotibial band laterally
provide passive restraints to the
patella in the transverse plane.
Longitudinally, the medial and
lateral patellotibial ligaments and
patellar tendon fixate the patella
inferiorly against the active pull of
the quadriceps muscle superiorly
Patellar Malalignment and Tracking
Problems
Malalignment and tracking problems
of the patella may be caused by
several factors that may or may not be
interrelated.
Increased Q-angle
With an increased Q-angle there may
be increased pressure of the lateral

facet against the lateral femoral

condyle when the knee flexes during
weight
bearing.
Structurally,
an
increased Q-angle occurs with a wide
pelvis, femoral anteversion, coxa vara,
genu valgum, and laterally displaced
tibial tuberosity. Lower extremity
motions in the transverse plane that
may increase the Q-angle are external
tibial
rotation,
internal
femoral
rotation, and a pronated subtalar joint.
Functional knee valgus that occurs
during
dynamic
activities
also
increases the Q-angle.
Muscle and fascial tightness
A tight iliotibial (IT) band and lateral
retinaculum prevent medial gliding of
the patella. Tight ankle plantarflexors
result in pronation of the foot when
the ankle dorsiflexes, causing medial
torsion of the tibia and functional
lateral displacement of the tibial
tuberosity in relationship to the
patella. Tight rectus femoris and
hamstring muscles may affect the
mechanics of the knee, leading to
compensations.
Lax medial capsular retinaculum or
an insufficient VMO muscle
The vastus medialis obliquus (VMO)
muscle may be weak from disuse or
inhibited because of joint swelling or
pain, leading to poor medial stability.
Poor timing of its contraction, which
alters the ratio of firing between the
VMO and vastus lateralis (VL) muscle,
may lead to an imbalance of forces.
Weakness or poor timing of VMO
contractions increase the lateral
drifting of the patella.
Hip muscle weaknes
: Weakness of the hip abductors and
external rotators may result in
adduction of the femur and valgus at
the knee under loaded weight bearing.
Patellar Compression
Patellar contact

Arthroplasty

The posterior surface of the patella

has several facets. It is not completely
congruent as it articulates with the
trochlear groove on the femur. When
the knee is in complete extension (0O),
the patella is superior to the trochlear
groove. By 15O of flexion the inferior
border of the patella begins to
articulate with the superior aspect of
the groove. As the knee flexes, the
patella slides distally in the groove,
and more surface area comes in
contact.
Beyond
60there
is
controversy as to whether the contact
area continues to increase, level off, or
decrease.80,81 In addition, as the
knee flexes past 90O, the quadriceps
tendon comes in contact with the
trochlear groove as the patella slides
inferiorly.

Compression forces
In full extension, because there is
minimal to no contact of the patella
with the trochlear groove, there is no
compression of the articular surfaces.
Furthermore, because the femur and
tibia are almost parallel, the line of
pull of the quadriceps muscle and
patellar tendon causes a very small
resultant
compressive
load.
The
resultant force of the quadriceps and
patellar tendon forces rises as the
knee flexes, but there is also greater
surface area of the patella in contact
with the groove to dissipate this force.
The joint reaction force on the articular
surface rises rapidly between 30 O and
60O. There is controversy as to the
extent of joint reaction forces in
greater degrees of flexion.
During squatting, the joint reaction
force continues to rise until 90and
then levels off or decreases
because the quadriceps tendon
begins making contact with the
trochlear groove and therefore
dissipates some of the force.
In an open-chain exercise with a
free weight on the distal leg, the
greatest joint reaction force occurs
at around 30O of flexion. This is

MUSCLE FUNCTION
The quadriceps femoris muscle group
is the only muscle crossing anterior to
the axis of the knee and is the prime
mover for knee extension. Other
muscles that can act to extend the
knee require the foot to be fixated,
creating a closed chain. In this
situation, the hamstrings and the
soleus muscles can cause or control
knee extension by pulling the tibia
posteriorly.
Closed-chain function.
During standing and the stance phase
of gait, the knee is an intermediate
joint in a closed chain. The quadriceps
muscle controls the amount of flexion
at the knee and also causes knee
extension through reverse muscle pull
on the femur. In the erect posture,
when the knee is locked, the
quadriceps need not function when
the gravity line falls anterior to the
axis of motion. In this case, tension in
the hamstring and gastrocnemius
tendons
supports
the
posterior
capsule.
Patella
The patella improves the moment arm
of the extensor force by increasing the
distance of the quadriceps tendon
from the knee joint axis. Its greatest
effect on the leverage of the
quadriceps is during extension of the
knee
from 60to 30and rapidly
diminishes from 15O to 0O of extension.
Torque. The peak torque of the
quadriceps muscle occurs between 70and

Arthroplasty

50.28 The physiological advantage of the

quadriceps rapidly decreases during the
last 15of knee extension because of its
shortened length. This, combined with its
decreased moment arm in the last 15,
requires the muscle to significantly
increase its contractile force when large
demands are placed on the muscle during
terminal extension.
Knee Flexor Muscle Function
The hamstring muscles are the
primary knee flexors and also
influence rotation of the tibia on the
femur. Because they are two-joint
muscles,
they
contract
more
efficiently
when
they
are
simultaneously lengthened over the
hip (during hip flexion) as they flex
the knee.
During closed chain activities, the
hamstring muscles can assist with
knee extension by pulling on the
tibia. The gastrocnemius muscle can
also function as a knee flexor, but its
prime function at the knee during
weight bearing is to support the
posterior
capsule
against
hyperextension forces. The popliteus
muscle supports the posterior capsule
and acts to unlock the knee. The pes
anserinus muscle group (sartorius,
gracilis, semitendinosus) provides
medial stability to the knee and
affects rotation of the tibia in a closed
chain.

ETIOLOGY

because of the changing moment

arm of the resistive force more
than the line of pull of the
quadriceps and patellar tendons. In
an
open-chain
with
variable
resistance, the peak stress is at
60and peak compression at 75O.
An increased Q-angle causes
increased lateral facet pressure as
the knee flexes.

Risk Factors Contributing to Joint Dislocatio

Patient-Related Factors
Surgery
Age > 80 to 85 years
Surgic
poste
THA for femoral neck fracture
or late
Medical diagnosis: higher risk in
Desig
patients with inflammatory
risk w
arthritis (mostly RA) than patients
Malpo
with OA
comp
Poor quality soft tissue from
Inade
chronic inflammatory disease
during
tissue
History of prior hip surgery

Preoperative and postoperative

muscle weakness (particularly the
abductor mechanism) and
contractures
Cognitive dysfunction, dementia

Hematogenous
Experience of
the surgeon
Postoperative
Osteotomy
Renal disease

Disorders of the Hip Joint for Which

Total Hip Arthroplasty May Be
Indicated

Cortisone induced
Alcoholism
Slipped capital femoral epiphysis

Arthritis

Tuberculosis

Rheumatoid

Contraindications to Total Hip Arthroplasty

Juvenile rheumatoid
(Still's disease)

Absolute

Pyogenic

Active joint infection

Ankylosing spondylitis
Avascular necrosis
dislocation Idiopathic

Postfracture

or

Bone tumor

Cassion disease
Degenerative joint disease
Osteoarthritis
Developmental dysplasia of the hip
Failed hip reconstruction
Cup arthroplasty
Femoral head prosthesis
Girdlestone procedure

Relative

Resurfacing arthroplasty
Total hip replacement
Fracture
or
dislocation
Acetabulum
Proximal femur Fusion or pseudarthrosis
of
hip
Gaucher's
disease
Hemoglobinopathies (sickle cell disease)
Hemophilia Hereditary disorders
Legg-Calve-Perthes disease (LCPD)
Osteomyelitis (remote, not active)

Arthroplasty

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

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

Complications of THR

Nerve injury the sciatic nerve is

particularly at risk resulting in foot drop
and numbness in the foot. Common
causes include traction on the nerve or
compression by retractor placement.
Bleeding average blood loss is 250
mL, but a proportion of patients lose more
and require blood transfusion.

Deep
vein
thrombosis
(DVT)/pulmonary embolism (PE)
without prophylactic bloodthinning, deep
vein thrombosis (DVT) is common after
THR.
Chemical
and
mechanical
thromboprophylaxis should be used
routinely.
Infection this is a major problem and
all measures are taken to avoid it,
including a clean air supply in theatre,
antibioticloaded
cement
and
perioperative antibiotics. If the prosthesis
becomes infected, a twostage revision
may be indicated in which the hip is
removed and the patient given antibiotics
for 6 weeks before a new prosthesis is
implanted.
Dislocation may occur if the soft
tissues are not balanced or the prosthesis
is
malpositioned
intraoperatively.
Precautions
including
avoidance
of
crossing legs, bending over and sitting in
low chairs, which are implemented by the
physiotherapists postoperatively.
Leg length discrepancy if the
acetabulum has been severely eroded or
the hip is an abnormal shape, leg length
differences are more common. Careful
preoperative planning helps avoid this. Up
to 15 mm difference is usually well
tolerated by the patient.
Primary Total hip arthroplasty

Indications
Total hip arthroplasty is indicated in
painful conditions of the hip that have
failed conservative management. These
are too numerous to list in this book but

Arthroplasty

the most frequent underlying conditions

are:
Osteoarthritis
Inflammatory arthritis and other
arthropathies
Avascular necrosis
Trauma.
Contraindications
Infection (generalized or of the limb)
Absolute dysfunction of the abductor
complex, including profound neurological
disease.
Revision Total hip arthroplasty
Indications
Revision hip replacement is indicated for
painful failure of a primary arthroplasty.
The mos tcommon causes are:
Aseptic loosening of the socket
and/or stem
Deep infection (see later section)
Instability, resulting in recurrent
dislocation
Fracture of either the implant or the
proximal femur.
Contraindications
Continuation of preoperative pain after
hip arthroplasty (this suggests that the
original diagnosis may have been wrong
and warrants further investigation).
Pain-free loosening is a relative
contraindica tion, except in cases associated with
significantand progressive osteolysis.

Complications of TKR: These include:

Infection as with all prosthetic joints,
infection may be introduced at the time of
surgery, develop in the wound in the
immediate perioperative period, or be
seeded years later by bacteraemia from
another source. Presentation is pain,
swelling, warmth and signs of sepsis.
Aspiration of the joint allows an organism
to be identified, but in contrast to a native
joint, if an arthroplasty is in situ, do not

aspirate in A&E or on the ward! It must be

done in theatre under aseptic conditions!
If the infection occurs within a few weeks
of surgery, the joint may be saved by
rapid return to theatre for debridement,
washout and change of the plastic liner. If
this fails or the patient presents late, the
joint must be revised in two stages with a
prolonged course of antibiotics.
Damage to nerves or blood vessels
the tibial nerve, common peroneal
nerve and popliteal artery are close to the
back of the knee and may be damaged
intraoperatively either by a saw blade or
traction. Always check pulses, power and
sensation in the foot when the spinal
anaesthetic has worn off.
Dislocation of patella improper
release of soft tissues or malpositioning of
the implants may result in the patella
dislocating.
Instability usually due to improper
balancing or damage to the collaterals.
Wear and loosening just as in total
hip replacement, in TKR the plastic
bearing wears, generating debris that
results in osteolysis and loosening.
Studies show that more than 90% of TKRs
survive for 15 years. A lucent line on X
ray, accompanied by pain and loss of
stability, is an indication for revision
although infection must be excluded first.
Revision Total knee arthroplasty
Indications
Revision total knee replacement is
indicated in the treatment of pain,
stiffness or instability from a failed total
knee arthroplasty. The cause of failure
must be diagnosed prior to embarking on
revision surgery. There may be several
causal factors present in combination.
The common causes of failure and
indications for revision are:
Aseptic loosening
Polyethylene wear
Osteolysis
Ligamentous instability

Arthroplasty

Patellofemoral dysfunction
Mechanical stiffness
Contraindications

Medically unfit for surgery or

anaesthetic
Active or recent local or generalized
infection
Critical arterial ischaemia
Non-functioning extensor mechanism
Unexplained pain
Insufficient skin coverage (relative)
Severe neurological disorders (relative)
Age (relative) very elderly patients
should be carefully selected depending on
severity of symptoms, quality of life and
options available.

CLINICAL SIGNS & SYMPTOMS/PHYSICAL DISABILITIES/IMPAIRMENTS

Total Hip Arthroplasty

Problems,
include:

and

associated

symptoms,

Infection: acute onset or chronic pain,

suspicious for infection with elevated CRP
and ESR; WBC count may be normal and
patient afebrile; wound may or may not
be inflamed; diagnosis is confirmed by
aspiration and culture
Dislocation: 14% rate in the early
postoperative
period,
decreases
thereafter but does not go to zero; acute
onset
of
pain
with
dislocation;
radiographs are diagnostic
Dissociation: any part of either
prosthesis can come apart; careful
scrutiny of radiographs is necessary to
identify
incongruous
components;
dissociation of the head from the stem is
obvious, dissociation of the plastic liner
from the metal shell, less so
Periprosthetic fracture: may be
present in patients with pain of sudden
onset after trauma
Loosening (septic or aseptic):
aseptic loosening is gradual by history,
with pain with weight bearing, start-up
pain, and no rest pain

Total Knee Arthroplasty

Problems, and associated symptoms,

include:
Infection: acute-onset or chronic pain,
suspicious for infection with elevated CRP
and ESR; WBC count may be normal and
patient afebrile; wound may or may not
be inflamed; diagnosis is confirmed by
aspiration and culture

Arthroplasty

Dissociation: the tibial plastic-bearing

surface can fracture, wear, or separate
from the tibial baseplate; some designs
allow motion of the plastic component;
careful scrutiny of radiographs can
occasionally discern whether this is the
problem

Instability:
can
manifest
at
tibiofemoral or patellofemoral joint; after
total replacement most knees have slight
anterior laxity due to sacrifice of the
anterior
cruciate
ligament,
but
mediolateral and posterior stability should
be good in flexion and extension; history
and physical exam can discern this
instability; lateral radiographs may show
anterior subluxation of the femur on the
tibia;
patellofemoral
instability
is
manifested by pain, subluxation, and
even dislocation; Merchant or sunrise
radiographs aid diagnosis
Loosening: aseptic loosening is
gradual by history, with pain on weight
bearing and start-up, but not at rest
Periprosthetic fracture: may be
present in patients with pain of sudden
onset after trauma

PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY
Aging

Rheumatoid
arthritis of the
knee

Fall

osteoarthritis
of the knee

Pain and stiffness

Gross limitation of

Total knee arthroplasty

Arthroplasty

Trauma

Traumatic
arthritis of the
knee

Complete
fracture of
the
acetabulu
m

Knocked

Malunion

Non-union

Total hip arthroplasty

DIAGNOSTIC TOOLS/TEST
TOTAL HIP ARTHROPLASTY
An evaluation with an orthopaedic
surgeon consists of several components.

Medical history. Your orthopaedic

surgeon will gather information about
your general health and ask questions
about the extent of your hip pain and
how it affects your ability to perform
everyday activities.

Physical examination. This will

assess hip mobility, strength, and
alignment.

X-rays. These images help to

determine the extent of damage or
deformity in your hip.
Other tests. Occasionally other tests,
such as a magnetic resonance imaging
(MRI) scan, may be needed to
determine the condition of the bone
and soft tissues of your hip.

(Left) In this x-ray of a normal hip, the

space between the ball and socket
indicates healthy cartilage. (Right) This
x-ray of an arthritic hip shows severe loss
of joint space.

Arthroplasty

This x-ray shows a large bone spur that

has developed on the ball of an arthritic
hip.
An evaluation with an orthopaedic
surgeon consists of several components:
TOTAL KNEE ARTHROPLASTY

A medical history. Your

orthopaedic surgeon will gather
information about your general
health and ask you about the
extent of your knee pain and your
ability to function.

A physical examination. This will

assess knee motion, stability,
strength, and overall leg alignment.

X-rays. These images help to

determine the extent of damage
and deformity in your knee.

Other tests. Occasionally blood

tests, or advanced imaging such as
a magnetic resonance imaging
(MRI) scan, may be needed to
determine the condition of the
bone and soft tissues of your knee.

(Left) In this x-ray of a normal knee, the

space between the bones indicates
healthy cartilage (arrows). (Right) This xray of a knee that has become bowed
from arthritis shows severe loss of joint
space (arrows).
Your orthopaedic surgeon will review the
results of your evaluation with you and
discuss whether total knee replacement is
the best method to relieve your pain and
improve your function. Other treatment
options including medications,
injections, physical therapy, or other
types of surgery will also be considered
and discussed.
In addition, your orthopaedic surgeon will
explain the potential risks and
complications of total knee replacement,
including those related to the surgery
itself and those that can occur over time
after your surgery.
http://orthoinfo.aaos.org/topic.cfm?
topic=A00389
http://orthoinfo.aaos.org/topic.cfm?
topic=a00377

Arthroplasty

Arthroplasty

DIFFERENTIAL DIAGNOSIS

PHARMACOLOGICAL MANAGEMENT
Opioid Analgesics

Opioids are the most effective

medicines for moderate to severe
pain, especially for managing
short-term pain after surgery..

Types of Opioids
Natural opioids are among the
world's oldest known drugs and are
made from the dried "milk" of the
opium poppy plant. There are also
other types of opioids that are
made artificially in a laboratory.
These types are called synthetic or
semi-synthetic opioids.
How Opioids Work
Whether natural or synthetic, all
opioids work by binding to opioid
receptors in the brain, spinal cord,
and gastrointestinal tract. When
these drugs attach to certain opioid
receptors,
they
block
the
transmission of pain messages to
the brain.
Opioids can do this because they
look just like your body's natural
painkillers, called endorphins. This
similarity
in
structure
"fools"
receptors and allows the drug to
activate the nerve cells, flooding
the area with dopamine, which
produces the "opioid effect."
Advantages and Disadvantages of
Opioids
Opioids work rapidly to block pain
and also change the way your brain
perceives pain. The pain relief they
provide allows you to be more
active during the day and get more
rest at night.
Opioids are effective when given
through a variety or routes, such as
by mouth, through the skin, under
the tongue, and directly into the
bloodstream. They do not cause
bleeding in the stomach or other
parts of the body.

Arthroplasty

Disadvantages to using opioids

include that they may interfere
with breathing or urination. In
addition, they may cause:

Drowsiness

Confusion

Nausea

Constipation

Itching

All of these side effects are treatable by

your doctor.
Intravenous
Analgesia

Patient-Controlled

In many cases, doctors provide

opioid medicines after surgery with
a
Patient-Controlled
Analgesia
(PCA) pump. This allows you to
press a button to release a small
amount of medicine through an
intravenous (IV) tube when you
begin to feel pain.

Opioid Dependency
Opioids can provide excellent pain
relief and help to speed your
recovery from surgery or injury.
They are, however, a narcotic and
can be addictive. While addiction is
unusual, it is important to use
opioids only as directed by your
doctor. You should stop taking
these medications as soon as your
pain starts to improve.
Non-steroidal
Drugs

Anti-inflammatory

Non-steroidal
anti-inflammatory
drugs (NSAIDs) reduce swelling and
soreness and are often used alone
for mild to moderate pain. To

manage the moderate to severe

pain after surgery, NSAIDs are
often used in combination with
opioids. Some examples of NSAIDs
include aspirin, ibuprofen, and
naproxen.
How NSAIDs Work
NSAIDs work by preventing an
enzyme (a protein that triggers
changes in the body) from doing its
job.
The
enzyme
is
called
cyclooxygenase, or COX, and it has
two forms. COX-1 protects the
stomach lining from harsh acids
and digestive chemicals. It also
helps maintain kidney function.
COX-2 is produced when joints are
injured or inflamed.
COX-1 and COX-2 enzymes play a
key role in making prostaglandins,
which cause pain and swelling by
irritating your nerve endings. By
blocking the COX enzymes, NSAIDs
essentially stop your body from
making too much prostaglandin,
and therefore reduce pain and
swelling.
Advantages
NSAIDs

and

Disadvantages

of

NSAIDs produce fewer side effects

when compared to opioids. After
surgery, using NSAIDs may reduce
your need for opioid medications
and, therefore, reduce opioid side
effects
like
constipation
and
drowsiness. NSAIDs also do not
lead to addiction or dependence.
NSAIDs alone, however, will not
relieve the moderate to severe pain
you may have after surgery.
Traditional
NSAIDs
block
the
actions of both COX-1 and COX-2
enzymes, which is why they can
cause stomach upset and bleeding,
and are associated with ulcers.
Aspirin and ibuprofen are common
traditional NSAIDs.

Arthroplasty

COX-2 inhibitors are a special

category
of
NSAIDs.
These
medications target only the COX-2
enzyme
that
stimulates
the
inflammatory response. Because
they do not block the actions of the
COX-1 enzyme, these medications
generally do not cause the kind of
stomach problems that traditional
NSAIDs
do.
COX-2
inhibitors,
however, have possible cardiac
side effects.

Centrally Acting Non-opioids

Acetaminophen
Like NSAIDs, acetaminophen may
be used after surgery to reduce the
amount
of
stronger,
opioid
medications you need to control
pain. Acetaminophen is often
combined with opioid medicine in a
tablet form. When taken in tablet
form, opioids are not easily
absorbed by the body. But when
combined with acetaminophen, the
medication absorbs easily and
effectively relieves moderate to
severe pain after surgery.
Acetaminophen does not interfere
with the COX-1 or COX-2 enzyme to
reduce pain, so does not have antiinflammatory properties. Scientists
believe
that
acetaminophen
relieves mild to moderate pain by
elevating your body's overall pain
threshold. It lowers your fever by
helping your body eliminate excess
heat.
Used alone, acetaminophen works
well for headaches, fever, and
minor aches and pains, but does
not reduce the inflammation and
swelling that might accompany a
muscle sprain.
Tramadol
Tramadol is a synthetic opioid,
which means that it is made in a
laboratory and modeled after a
popular opioid called codeine.
Although it is technically an opioid

because of its structure, the way it

works in your body sets it apart
from
all
the
other
opioids
previously discussed.
Tramadol relieves pain through two
totally different methods. In one
sense, tramadol works in the brain
and spinal cord to change the way
the body senses pain (like a
traditional
opioid).
However,
tramadol also works in a similar
manner as some antidepressant
medications, by interfering with the
regulation
of
certain
neurochemicals
(serotonin
and
norepinephrine). When the amount
of these chemicals is changed, it
becomes
difficult
for
pain
messages to be relayed from one
nerve cell to the next. Therefore, it
reduces the amount of pain you
feel..

Local Anesthetics

Local anesthetics block pain in a

small area of the body. In
orthopaedic surgery, they may be
used as anesthesia during a
procedure, or as part of a pain
management
program
after
surgery.
For
pain
management,
local
anesthetics are given in a shot (or
multiple shots) near your surgical
incision, or as an epidural through
a small tube in your back. These
medicines work by blocking the
pain signals that travel along the
nerves to your brain.
Local anesthetics do not cause the
side
effects
of
drowsiness,
constipation, or breathing problems
that you get with opioids. In
orthopedic surgery, the most
commonly used local anesthetics
include lidocaine, bupivacaine, and
ropivacaine.
Using local anesthetics carries the
risk of a possible allergic reaction
and may cause nerve damage,
muscle spasms, and convulsions.

Arthroplasty

For the most part, side effects can

be avoided when you share your
complete medical history with your
doctor.
Regional Anesthetics

Regional anesthetics offer the

advantage of providing anesthesia
during surgery and pain relief for
several hours afterward.
Medication is injected around the
nerves in the part of your body
having surgery.
The medication can block feeling
and movement in the lower part of
your body (spinal, epidural) in one
of
your
arms
(intra-scalene,
supraclavicular, axillary) or one of
your legs (femoral, sciatic).
Often, you can remain conscious
during the procedure and require
only light sedation. Other times,
regional blocks may be used to
supplement general anesthesia.
Either way, you will have little or no
pain when you wake up.

Spinal and Epidural

Spinal and epidural anesthesia
are neuraxial blocks. They block
feeling and movement below the
level at which they are given,
typically the lower portion of the
spine. They can numb the area
from the lower abdomen and pelvis
down to the toes.
A spinal is given as a single
injection of a local anesthetic or
morphine directly into the spinal
canal. Since it is only a single
injection its effect will last for the
duration of the procedure but only
a few hours afterward.
Epidural anesthesia is given in the
space around the spinal canal. The
canal itself is protected by a lining
membrane called the dura. The
medication will pass through the
dura and reach the spinal nerves. A
small tube or catheter may be
placed in the space around the

dura and left in place for one or

two days after surgery. Medication
may then be given at intervals
through the catheter.
Epidural anesthesia often has less
effect on the motor nerves than
spinal and will allow for some
function and mobility even when
then catheter is in place.

Many
anesthesiologists
now
use
ultrasound technology to help guide
placement of the needle or catheter
before medication is injected around the
nerves. An image on a monitor shows the
nerves, muscles, arteries, and veins in
the affected area. This allows the
anesthesiologist to make sure the
medication is injected into the right place.

Extremities
Regional anesthetics can also be used to
numb up a smaller area such as your arm
or leg.

Ultrasound is most commonly used for

blocks involving the upper and lower
extremities. Because it is not an x-ray
there is no radiation exposure from the
procedure.

In the upper extremity the most common

blocks are

Intra-scalene. Given at the

base of the neck to numb up
your shoulder and arm

Supraclavicular. Given above

your collarbone to numb up your
shoulder and arm

Axillary. Given into the axillary

area (armpit) for procedures in
your arm below the level of the
shoulder

In the lower extremity the most common

blocks are

Femoral. Given in the groin

area to numb the front of your
thigh and knee

Sciatic. Given at the back of

your knee to numb your lower
leg, foot, and ankle

As with an epidural, a catheter may be

left in place following intra-scalene,
supraclavicular, or femoral nerve blocks.
It is used to provide pain relief for 24 to
48 hours following knee or shoulder
surgery before it is removed by the
anesthesiologist.

Arthroplasty

http://orthoinfo.aaos.org/topic.cfm?
topic=A00650

MEDICAL AND SURGICAL MANAGEMENT

KNEE ARTHROPLASTY
Lateral parapatellar approach
Advantages
Subvastus approachDisadvantages
-Advantages
Technically
-Disadvantages
Very rare
useful
in of
valgus
- Claims
less
- Patella can be
deformity
cases
intraoperative
difficult to evert
-blood
Preserves
the
-but
Difficulty
in
loss and
it can be
patellar
blood
everting
the
more rapid
instead
supply
patella
medially
rehabilitation
subluxated
- Prevents lateral -laterally
May require
patellar
tibial
tubercle
- Elevates the
- Difficult
to apply
subluxation
osteotomy
vastus medialis
in muscular
muscle instead of patients
cutting into it
- Preserving the
quadriceps
tendon intact
- Preserving
blood supply to
the patella
Midvastus approach
Advantages
Disadvantages
- Better exposure - Cutting and
than the
disrupting the
subvastus
vastus medialis
muscular
substance
- Allows rapid
- Patella can be
restoration of
difficult to evert
extensor
and can be
mechanism
instead
- Advantage over subluxated
the standard
laterally
incision is that
the vastus
medialis insertion
into the medial
border of the
quadriceps
tendon is
preserved
Lateral approach
Advantages
- Technically
useful in valgus
deformity cases

Arthroplasty

Disadvantages
- Being rare
becomes
uncomfortable.
Technically is

more demanding
and needs an
experienced
surgeon
- Preserves the
- Difficulty in
patellar blood
everting the
supply
patella medially
- Prevents lateral - May require
patellar
tibial tubercle
subluxation
osteotomy
http://www.intechopen.com/books/arthrop
lasty-a-comprehensive-review/surgicalapproaches-for-total-knee-arthroplasty

TOTAL KNEE ARTHROPLASTY

Approach
Internervous
Interval

Major
Advantages
Disadvantages/
Structures
Risks
At Risk
Anterior (Smithsuperficial
Lateral
Allows hip
Limits posterior
Petersen)
Sartorius (femoral femoral
dislocation without acetabular
nerve) and
cutaneous
risk to the femoral
visualization
tensor fasciae
nerve
head blood supply Extensive release
latae (superior Ascending
Useful for anterior
of the abductors
gluteal nerve)
branch of
column exposure
can result in
Deep
the lateral
(eg, pelvic
weakness and a
Rectus femoris
femoral
osteotomy or
high incidence of
(femoral nerve)
circumflex
fracture)
heterotopic
and gluteus
artery
Extensive access to
ossification
medius (superior
inner and outer
gluteal nerve)
tables of the ilium,
anterior femoral
head and neck,
and acetabulum
Two-incision
Same as anterior Lateral
Further study and
Technically difficult
anterior
approach
femoral
long-term followDoes not allow
(Berger)
cutaneous
up needed to
wide exposure of
Anterior incision
nerve
determine if it
the hip joint
for acetabular
expedites patient
insertion
recovery
Lateral incision
for femoral
component
Anterolateral
Tensor fasciae
Branch of
Low incidence of
Damage to the
(Watson-Jones) latae (femoral
the
postoperative
femoral shaft and
nerve) and
superior
dislocation
malpositioning of
gluteus medius
gluteal
Good exposure of
the femoral
(femoral nerve)
nerve that
hip joint and
component during
supplies
proximal femur
femoral canal
the tensor
without
preparation
fasciae
trochanteric
Damage to the
latae
osteotomy
abductors
Femoral
nerve
Lateral
None
Same as
Access to the
Postoperative limp
(Hardinge)
Modified Hardinge anterolater anterior and
(18% incidence in
approach divides al approach posterior hip joint
primary THA)
the gluteus
without osteotomy Heterotopic
medius at the
of the trochanter
ossification
junction of the
Low rate of
(incidence as high
anterior third and
postoperative
as 47% in primary
posterior two
dislocation
THA)
thirds
Improved access to
the proximal femur
for reaming
compared to

Arthroplasty

anterolateral and
anterior
approaches
Same as
Excellent exposure;
anterolater allows complete
al approach visualization of the
anterior and
posterior aspects
of the hip and a
full view of the
acetabulum
Ability to preserve
blood supply to the
femoral head
Improved
biomechanics of
the abductor
mechanism
through the
advancement of
the greater
trochanter through
distal
reattachment
Allows exposure of
the hip without
applying torque to
the femur,
decreasing fracture
risk (osteoporosis,
cortical defects)

Transtrochanteri No internervous
c lateral
plane, access to
(Charnley)
joint through
osteotomy of the
greater
trochanter
Level of the
osteotomy may
be varied based
on necessary
exposure
Small
wafer/trochanteri
c slide
Standard-size
osteotomy at the
vastus ridge
Extended
trochanteric
osteotomy 3 to
10 cm distal to
the trochanteric
ridge
Various techniques
for repair of the
trochanter have
been described,
including wire
knots and the
commonly used
Dall-Miles* cable
grip system
May be combined
with
anterolateral,
posterolateral, or
direct lateral
approaches
Posterolateral
None
Sciatic nerve Minimal anatomic
disruption
(abductors
preserved)
Excellent exposure
of socket and
femur
Quick recovery/no
limp
Higher patient
satisfaction
Less heterotopic

Arthroplasty

Increased
intraoperative
time and blood
loss because of
the time needed
to repair the
trochanteric
osteotomy site
Slower
rehabilitation
resulting from
weight-bearing
protection
postoperatively;
usually a period
of 6 weeks to
allow for
trochanteric
healing
Trochanteric
nonunion (rates
reported: 5% to
32%)
Broken wires,
trochanteric
bursitis, and
ectopic bone
formation

Slightly higher
dislocation rate

Mini-posterior

ossification
Extensile exposure
easy to obtain
Lower rate of
reported overall
complications
Same as standard Same as
Further study and
posterolateral
standard
long-term followapproach
posterolate up needed to
ral
determine if it
approach
expedites patient
recovery

*Stryker Corporation, Mahwah, NJ.

Arthroplasty

Same as standard
posterolateral
approach
Increased
potential for
component
malpositioning

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.

GOALS AND EXERCISE INTERVENTIONS

Weight bearing as
cemented
prosthesis,
uncemented or hybrid

tolerated
delayed

with
with

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 E-stim)
Patellar mobilization (grades I and II)
Flexibility program hamstrings, calf, IT
band
Trunk/pelvis strengthening
Gait training
Prevent vascular
complications.

and

pulmonary

Maximum Protection Phase: Weeks 14

Ankle pumping exercises with the leg

elevated immediately after surgery to
prevent a DVT or pulmonary embolism

Patient presentation

Deep breathing exercises

Patient enters rehabilitation 12 days

postoperatively

Prevent reflex inhibition or loss of

strength
of
knee
and
hip
musculature.

Postoperative compression dressing

Postop pain controlled
ROM 1060

Arthroplasty

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
side-lying 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 agonistcontraction 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

Arthroplasty

or while seated with the operated leg

elevated to reduce the risk of developing
a knee flexion contracture.
Moderate Protection Phases: Weeks 48
Patient presentation

Minimum pain
Full weight bearing
uncemented or hybrid
ROM 090
Joint effusion controlled

except

with

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 110knee flexion and active

knee extension to 0and 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 muscular
endurance of knee and hip.
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.

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

while

Heel-toe walking; ambulation on a

variety of surfaces and inclines.
Stepping over small objects.

Resisted SLRs in various positions to

increase the strength of hip musculature,
with emphasis on the hip extensors and
abductors.

Minimum Protection/Return to Function

Phases: Beyond Week 8

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.

Patient presentation

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.

Arthroplasty

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

Ballroom or square dancing

Table tennis

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.

Recommended If Experienced Before

TKA**
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

RECOMMENDATIONS FOR PARTICIPATION

IN PHYSICAL ACTIVITIES FOLLOWING
TKA

Football, soccer
Gymnastics, tumbling
Water-skiing

Highly Recommended*
Stationary cycling

TOTAL HIP ARTHROPLASTY

Swimming, water aerobics

Walking
Golf (preferably with golf cart)

Arthroplasty

Early
Postoperative
Motion
Precautions
After
Total
Hip
Arthroplasty*

Posterior/Posterolateral Approaches
ROM
Avoid hip flexion 80to 90and adduction
and internal rotation beyond neutral.
ADL
Transfer to the sound side from bed to
chair or chair to bed.
Do not cross the legs.
Keep the knees slightly lower than the
hips when sitting.
Avoid sitting in low, soft chairs.

Avoid the combined motion of flexion,

abduction, and external rotation.
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.
ADL
Do not cross the legs.
During early ambulation, step to, rather
than past, the operated hip to avoid
hyperextension.
Avoid activities that involve standing on
the operated extremity and rotating away
from the involved side.

If the bed at home is low, raise it on

blocks.
Use a raised toilet seat.
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.

Arthroplasty

Maximum Protection Phase After

Traditional THA

Goals and interventions.

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.
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.

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.
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 and Minimum Protection
Phases

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

Arthroplasty

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

Arthroplasty

progressive weight
operated limb.

bearing

on

the

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.
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.

Arthroplasty

Arthroplasty

REFFERENCES

http://orthoinfo.aaos.org/topic.cfm?
topic=A00389
http://orthoinfo.aaos.org/topic.cfm?
topic=a00377
Current Essentials: Orthopedics by
Harry B. Skinner, MD, PhD
Brunner and Suddarth's Textbook of
Med.-Surg. Nursing 12th edition

Arthroplasty

Essential Physical Medicine and

Rehabilitation
Therapeutic Exercise Foundations
and Techniques Sixth Edition by
Kisner & Colby