Post on 22-Dec-2015
Total Hip & Knee Arthroplasty & Rehabilitation Implications: Past, Present, & Future
Celia Pechak, PT, MPH, PhDEast Texas District TPTA
April 26, 2008
Today’s Objectives• Review the evidence related to standard & minimally invasive
THA & TKA
• Encourage discussion related to participants’ clinical experiences with this patient population
• Offer practical resources for accessing the evidence & clinical expertise
• Stimulate participants’ interest in accessing & supporting clinical research in this area
Overview of Total Hip Arthroplasty (THA) & Total Knee Arthroplasty (TKA)
Currently 193,000+ THAs are performed per year in the US
Currently 381,000+ TKAs are performed per year in the US
750,000+ THA/TKAs per year are projected by 2030
Jones, Westby, et al., 2005
THA:Trip Down Memory Lane
1970s Admitted 1-2 days
before surgery Bedrest 2-3 days
post-op Partial weight
bearing LOS 17 days
Now Admitted morning of
surgery Mobilize day of
surgery or POD 1 Usually WBAT LOS < 5days
Ganz, 2004
And, the FUTURE… is it already here???........
Charnley THA
Sir John Charnley introduced the THA worldwide in 1960s
“…one of the most successful surgical interventions ever developed.”
25-year follow-up of 1689 patients (2000 arthroplasties) who had Charnley THA between 1969 and 1971:
• 461 patients still living• 77.5% free of reoperation• 80.9% free of revision or removal of the implant for any reason• 86.5% free of revision or removal for aseptic loosening
Berry et al., 2002Image: www.totaljoints.info/ Charnley_foto.jpg
Standard THA
Standard total hip arthroplasty • Incision > 10 cm
» Posterior lateral» Anterior lateral» Direct lateral» Transtrochanteric
Pros & Cons of Approaches
Posterolateral approach• Return to normal abductor strength and
ambulation is faster in the posterolateral• Higher rates of dislocation than other
approaches
Lateral & transtrochanteric approaches• Higher rates of post op limp due to gluteal
nerve injury or avulsion of gluteal flap Wenz et al., 2002
Optimal Approach?
Cochrane Systematic Review was done to determine optimal approach for adults with OA
Insufficient data to reach firm conclusion
Jolles & Bogoch, 2006
Complications DVT (8% to 70%) Leg length discrepancy Component malalignment Infection Improper implant fixation to surrounding
bone Nerve palsy Prosthetic hip dislocation
Otto, 2005
Revisions with Charnley THA
• Men had 2-fold higher rate of revision for aseptic loosening than women
• Patients with inflammatory arthritis were at lower risk of needing revision compared to patients with osteoarthritis
• Younger age at time of surgery, increased rate of acetabular > femoral component failure
Berry et al., 2002
Nerve Palsy
Prevalence rate of 0.17% in one review of 27,000 patients
Risk factors: hip dysplasia, posttraumatic arthritis, posterior approach,
lengthening > 1.1cm
70% of patients with incomplete palsy recovered fully
36% of patients with complete palsy recovered fully at a mean of 21 months
Huo et al., 2006
Cumulative Long-term Risk of Dislocation
Retrospective study 5459 patients s/p Charnley THA between 1969 and 1984
routinely followed until revision or death
4.8% dislocated
Highest risk in first year s/p surgery
Patients at highest risk:• females, those with dx of osteonecrosis of femoral head,
acute fx, or nonunion of proximal part of femur
Berry et al., 2004
Late Dislocation
15964 pts s/p THA between 1969 & 1995
32% of the dislocated hips first dislocated 5 or more years after primary THA
(median 11.3 yrs)
Late dislocations associated with:• long-standing problem with prosthesis, trauma, neurologic decline,
polyethylene wear, or combination
Image: www.wheelessonline.com/ image8/adihp1.jpg
Knoch et al., 2002
Are Hip Precautions Necessary?
499 patients s/p THA via anterolateral approach
No post-operative restrictions
3 dislocations within 6 weeks post-op (0.6%)
Stable hip achieved after closed reduction
Low early dislocation rate can be achieved using anterolateral approach without restrictions
Talbot et al., 2002
Treatment of Dislocation
Cochrane Systematic Review was completed to determine the best methods of treatment of recurrent dislocation following THA
No studies met their search criteria
Recommended multi-center study
Khan et al., 2006
Comparing Cemented vs. Cementless
Cemented technique:• 98% survivorship of implant at 10 years• 93% survivorship of implant at 25 years
Cementless technique:• Similar to above numbers for femoral
component, and better with acetabular component at 15 year mark
Cementless technique is now preferred method, especially in younger patients
Jones, Westby, et al., 2005
Weight Bearing with Cementless THA
In the ole days: NWB &/or PWB Now: WBAT/FWB Rationale:
• NWB and TDWB produces greater joint pressure than FWB
• FWB does not adversely affect bone ingrowth or prosthetic stability
Jones, Westby et al., 2005
What Else Has Changed Since the Ole Days?
Trend towards less stiff & more biologically inert metal alloys
Greater use of modularity
Different bearing surface options
Experiments with bioactive ceramic coatings that increase bone ingrowth
Jones, Westby et al., 2005
Evolution in Bearing Surfaces
Metal-on-polyethylene• Problems with debris & osteolysis
Metal on cross-linked polyethylene• Greater wear resistance
Metal-on-metal• Low wear rates• Increasingly used in young, active patients
Ceramic on cross-linked polyethylene Ceramic on ceramic
• Low risk of ceramic bearing fracture
Jones, Westby et al., 2005
Impact of Analgesia Choice
• Compared 45 patients undergoing classic THA (3 groups of 15)
» IV patient-controlled analgesia with morphine» Continuous femoral nerve sheath block (FNB)» Continuous epidural analgesia
• All 3 provide similar pain relief & allow similar hip rehab
• FNB is associated with less side effects, so is recommended as first choice for analgesia
Singleyn et al., 2005
What is the Evidence Related to
THA & Rehabilitation?
Shift in Focus of Outcome Studies (THA & TKA)
Past research focused on surgical/technical aspects of surgery
Recent research uses more patient-centered outcomes
Outcome Measures in the Literature for THA
Harris Hip Score FIM
Oxford Hip ScoreWOMAC
SF-12HQ-12
Iowa Level of Assistance Scale12-Item Hip Questionnaire
Visual Analogue Scale
General Outcomes
Overall satisfaction with outcomes “good” to “excellent”
Patients s/p THA had SF-36 scores closer to the norm than patients s/p TKA
Predictors of overall satisfaction with THA: older age, not living alone, worse preoperative hip scale score, shorter LOS
Jones et al., 2005
What We Don’t Know
No randomized controlled trials have been done to determine the most effective rehab protocol
No prospective studies have determined the advantage of inpatient rehab post THA
No specific data on the type and duration of ROM restrictions
What We Are Not Sure About
Role of pre-op education• Inconsistent outcomes, but the studies have
generally reported decreased post-op pain, medication use, LOS, and fear/anxiety
Effect of pre-op exercise• Some evidence that pre-op exercise is of
benefit
Jones, Westby et al., 2005
What We Are Not So Sure About
It has not been determined if inpatient, outpatient, or home-based rehabilitation provides better long-term results and patient satisfaction
But more studies are appearing…
Jones, Westby et al., 2005
What We Do Know
Early transfer to inpatient rehabilitation is associated with faster achievement of goals
Very low hematocrit at inpatient rehabilitation admission is related to longer LOS & greater hospital charges, but did not impede overall gains in function (THA & TKA)
Munin et al. in Jones, Westby et al., 2005
Vincent & Vincent, 2007
What We Do Know Ongoing impairments and functional deficits for
as long as 2 years post THA
Of 67 patients treated with unilateral THA (original and revised) who presented for rehab with problems
6-9 weeks to one year post-op…
47% hip abductor weakness 28% muscle contracture 13% limb length difference 12% malalignment
> See article for treatment suggestionsBhave et al., 2005
Jones, Westby et al., 2005
Home Programs
Jan et al., 2004: • Patients s/p THA > 1.5 years in the past underwent a 12-
week home program that included hip flexion ROM, low resistance strengthening hip flex/ext/abd, and 30 min walking every day
• Exercise-high compliance group showed greater improvement in strength on operated side, fast walking speed, and functional score on Harris Hip Score than exercise-low compliance and control groups
• Recommend HEP 3x/week for training effect
Weight Bearing and Postural Stability Exercises
Trudelle-Jackson & Smith, 2004:• 34 subjects who had undergone THA 4-12 months
previously; 28 completed the study
• 8 week intervention: experimental group rec’d strength & postural stability exercises; control group rec’d basic isometric & AROM
• Exercise program emphasizing weight bearing & postural stability significantly improved muscle strength, postural stability & self-perceived function
**Study supported by the Texas Physical Therapy Foundation
Treadmill Training
Hesse et al., 2003: Treadmill training with Body-Weight Support is more effective than conventional PT at restoring symmetrical independent walking after hip replacement
White & Lifeso, 2005: Treadmill walking program may help persons with a THA achieve more symmetric gait
Biomechanical Considerations Related to Rehab
Hip exercises (such as SLRs) are more stressful to hip than walking
Functional activities including descending stairs, getting out of a chair, and bending/lifting with bent knees put the most stress on hips and knees
Jones, Westby, et al., 2005
Issues Related to Sports & Recreational Activities During daily activities, loads of 3-4 X body weight
occur
5-10 X in sports activities to 25X with weight lifting
Increased speed of walking or running, increased loads
But slower than “normal walking speed” also increases joint forces
Kuster, 2002
Jones, Westby, et al., 2005
Risk vs Benefit of Inactivity?
Strong evidence exists that total joint in INACTIVE person will show less wear than that in an active person
But, exercise will decrease fall risk, increase bone density & thus prosthesis fixation (amongst other benefits!!)
Kuster, 2002
Sports Activity Recommendations Recommendations on athletic activities after joint
replacement are based on opinions of orthopedic surgeons, not research
Consensus recommendations for patients s/p THA per 1999 Hip Society Survey
• Recommended/allowed – e.g., swimming, walking• Allowed with experience – e.g., canoeing, hiking,
XC skiing• Not recommended – e.g., high impact aerobics, jogging• No conclusion – e.g., speed walking, downhill skiing,
weight machines, ice skating
Kuster, 2002
When Can Patients Resume Sexual Relations After THA?
67% 254 surgeons surveyed recommended waiting 1 to 3 mos. following THA
30% would allow within first 4 weeks
5 safe positions for men and 3 for women were approved by 90% surgeons
Dahm et al., 2004
Exercise & Activity Recommendations
Patients should be advised to comply with their exercise programs for at least one year after surgery
Avoid sporting activities that create high compressive or rotary forces or increase risk of injury to the new joint
Jones, Westby, et al., 2005
Minimally-invasive THA General definition: incision < 10 cm Strict definition: incisions that do not
involve cutting muscles or tendons
Single incision (1-MITHA)• Modification of old approach
» E.g., top half of post-lat or ant-lat approach
• May be less cutting of muscles/tendons, or not
Two incisions (2-MITHA)• New approach• Use intermuscular planes to access joint
2-MITHA
Anterior incision: over femoral neck; femoral head & neck removed; acetabular component placed
Posterior incision: in line with femoral canal; femoral component placed(Berry DJ et al., 2003 - http://ezproxy.twu.edu:2754/cgi/content/full/85/11/2235)
Enthusiasm vs. Skepticism
Potential for quicker recovery
Better cosmesis Less perceived invasion
of the body M-I procedures work
well for other surgeries Patients are asking for
MITHA
Potential for increased complications
• Smaller visual field• Learning curve
Difficult to perform studies without observer or selection bias
Are short-term benefits worth increased risk?
Why fix what isn’t broken? (classic THA is one of most successful operations invented)
Is it really minimally invasive?Berry, 2005
Is MITHA ReallyMinimally Invasive?
Mardones et al., 2005• 2-MITHA & posterior approach 1-MITHA
performed on 10 cadavers• Authors conclude that they cannot support 2-
MITHA can be done reliably without substantial damage to abductor muscles, external rotator muscles or both
• Abductor muscle damage also occurred in every 1-MITHA
Overview of 2-MITHAper Dr. Richard Berger
(surgeon-developer of 2-MITHA)
Best candidate: thin woman with atrophic changes
Need specialized instruments Fluoroscopy used during procedure Computerized navigation systems might
improve technique Limited to cementless application Surgery itself is more expensive, but shorter
hospital stay & rehabBerger, 2004
Berger: 2-MITHA
Berger et al., 2004• 100 patients received 2-MITHA with minimal
soft tissue trauma, capsule incised not excised• Initiated WBAT on day of surgery with no
post-op precautions• All patients independent with transfer,
ambulation w/ crutches, and stairs within 23 hours
• Mean age of 56 years old
Berger: 2-MITHA
• Mean of 6 days to discontinue crutch use, d/c narcotic pain meds, and start driving
• Mean of 8 days to return to work• Mean of 9 days to d/c any assistive
devices• Mean of 16 days to walk ½ mile• No readmissions, dislocations,
reoperations by 3 months follow-up
2-MITHA: on the other hand…
Pagnano et al., 2005• 80 patients treated with 2-MITHA, compared
with standard posterior approach done in past• Modest early functional outcomes
» 2.8 days in hospital vs. 5.2 in control» 90% d/c’d home vs. 65% in control
• But, there have been improvements in anesthesia and lifting of WB restrictions since ‘control’ group operated on, and so these might have contributed to better outcomes
2-MITHA: on the other hand…
Pagnano et al., 2005• 14% complication rate• 5% required reoperation• Older, obese women at risk in particular• Unpredictable technical challenges• Complications not just related to learning curve• Mean age of 70 years old
1-MITHA
Woolson et al., 2004• 50 patients with 1-MITHA compared with 85
patients with standard incision• No significant differences in average surgical
time, intraoperative blood loss, in-hospital transfusion rate, LOS, or disposition
• 1-MITHA had significantly increased risk of wound complication, acetabular component malposition, and poor fit/fill of femoral components
• No benefit except smaller scar
MITHA
Advances in practice are ahead of the evidence
Much more research is needed
One More Surgical Option
Hip resurfacing
(standard vs. mini-incision)
http://www.totaljoints.info/surface_hip_replace.htm
QUESTIONS
&
DISCUSSION
About THAs
Time for TKAs!
TKA: Another Trip Down Memory Lane
1970s Admitted 1-2 days
before surgery Bedrest 2-3 days post-
op Ambulation with knee
splint begun POD 3 Knee ROM begun POD 7 No discharge until knee
flex = 90
Now Admitted morning of
surgery Mobilize day of surgery
or POD 1 Usually WBAT LOS < 5days CPMs placed in post-op
Ganz, 2004
Cemented TKA
Cemented TKA is current gold-standard
10-14 year survival rate of 94-98%
Cobalt-chromium alloy femur articulating with standard polyethylene tibial surface is most common
Image: http://www.nlm.nih.gov/medlineplus/kneereplacement.html Jones, Westby et al., 2005
TKA Options
Not enough evidence to say whether keeping or removing PCL is best
Recent literature synthesis suggests that resurfacing the patella probably improves outcomes and pain-free function
Jacobs et al., 2007
Jones, Westby et al., 2005
Reducing Polyethylene Wear Use of cross-linked polyethylene decreases
wear – but long-term effectiveness has not been established
Use of rotating platform or mobile bearing knee implants are used to decrease contact stresses at implant interface
Mobile bearing knee implants provide about the same amount of ROM and pain relief as fixed bearing implants
Jones, Westby et al., 2005
Jacobs et al., 2001
What Is the Evidence Related to TKA & Rehabilitation?
Outcome Measures in TKA Literature
FIM Lower Extremity Functional Scale Six-Minute Walk Test SF-36 WOMAC Knee Society Clinical Rating System
Patient Satisfaction & Pain
15 year follow-up study of 4606 primary TKAs
Men, patients with OA, and those requiring revision indicated least satisfaction
Older patients, females, and patients without revisions reported the least pain
Roberts et al., 2007
What We Don’t Know
No randomized controlled trials have been done to determine the most effective rehabilitation protocol
No studies have prospectively assessed benefit of inpatient rehab post-TKA
Jones, Westby et al., 2005
What We Are Not Sure About
Role of pre-op education• Inconsistent outcomes, but the studies have
generally reported decreased post-op pain, medication use, LOS, and fear/anxiety
Pre-op exercise• Inconclusive studies• Improvement with pre-op function but not in
post-op recovery, decrease of LOS or complications
Jones, Westby et al., 2005
What We Are Not So Sure About
It has not been determined if inpatient, outpatient, or home-based rehabilitation provides better long-term results and patient satisfaction
But more studies are appearing…
Jones, Westby et al., 2005
What We Do Know
Significant long-term impairments and disability (including pain) can continue for one year or more post-TKA
Jones, Westby et al., 2005
Functional Activities
Systematic Review
Exercises based on functional activities may be more effective than traditional exercise programs (ROM & isometrics)
Any benefits seen after treatment did not persist to one year follow up
Lowe et al., 2007
Rehab Progress Post TKA Repeated measurements taken over one year period
of patients post TKA who had received short-term inpatient rehab, HEP, and some had additional rehab in community
Greatest improvements found in first 12 weeks post-TKA
Slower improvement 12-26 weeks
Little improvement post 26 weeks
Kennedy et al., 2008
Continuous Passive Motion Cochrane Systematic Review
CPM + PT significantly increased active knee flexion, decreased length of stay, and decreased the need for post-op manipulation (compared to PT alone)
CPM may improve short-term rehabilitation
But CPM does not appear to offer long-term advantage
Milne et al., 2007
Jones, Westby et al., 2005
Obesity & TKA
Review of recent literature
Conflicting evidence as to whether obese patients have lower functional gains and higher complication rates
Thompson et al., 2008
Extensor Mechanism Disruption
290 patients post TKA
6 had extensor mechanism disruption
This group had overall worse functional outcomes, requiring intensive rehab
Schoderbek et al., 2006
Bilateral TKAs
Compared 12 patients with unilateral TKA to gender/age/BMI-matched patients with bilateral TKAs
Short-term and long-term outcomes were equal by 12 weeks, except quad strength
Quad strength was equal by 52 weeks
Patterson & Snyder-Mackler, 2006
Sports & Activity Recommendations
Knee Society recommendations: Suitable: cycling, swimming, low-resistance
rowing, walking, hiking, low-resistance weight-lifting, ballroom dancing, square dancing
Suitable but more risky: downhill skiiing, ice-skating, speed walking, hunting, low-impact aerobics, volleyball
Avoid: Baseball, basketball, football, hockey, soccer, high-impact aerobics, jogging, parachuting, power-lifting
http://www.kneesociety.org/index.asp/fuseaction/site.totalKnee
Minimally Invasive TKA
Shorter incision Quadriceps sparing
http://www.orthop.washington.edu/uw/tabID__3376/ItemID__25/mid__10357/wversion__Staging/index__False/DesktopModules/Pictures/PictureView.aspx
Minimally Invasive TKA
Early, limited results:• Better ROM• Less blood loss• Shorter LOS
No long-term studies yet
Jones, Westby et al., 2005
Image: http://www.orthop.washington.edu/uw/tabID__3376/print__full/ItemID__68/mid__0/Articles/Default.aspx
Minimally Invasive TKA First 100 MITKAs were compared to previous 50
standard TKAs by one high volume surgeon
Longer operative time, less accuracy, more patellar tilt in first 25 MITKAs
Overall, shorter LOS, less need for inpatient rehab, less narcotic usage, and less need for assistive devices at 2 weeks post-op
Conclusion: Learning curve may be too long for low-volume surgeon
King et al., 2007
Unicompartmental Arthroplasty
“Partial” knee replacement Usually done with minimally
invasive technique
Image: http://www.orthop.washington.edu/uw/minimallyinvasive/tabID__3376/ItemID__7/PageID__3/Articles/Default.aspx
Unicompartmental Arthroplasty
More rapid recovery Minimal bone loss Less pain Shorter LOS 10-15 year survival rates range from
95-98%
Jones, Westby et al., 2005
QUESTIONS
&
DISCUSSION
About TKAs
Conclusion - Key Points
Surgical techniques and subsequent rehabilitation of THA & TKA patients continue to evolve
All minimally-invasive arthroplasties are not equal
Still much controversy amongst orthopedic surgeons as to whether benefits outweigh costs & risks of minimally invasive arthroplasties
More research related to THAs/TKAs rehabilitation is needed!
Resources for Evidence-Based Practice & Best Practices
Open Door:• Easy access to the literature• Find it in the “Research” section of www.apta.org
APTA Listservs– Geriatrics Section– Acute Care Section >> Quick and easy access to faculty & clinicians
who can help answer your questions
RESEARCH
Always use it!
Maybe do it?
Please support it!
Texas Physical Therapy Foundation
Foundation for Physical Therapy
THANK YOU!