1. chapter 16 Therapeutic Exercise for Joint Replacement

2. History Partial joint replacement began in late 1800s First successful total joint replacement (TJR) –Dr. John Charnley –Total hip –Metal ball, Teflon socket secured with dental cement

3. Today’s Total Joints Metal alloys –Chromium –Cobalt –Titanium Polymers Cement and cementless

4. Longevity and Candidates Early versions lasted: 10 years No one under 70 years old Today’s version last: >20 years Hips: as young as 30s Knees: as young as 50s

5. Terminology Arthroplasty = total joint procedure Also, arthroplasty = replacement, so –THR = THA = total hip –TKR = TKA = total knee –TSR = TSA = total shoulder

6. Arthritis Many kinds Most often candidates for total joint replacements have: –Osteoarthritis –Rheumatoid arthritis –Aseptic necrosis

7. Progression of Arthritis Injury or disease  fraying, thinning  surface degeneration  exposure of bone  pain, disability, deformity Weakness, motion loss Pain, disability, deformity

8. Arthroplasty Risks and Their Management Risk of embolism (deep vein thrombosis) –Management includes thromboembolic disease (TED) hose, early exercise, and ambulation Risk of dislocation –Management includes restricted motion during first postoperative weeks, use of protective splints, and braces

9. Prearthroplasty Treatment Options 1.Medications 1.Non-steroidal anti-inflammatory drugs (NSAIDS) 2.Glucosamine and chondroitin 2.Articular cartilage treatment options 1.Cleaning: arthroscopic debridement 2.Reparative: 1.Abrasion arthroplasty 2.Arthroscopic subchondral drilling 3.Microfracture 3.Restorative: 1.Osteochondral plugs 2.Autologous chondrocyte transplantation

10. Prearthroplasty Candidates Severe joint degeneration Excessive, continual pain Reduced function that interferes with daily activities Muscle weakness and atrophy Loss of motion Pathological gait (for lower extremity) Weakness in other extremity segments

11. Arthroplasty Surgical Procedure Remove articular surface section of each joint end. Select appropriate prosthesis size. Prepare bone for prosthesis. Align prosthesis parts. Cement or cementless introduction of prosthesis to bone. Reapproximate joint ends.

12. Postoperative Care Continuous passive motion (CPM) is an option. TED hose for lower extremity In-bed exercises no later than first day post-op Gait (for lower extremity) on first day Active exercises for non-excised muscles Rehabilitative environment progression –In hospital –At home or in extended care facility –Outpatient program

13. Figure 16.2

14. THA Precautions If gluteus medius was cut, no active abduction for 6 weeks No sitting at 90° or less for first 2-3 months Use abduction pillow in bed for first 2-3 months No crossing of legs No medial rotation of hip beyond 0° (with posterolateral approach) Avoidance of hip extension and lateral rotation (with lateral or anterolateral approach)

15. Figure 16.3

16. TKA Precautions Patient may be able to bear full weight even with a cementless procedure; must be indicated by surgeon Patella dislocation or subluxation may occur. Patient is not to drive car for first 8 weeks. Post-op results are better with patella resurfacing. Quadriceps will be excessively weak, but rehabilitating it is secondary to the following concerns: Pain Prolonged weakness (premorbidly) Edema Surgical procedure

17. Figure 16.4a

18. Figure 16.4b

19. TSA Precautions If rotator cuff is not viable or reparable, reverse TSA (rTSA) may be required. Results for full function with rTSA are less optimal. Deltoid is split, and subscapularis and pectoralis major are excised; therefore, no active exercise for shoulder abduction and medial/lateral rotation for first 4-6 weeks.