Total Joint Replacement Rehabilitation

Updated: Apr 15, 2016
  • Author: Abraham T Rasul, Jr, MD, FAAPMR, FCCP; Chief Editor: Stephen Kishner, MD, MHA  more...
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Overview

Overview

Postoperative rehabilitation is of the utmost importance following total joint replacement in order to ensure pain-free function of the joint and improve the patient's quality of life (QOL).

Total joint replacement, or arthroplasty, represents a significant advance in the treatment of painful and disabling joint pathologies. Such surgery can be performed on any joints of the body, including the hip, knee, ankle, foot, shoulder, elbow, wrist, and fingers. Among these procedures, hip and knee total joint replacements, which are the focus of this article, are by far the most common. (See the images below.)

Image from a patient who had a normal total hip ar Image from a patient who had a normal total hip arthroplasty. This reformatted, coronal computed tomography (CT) scan shows the femoral (ceramic head [right yellow arrow], metal stem, cementless, cable) and acetabular (ceramic cup [top yellow arrow], metal backing, cementless) components.
A total knee replacement prosthesis before implant A total knee replacement prosthesis before implantation.

The number of joint replacements that are performed annually has been increasing steadily, with 234,000 total hip replacements (THRs) and 478,000 total knee replacements (TKRs) performed in the United States in 2004. [1]

Terminology

Terms pertinent to total joint replacement surgery include the following:

  • 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 (see the image below)
    Image from a patient who had a normal bipolar hemi Image from a patient who had a normal bipolar hemiarthroplasty. This anteroposterior radiograph shows the femoral (metal head and stem, cemented) and acetabular (polyethylene cup, metal backing) components
  • 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)
    Definitive components of total knee arthroplasty, Definitive components of total knee arthroplasty, in situ.
  • Unicompartmental knee replacement (unicompartmental arthroplasty) - Replacement only of the medial or lateral tibiofemoral compartment of the knee (see the image below)
    Radiograph demonstrating a medial unicompartmental Radiograph demonstrating a medial unicompartmental replacement. Note the relative preservation of the lateral joint compartment.
  • 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 fracture-healing model (see the image below)
    Radiograph of an uncemented, hydroxyapatite-coated Radiograph of an uncemented, hydroxyapatite-coated total knee replacement. No gaps are present in the bone-prosthesis junction, indicating incorporation of the bone onto the prosthesis.
  • 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 (see the image below)
    Image from a patient who had a cementless total hi Image from a patient who had a cementless total hip arthroplasty with a subsequent loose femoral component. This anteroposterior radiograph shows a lucency of over 2mm (arrow) around the femoral stem due to an abnormal distal toggling motion. Note the presence of sclerosis at the femoral stem tip, which is termed pedestal formation.

Patient education

For patient education information, see the Arthritis Center, as well as Knee Joint Replacement and Total Hip Replacement.

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Managing Comorbidities

During the initial evaluation of the patient, the physician must perform a thorough physical examination, not just an examination of the affected joint. Associated medical conditions also need to be identified and addressed, because these comorbidities directly impact the outcome of rehabilitation. Communicating with the patient's primary care physician ensures that there is continuity of treatment of associated medical conditions. Medications may need to be changed or modified, depending on the patient's vital signs and laboratory profiles.

Nutrition and hydration

Elderly patients are at risk for malnutrition or dehydration stemming from physical limitations or cognitive deficits. These patients need to be screened by a dietitian for appropriate nutritional intake. Dehydration can lead to acute metabolic or renal problems that affect the patient's participation in his or her rehabilitation program.

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Pain Control

Adequate analgesia for the patient should be a priority during rehabilitation. [2] It must be remembered that these patients have undergone a major joint reconstruction and may experience moderate to severe pain. It should also be kept in mind that with any surgical procedure, complications, such as infection and neurovascular injuries, can cause postoperative pain.

The administration of analgesics should be performed around the clock rather than just on an as needed (prn) basis. With prn dosing schedules, the analgesics are usually given too close to the time that patients are seen for therapeutic exercises. Consequently, patients complain of pain and are not as cooperative as they would have been had they been following a regular pain medication schedule.

A long-acting narcotic analgesic provides extended pain relief in appropriate cases. However, attention to side effects of these narcotic analgesics is a priority. Elderly patients, for example, are prone to develop side effects, such as mental status changes, that limit their participation in rehabilitation sessions. These individuals are perceived as confused and uncooperative and are therefore thought of as poor candidates for rehabilitation. Long-acting narcotic analgesics should be tapered once this becomes appropriate and should subsequently be changed to a prn schedule.

A prospective, randomized, controlled study by Di Francesco et al indicated that levobupivacaine administered through a pain-control infusion pump effectively relieves pain following total knee arthroplasty, reducing the amount of narcotics needed by the patient as well as adverse events and length of hospital stay. The study involved 55 patients who underwent unilateral total knee arthroplasty for osteoarthritis, including 27 controls. [3]

Diagnostic strategies

Determination of the cause of pain is a very important aspect of pain treatment. The physician may want to take the following questions into consideration:

  • Is the patient suffering from pain at the operative site or from joint pain, periarticular pain, or neuropathic or radicular pain
  • Is the pain associated with fever
  • Is the pain associated with weight bearing or range of motion (ROM)
  • Is there evidence of a vascular compromise associated with the pain

An appropriate diagnostic workup should be performed to identify the cause of pain. For example, a complete blood count (CBC), wound cultures, and erythrocyte sedimentation rate (ESR) tests would be performed in cases of suggested infection

If appropriate, an electromyogram (EMG) and a radiologic exam, using radiography, ultrasonography, magnetic resonance imaging (MRI), or computed tomography (CT) scanning, should be performed in cases that suggest nerve injury. Radiologic evaluations may be limited to plain films, because the presence of a metallic implant limits the use of MRI and CT scanning.

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Bowel and Bladder Management

Constipation is one of the most frequent complaints during rehabilitation. This condition can be caused by decreased mobility or postanesthesia effects; it can also be a side effect of narcotic analgesics. If untreated, constipation can lead to nausea and vomiting, bowel obstruction, and even sepsis, especially in the elderly patient.

An adequate bowel program using stool softeners and laxatives is needed. An enema may be appropriate in some cases. At times, patients are admitted to the rehabilitation unit with a Foley catheter still in place. The Foley catheter should be removed if there has been no problem with bladder retention. Patients with persistent bladder dysfunction should be referred to a urologist for evaluation.

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Prevention of Thromboembolic Complications

Compared with other surgical procedures, joint replacement is associated with a high risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Without prophylaxis, the incidence of DVT after total knee replacement (TKR) is 50-84%, and after total hip replacement (THR), 47-64%. With prophylaxis that uses anticoagulation therapies, the incidence is reduced 22-57% after TKR and 6-24% after THR.

Clinical surveillance of thromboembolic disorders is not reliable. The accuracy of relying on signs and symptoms that are attributed to DVT is less than 50%. Any suggestion of DVT warrants a radiologic evaluation, such as a Doppler ultrasonogram. A venogram may be necessary.

If a PE is suggested, a ventilation-perfusion (VQ) scan should be performed. A pulmonary angiogram also may be necessary. A pulmonologist should be consulted in these cases. Although uncommon, distal DVT has been associated with PE.

Prophylaxis

Each institution has its own prophylaxis protocol, but most use low–molecular-weight heparin (such as enoxaparin) or warfarin. [4, 5, 6] Low–molecular-weight heparin is administered subcutaneously at 30mg twice daily or every 12 hours or at 40mg once daily, depending on the institution. The warfarin dose is titrated to maintain an activated partial thromboplastin time/international normalized ratio (aPTT/INR) of 2.0-3.0. The duration of prophylaxis varies. Most orthopedic surgeons, however, use 3 weeks as an appropriate time frame.

Mechanical devices

If the use of anticoagulation therapy is contraindicated, mechanical devices, including intermittent pneumatic stockings, have proven to be of benefit. Using the same principle, newer devices that apply compression only around the foot and ankle area have been used (PlexiPulse boots). High-risk patients may need placement of an inferior vena cava (IVC) filter.

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Precautions Against Hip Dislocation

Standard precautions given to patients to prevent posterior hip dislocation following total hip replacement (THR) include the following:

  • Do not cross your legs
  • Put a pillow between your legs if you lie on your side
  • Do not turn your leg inward
  • Sit only on elevated chairs or toilet seats
  • Do not bend over from the hips to reach objects or tie your shoes
  • An assistive device or reacher is necessary to safely perform activities of daily living (ADL)

In some patients at risk for hip dislocation, individualized precautions are necessary, and the use of a hip abduction brace may be required.

An increase has occurred in the number of hip replacements performed through the anterior surgical approach. Among the advantages of this procedure is the fact that it is minimally invasive, preserving the hip musculature. The posterior approach, in contrast, involves the detachment of the posterior hip rotator muscles and the mobilization of the gluteus medius muscle.

With the anterior approach, the risk for hip dislocation reportedly is reduced, and the patient has almost no restriction of physical activity during the postoperative period. Less tissue injury and, subsequently, less pain occur. In addition, recovery is faster. [7]  On the other hand, a study by Maratt et al found no difference in the risk of dislocation between the direct anterior approach and a modern posterior approach in total hip arthroplasty. However, the conclusions were drawn from short-term outcome and complication data. [8]

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Restrictions on Weight Bearing and Exercise

Weight-bearing and exercise restrictions following total joint replacement include the following (in the situations below, clarification should be received specifically from the orthopedic surgeon):

  • Patients with cemented joint replacements can weight bear as tolerated (WBAT) unless the operative procedure involved a soft-tissue repair or internal fixation of bone
  • Patients with cementless, or ingrowth, joint replacements are put on partial weight bearing (PWB) or toe-touch weight bearing (TTWB) for 6 weeks to allow maximum bony ingrowth to take place
  • A knee immobilizer sometimes is worn by the patient after a total knee replacement until quadriceps strength is regained; the use of the immobilizer is typically discontinued once the patient can do straight leg raising (SLR) without difficulty
  • Ambulating with weak quadriceps muscles can lead to instability or giving way of the knee, which can be painful and may lead to unnecessary stress on the newly implanted joint [9]
  • Quadriceps ruptures can result from high tensile forces acting on the quadriceps tendon when the patient tries to break a fall; in certain situations, careful resistive or gradual ROM exercises are initiated
  • During the surgical approach to the hip joint, a trochanteric osteotomy, which involves detachment of the hip abductor mechanism, may be necessary, especially in revision surgery; after the hip abductor mechanism is repaired, the patient should avoid abduction exercises
  • With surgical approaches to the knee, an extensive quadriceps exposure may require repair or a patellar tendon exposure may need to be fixed; ROM exercises may have to be limited and gradually increased
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Continuous Passive Motion After Total Knee Replacement

The issue of the utility of employing a continuous passive motion (CPM) machine to improve ROM of the knee after total knee replacement (TKR) has never been resolved. [10, 11, 12, 13, 14]

Outcome measures focus only on the ROM that is measured postoperatively and then again at the time of discharge or at a later follow-up time. To decide whether to use a CPM machine, the physician must review the kinematics of the gait cycle. These data, in turn, need to be analyzed with regard to the immediate functional needs of each patient.

Research has shown that the total knee flexion needed to ambulate on level surfaces is approximately 65-70 º. In the preswing stage, flexion of 35-40 º is needed to clear the foot, followed by an additional 30 º in the initial swing, assuming that the patient has normal hip function. To be able to do stair climbing, approximately 83 º of knee flexion is required to clear the foot. Similar measurements have been obtained in other studies; joint reaction forces also have been measured. [15]

A patient who lives in a 1-level home needs less knee flexion during the immediate postoperative period than does a patient who lives in a multilevel home. Another situation to consider is whether the patient lives alone. This individual requires maximum knee flexion to negotiate stairs independently and safely. [16]

Although there has been no agreement on the benefits of using a CPM machine in the perioperative period, there has been unanimity of opinion that patients achieve the same amount of knee flexion on long-term follow-up with or without the use of a CPM machine.

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Total Hip Replacement Exercise Protocol

A number of rehabilitation exercise protocols are used by various institutions for total knee or hip replacement; however, the functional goals of these protocols are the same. [17] This section discusses total hip replacement (THR) protocol.

Preoperative (1-2 weeks prior to surgery)

Preoperatively, the protocol includes educating the patient about the surgical process and its outcomes, instructing him or her on a postoperative exercise program, and assessing the patient's home environment. It also involves educating the patient on total hip precautions, as follows:

  • No hip flexion beyond 90°
  • No crossing of the legs (hip adduction beyond neutral)
  • No hip internal rotation past neutral

The above precautions apply to the posterior surgical approach to the hip. With the anterior hip approach, the patient can cross his or her legs and internally rotate the hip, although positions that involve extreme hip extension and external rotation will dislocate the hip.

Postoperative (day 1)

The first-day postoperative protocol includes the following:

  • Initiation of bedside exercises - Such as ankle pumps, quadriceps sets, and gluteal sets
  • Review of hip precautions and weight-bearing status
  • Initiation of bed mobility and transfer training - Bed to/from chair

Postoperative (day 2)

The second-day postoperative protocol includes the following:

  • Initiation of gait training with the use of assistive devices, such as crutches and a walker
  • Continuation of functional transfer training

Postoperative (days 3-5 or on discharge to the rehabilitation unit)

The protocol during this period includes the following:

  • Progression of ROM and strengthening exercises to the patient's tolerance
  • Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device [16]
  • Progression of ADL training

Rahmann et al found that aquatic physiotherapy can promote early recovery of hip strength in patients who have undergone hip or knee arthroplasty. [18] In a randomized, controlled trial that compared the results of supplementary inpatient physiotherapies—aquatic physiotherapy, nonspecific water exercise, and additional ward physiotherapy—in 65 patients, a specific inpatient aquatic physiotherapy program, begun on day 4, was associated with significantly greater hip abductor strength by day 14.

Postoperative (day 5 to 4 weeks)

The protocol includes the following:

  • Strengthening exercises - For example, seated leg extensions, side-lying/standing hip abduction, standing hip extension and hip abduction, knee bends, bridging
  • Stretching exercises to increase the flexibility of hip muscles
  • Progression of ambulation distance
  • Progression of independence with ADL

A study by Husby et al indicated that maximal strength training, starting 1 week postoperatively, is a valuable addition to conventional rehabilitation after THR. [19] In a randomized, controlled study in 24 patients, one group performed maximal strength training in leg press and abduction only with the operated leg, 5 times weekly for 4 weeks.

Compared with patients who received only conventional rehabilitation, the patients who engaged in strength training demonstrated increased 1-repetition maximum leg press strength, an increased rate of force development, and a tendency toward improved work efficiency. No differences in gait patterns were noted between the groups.

Measurement of leg lengths

Leg lengths are measured meticulously during the preoperative phase to prevent postoperative leg-length discrepancy. Measurement is performed radiologically and clinically by measuring the actual leg lengths. During the operative process, however, leg lengths can change, depending on how the prosthesis is fixed or stabilized or on how much bone needs to be removed, among other surgical considerations.

Therefore, it is important in the postoperative phase to correct any leg-length discrepancy by using appropriate orthoses or heel lifts. The correction of discrepancies has a direct impact on the patient's gait pattern, as well as on the development of low back pain.

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Total Knee Replacement Exercise Protocol

Preoperative (1-2 weeks prior to surgery)

The preoperative protocol includes the following:

  • Education on the surgical process and outcomes
  • Instruction on a postoperative exercise program
  • Assessment of the home environment

Postoperative (day 1)

The first-day postoperative protocol includes the following:

  • Bedside exercises - For example, ankle pumps, quadriceps sets, and gluteal sets
  • Review of weight-bearing status
  • Bed mobility and transfer training - Bed to/from chair

Postoperative (day 2)

The second-day postoperative protocol includes the following:

  • Exercises for active ROM, active-assistive ROM (AAROM), and terminal knee extension
  • Strengthening exercises - For instance, ankle pumps, quadriceps sets, gluteal sets, heel slides, straight leg raises, and isometric hip adduction
  • Gait training with an assistive device and functional transfer training - Such as sit to/from stand, toilet transfers, bed mobility)

Postoperative (days 3-5 or on discharge to the rehabilitation unit)

The protocol during this period includes the following:

  • Progression of ROM and strengthening exercises to the patient's tolerance
  • Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device [16]
  • Progression of ADL training

Postoperative (day 5 to 4 weeks)

The protocol includes the following:

  • Strengthening exercises - Including seated leg extensions, standing hip abduction and extension, knee bends, and short arc quads
  • Stretching of quadriceps and hamstring muscles
  • Progression of ambulation distance
  • Progression of independence with ADL
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