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Rehab for Total Joints: From Shoulder to Hip to

Knee

Jaime Holt, PT, MPT, SCS, CSCS

Holt Physical Therapy & Performance Training

jaimeholtpt@gmail.com

Twitter: @HOLTPT1

Biography

APTA Sports Certified Specialist

NSCA Certified Strength and Conditioning Specialist

Owner and Sports Orthopaedic PT at Holt Physical Therapy & Performance Training

PT Consultant NHL Carolina Hurricanes (2007 –2014)

Biography

East Carolina University

BS Exercise Physiology 1995

MS Adapted Physical Education 1997

MPT Physical Therapy 1999

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Mentors

Pete Friesen

Doug Geiger

Gary Gray

Walt Jenkins

Bill Moore

Kevin Wilk

Co-workers

Patients!!

OutlineTKR

Current Research

Knee Anatomy

Radiographs

TKR/UKR/Mobile

Bearing

Exercises

THR

Current Research

Hip Anatomy

Radiographs

Ant vs Post

Exercises

TSR

Current Research

Shoulder Anatomy

Radiographs

Total vs Reverse

Exercises

When is it time?

Lasts 15-20 years??

What advances will we make in next 15 years?

Why be miserable in life when there is an option to improve your quality of life?

Personally: Has to effect your every day activities/sleep etc. and the surgery has to be 80% successful

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Incidence of Total Knee Replacements

Total Knee: Age 50+ Male: 3.4% Female: 4.8%

OA: Age 50+ Male: 9.4% Female: 13.3%

4 million Americans with TKA and 500,000 with TKR

11 million Americans dx with OA

31.6% males and 31.3% females with TKA

Pain after TKA

Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after TKA: A Randomized, Double-Blinded, Placebo-Controlled Trial. Mayoral, Salvat, Martin, Martin, Santiago, Cotarelo, Rodriguez. Evidence Based Complementary and Alternative Medicine. 2013.

Half of the group TPDN pre-op after sedation

TPDN group reached the same degree of pain reduction in 1 month as the placebo group achieved in 6 months!

Early NMES after TKA

Stevens-Lapsley et al. Physical Therapy February 2012

Study regarding early NMES to improve quadriceps muscle strength after TKA

Results: Significant benefit in NMES group one month post op but no difference at 1 year post op

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Biofeedback after TKA

McClelland et al. JOSPT February 2012

Research study on functional and biomechanical outcomes after using biofeedback after TKA

Non-control group showed statistically significant improvement in strength, ROM, function and better symmetry in movement patterns.

Mobile Bearing vs. Fixed Bearings TKR

Bone and Joint Journal April 2013

Breeman, Campbell, Dakin, Fiddian et al

After 5 years TKR functional outcomes, re-operation rates and healthcare costs appear to be the same

Health related Quality of Life after TKR or THA

Archives of Orthopaedic and Trauma Surgery Nov 2012

Improvements observed in the HRQOL at short term after surgery are at least maintained over 7 year follow up

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Why choose UKA vs. TKA?

Orthopaedic Physical Therapy Secrets. 2nd Ed. Placzek and Boyce.

10 year survivorship of UKA in patients over the age of 60 is 96%!

CRITICAL to pick the right patient for this

Knee Arthritis

Most common cause of chronic knee pain and disability

Osteoarthritis (most common), rheumatoid arthritis, post-traumatic arthritis

Pathological Changes in OA

Thinning and damage to articular cartilage

Subchondral bone sclerosis

Marginal bone and cartilage growth as osteophytes

Periarticular muscle wasting

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Clinical Signs of an Acutely Infected Total Joint

Prosthesis

Wound dehiscence or drainage

Pain

Redness

Heat

Swelling

Loosening of prostheses is a sign later on

Total Knee: Anatomy

Total Knee: Anatomy

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Knee OA X Rays

Total Knee Radiographs

Total Knee

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Standard Total Knee

More long term outcome studies

Most common technique for surgeons

Very stable/strong

Standard expected results

Mobile Bearing Knee

Mobile-bearing prostheses permit a limited amount of rotation in the joint that fixed-bearing implants do not. When the mobile-bearing designs were introduced, it was hoped -- but never proven -- that they would increase range of motion.

Need increased strength with mobile bearing

May be more suitable for athletic population

Unicompartmental Replacement

Quicker recovery

Less pain after surgery

Less blood loss

Because the bone, cartilage and ligaments in the healthy parts of the knee are kept, most patients report that a unicompartmental knee replacement feels more “natural”

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TKR Initial Exercises

Patellar mobs

Quad sets with NMES

Heel slides

TKEs

Calf Raises

Weight Shifts

Straight Leg Raises

IT Band CFM

Ankle Pumps

HS stretches

Gastroc/Soleus stretches

TKR Videos

• Total Knee

• TKR Dynamic

• TKR Mini-band

TKR: Advanced ExercisesHip Mini Band Exercises

LE isometric exercises

Step Downs

Star Reaches

Star Lunges

Sliders

Core Exercises

AIS Rope Stretches

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Total Hip Replacement

Incidence of Total Hip Replacements

Total Hip Replacements: 332,000 performed per year

Increased 25% over past decade

Projected to increase 174% by 2030

Average surgical cost in the US is $17,000+

Level of Activity 1 Year after THA

Wagenmakers et al. Physical Therapy 2011

Study on physical activity behavior of patients one year after THA

Patients that were more physically active had the following characteristics:

Younger in age, Male, Lower BMI

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Functional Recovery during First Post Op Year THA

Journal of Biomechanics February 2011

one incision and two incision approaches

Daily step counts the same after 1 year

was decreased hip abduction strength at 1 year on two incision approach

Hip Strength Recovery w Direct Anterior and Posterior Approaches

Bone and Joint Journal , 2013

Rathod, Fukunga, Deshmukh, Ranawat and Rodriguez

Both DAA and PA offer similar recovery in muscle strength up to 6 months with expections of ER weakness in PA and hip flexion weakness in DAA at 6 weeks

Reduced Post Op Pain in THA with minimal invasive anterior

approach

International Orthopedics, March 2012

Decreased overall post operative pain, decreased pain meds, decreased hospital stay time

Increased PT pain but could be due to being too aggressive due to approach

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Total Hip Replacement: Anatomy

Total Hip Replacement: Anatomy

Total Hip Replacement: Anatomy

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Total Hip Replacement: Anatomy

THR: Radiographs

THR: Radiographs

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Total Hip Radiographs

Not What You Want!

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THR: Anterior vs Posterior Approach

Posterior Approach

Benefits

Proven track record of success

Low complication rate

Minimally invasive surgical approach available

No violation of abductor muscles

Posterior Approach

Potential Risks

Early dislocation rate higher than anterior approach

Must follow hip precautions

Overall risk of hip dislocation is 1-2%

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Total Hip Precautions

Usually til 6 weeks post op with posterior approach but......

No hip flexion greater than 90 degrees

No hip adduction

No hip internal rotation

Anterior Approach

Benefits

4 inch incision in front of leg between glute med and TFL

Can reach the joint by separating the muscles not cutting them

Swifter recovery?

Shorter hospital stays

Anterior Approach

Potential Risks

Substantial risk of a numb, burning or tingling sensation in the front of the thigh due to proximity of lateral femoral cutaneous nerve

Not candidates: previous metal implants, muscular, wide pelvis or very obese

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THR: Initial ExercisesPost Op Day 1 to Week 2

Heel slides

Quad sets

Glute sets

SLR ?

Ankle pumps

Supine abduction

Weight shifts

Mini squats

Gait training

WB on involved: hip flex, abduction and extension

Encourage heel to toe gait

THR: Initial ExercisesPost Op Day 1 to Week 2

Heel slides

Quad sets

Glute sets

SLR ?

Ankle pumps

Supine abduction

Weight shifts

Mini squats

Gait training

WB on involved: hip flex, abduction and extension

Encourage heel to toe gait

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THR: Exercise ProgressionWeeks 3-6

Soft tissue prn

Anterior/Medial step ups/downs

Mini squats with T band

Balance Exercises

Sliders

LE Reaches

Gait train: progress from SPC to independent

T Band supine abd

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THR: Advanced ExercisesWeeks 7-12

Initiate sidelying abduction

T Band hip flexion, extension and abduction

LE isometrics

ROM goals: 110 flexion, 30 abduction, 0 extension

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Total Shoulder Replacement

Incidence of Total Shoulder Replacements

Total Shoulder

Approx 27,000 shoulder arthroplasties and 20,000 hemiarthroplasties per year

2/3 in adults age 65 or older

OA primary dx in 43% of hemiarthroplasties and 77% of arthroplasties

Humeral fracture top primary dx leading to hemiarthroplasty

Revision using Reverse Design Prosthesis

Bone and Joint Journal, May 2013

Abdel, Hattrup, Sperling, et al

Decreased pain, increased, fwd flexion

No diff in ER/IR

94% stable at 3 year follow up

40% excellent, 30% satisfactory, 10% unsatisfactory

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Hemiarthroplasty vs TSR for Rotator Cuff Intafct OA

Journal of Shoulder and Elbow Surgery, 2012

Sandow, David, Bentall

6 mos and 1 yr follow up

TSR had less pain, even more so at 2 years

10 years: no diff in function/daily activities

0% HA had no pain and 42% TSR were pain free

Total Shoulder Anatomy

Shoulder Anatomy

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TSR: Radiographs

TSR: Radiographs

Goal of Total Shoulder Replacement

DECREASE PAIN!!!

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Total Shoulder

A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic "cup" is fitted into the shoulder socket (glenoid), and a metal "ball" is attached to the top of the upper arm bone (humerus).

Total Shoulder

A conventional replacement device also uses the rotator cuff muscles to function properly. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.

Reverse Total Shoulder

In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.

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Reverse Total Shoulder

A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles to move the arm. In a healthy shoulder, the rotator cuff muscles help position and power the arm during range of motion.

TSR: Protection PhaseGoals

Protect healing repair

Decrease pain and swelling

Preserve strength of the elbow, wrist and hand

Initiate AAROM

TSR: Protection Phase(1-2 Weeks)

FF to 90 deg

Abd to 75 deg

ER to 30 deg/45abd

IR to 30 deg/45abd

Cont to progress PROM

Initiate joint mobs

Cont initial HEP

Modalities to decrease pain and swelling

Initiate AAROM flex/abdw pulleys and UBE

Isometrics all planes except IR (6 weeks)

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TSR: Protection PhasePrecautions

No lifting heavier than a coffee cup

While lying in supine position, place pillow behind elbow to limit shoulder extension

Keep incision clean and dry

No quick, sudden movements

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TSR: Controlled Strengthening Phase Goals

Protect healing of surgery

Begin to strengthen periscapular muscles

Continue to gradually increase PROM

Progress AAROM

TSR: Controlled Strengthening Phase (3-4 Weeks)

FF to 120 deg

Abd to 90 deg

ER to 50 deg/75abd

IR to 45 deg/75abd

DC sling at 4 weeks

Cont PROM FF and IR

Keep ABD below 90 degand ER less than 50 deg

Table slides (flex, ER and abd)

Cont modalities

Initiate isometric scapular proprioceptive exercises

Initiate light biceps and triceps strengthening

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TSR: Controlled Strengthening Phase Phase

Continue with previous precautions

TSR: Strengthening PhaseGoals

Protect repair

Progress strengthening of scapular muscles; initiate strengthening of RTC muscles

Progress AAROM to AROM

Increase PROM

TSR: Strengthening Phase 6 Weeks

FF to 140 deg

Abd to 120 deg

ER to 75 deg/45Abd

IR to 45 deg/90Abd

Increase UBE

Pulleys

Progress scapular proprioceptive exercises to PRE (T band, DB)

AROM exercises: SL ER, prone flexion, prone HABD, standing scaption

Initiate resistance for IR isometrics

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TSR: Strengthening Phase8 Weeks

Progress patient to full ROM in all planes, equal to unaffected side

Initiate T Band IR/ER

Progress SL ER to PRE

Continue to progress AROM exercises (prone HABD with ER, UE PNF)

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TSR: Strengthening Phase Precautions

No lifting greater than 5 pounds with outstretched arm

No sudden lifting or pushing activities

TSR: Advanced Strengthening Phase Goals

Progress strengthening

Continue to increase ER ROM

Initiate functional strengthening

Begin functional training (return to sport or work)

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TSR: Advanced Strengthening Phase 10 Weeks+

Continue w RTC and scapular PRE’s

Initiate stabilization exercises (Body Blade, WB stabilization exercises, rhythmic stabilizations)

Progress single arm prone exercises

Gradually return the patient to pre-morbid activity level

TSR Videos

• Shoulder Video #1

• Stick Work

• Shoulder Video #2

• Shoulder Strength #1

• Shoulder Strength #2

• Tennis

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Return to Work/Sport

Per MD recommendation

Patient must have full ROM and 5/5 strength in all planes to be considered for return to sports and jobs requiring manual labor/lifting

Conclusion

Questions?

jaimeholtpt@gmail.com

Twitter: @HOLTPT1

References

Abdel MP, Hattrup SJ et al. Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prothesis. Bone Joint J May 2013 Vol 95-B No. 5 668-672.

Stevens-Lapsley JE, Balter JR, Wolfe P, Eckhoff DG and WM Kohrt. Early Neuromuscular Electrical Stimulation to Improve Quadriceps Muscle Strength After Total Knee Arthroplasty: A Randomized Controlled Trial. Physical Therapy, February 2012 Vol 92 No. 2. 210-235.

Wagenmakers R, Stevens M, Groothoff JW, Zijlstra W, et al. Physical Activity Behavior of Patients 1 Year After Primary Total Hip Arthroplasty: A Prospective Multicenter Cohort Study. Physical Therapy, March 2011 Vol. 91 No. 3 373-380.

McClelland J, Zeni J, Haley R and L Snyder-Mackler. Functional and Biomechanical Outcomes After Using Biofeedback for Retraining Symmetrical Movement Patterns After Total Knee Arthroplasty: A Case Report. JOSPT, February 2012 Vol. 42 No. 2 135-144.

Sandow M, David H and Bentall S. Hemiarthroplasty vs Total Shoulder Replacement for Rotator Cuff Intact Osteoarthritis: How do they fare after a decade? J Shoulder and Elbow Surgery; Vol 22: Issue 7; July 2013: 877-885.

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References

Ethgen O, Bruyere O, Richy F, Dardennes C and J Reginster. Health-related quality of life in total hip and total knee arthroplasty: A Qualitative and Systematic Review of the Literature. JBJS. Vol 86; Issue 5; May 2004. 963-974.

Breeman S, Campbell M, Dakin H, Fiddian N, et al. Five-year results of a randomised controlled trial comparing mobile and fixed bearings in total knee replacement.

Mayoral O, Salvat I, Martin MT, et al. Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after Total Knee Arthroplasty: A Randomized, Double Blinded, Placebo Controlled Trial. Evidence Based Complementary and Alternative Medicine. Vol 2013. Article ID 694941, 8 pages, 2013.

Goebel S ,Steinert AF, Schillinger J et al. Reduced postoperative pain in the total hip arthroplasty after minimal invasive anterior approach. International Orthopaedics. March 2012, Vol 36, Issue 3, pp. 491-498.

Rathod P, Fukunaga T, Deshmukh A, Ranawat A and J Rodriguez. Hip Strength Recovery with Direct Anterior and Posterior Approach Total Hip Arthroplasty: Are There Any Differences? Bone and Joint Journal 2013. Vol 95-B, No Supp 15, page 312.

Orthopaedic Physical Therapy Secrets. 2nd Edition. Jeffrey D. Placzek and David A Boyce. Elsevier Mosby. 2006.