EVIDENCE-BASED EXAMINATION AND MANAGEMENT OF

JOINT ARTHROPLASTIES

Presented by C&M OrthoSports Inc

Michael Masaracchio, PT, PhD, OCS, SCS, FAAOMPT

Stephen Caronia, PT, DPT, OCS

Hosted by

Downstate Medical Center and the Brooklyn / Staten Island

District of the New York Physical Therapy Association

April 15, 2018

www.cmorthosports.com

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EVIDENCE-BASED EXAMINATION AND MANAGEMENT OF HIP, AND KNEE JOINT ARTHOPLASTY

Sunday April 15th, 2018 Time: 9:00am-4:30pm

Michael Masaracchio PT, PhD, DPT, OCS, SCS, FAAOMPT Steve Caronia PT, DPT, OCS, COMT DESCRIPTION: This course will present a brief review of clinical anatomy and biomechanics of the hip, and knee. The main purpose will be to discuss the evidence-based features of the examination and management of individuals with hip and knee joint arthroplasty with emphasis on therapeutic exercises, and manual therapy interventions within a clinical reasoning framework. In addition, participants will gain insight into the potential complications following surgery, as well as the epidemiology of osteoarthritis and the indications and contra-indications to joint replacement. TARGET AUDIENCE: This course will be intended for physical therapists, physical therapist assistants, and students with varying years of clinical experience. The concepts and principles covered will benefit all participants and enable them to translate this information immediately into clinical practice. INSTRUCTIONAL METHODS: This course will use a combination of lecture, discussion, and lab activities of therapeutic exercises and manual therapy to facilitate learning and exchange of ideas, with an emphasis on clinical decision making in a variety of rehabilitation settings. CONTACT HOURS: All participants that attend the course will receive 8.4 contact hours towards their continuing education requirements in New York State. OBJECTIVES: Upon completion of this course participants will be able to:

1. Understand the relevant clinical anatomy of the hip and knee joints. 2. Understand the relevant biomechanics in open and closed kinetic chain of the hip,

and knee joints. 3. Understand how abnormal anatomy and biomechanics can lead to clinical pathology. 4. Become independent in the examination of individuals following joint arthroplasty

surgery 5. Become independent in recognizing complications following total joint arthroplasty

and making appropriate referrals. 6. Incorporate appropriate therapeutic and manual therapy interventions with evidence-

based guidelines where appropriate in the management of the patients with joint arthroplasties.

7. Be independent in understanding the rehabilitation guidelines for hip, and knee joint replacements based on tissue healing principles.

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8. Understand outcomes related to joint replacements in the acute, subacute, and outpatient settings.

SCHEDULE: Sunday April 15th, 2018 (9:00am-5:00pm) 9:00 – 10:00 Hip and Knee Anatomy and Biomechanics 10:00 – 10:45 Prevalence, Risks of Total Hip Arthroplasty, Surgical Techniques 10:45 – 11:00 Complications 11:00 – 12:00 Rehabilitation – Precautions, Pre-Operative, Post-Operative Care 12:00 – 1:00 Lunch 1:00 – 1:30 Prevalence, Risks of Total Knee Arthroplasty, Surgical Techniques 1:30 – 2:00 Complication 2:00 – 3:00 Rehabilitation – Acute Care, Subacute Care, Outpatient, 3:00 – 5:00 Lab Activities – manual therapy and motor control training

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14. Newman M, et al. Outcomes after metal-on-metal hip resurfacing: could we achieve better function? Arch Phys Med Rehabil. 2008;89:660-666.

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16. Brander V, et al. Rehabilitation after hip and knee joint replacement. An experience and evidence-based approach to care. Arch Phys Med Rehabil. 2006;85:S98-118.

17. Balasubramaniam U, et al. Functional and clinical outcomes following anterior hip replacement: a 5-year comparative study versus posterior approach. Anz J Surg. 2016;86:589-593.

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21. Wang L et al. Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomized controlled trials. British Medical Journal. 2016;6:1-15.

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23. Galea M, et al. A targeted home and center based exercise program for peopleafter total hip replacement: a randomized clinical trial. Arch Phys Med Rehabil. 2008;89:1147-1447.

24. Unlu E, et al. The effect of exercise on hip muscle strength, gait speed, and cadence in patients with total hip arthroplasty: a randomized controlled study. Clin Rehabil. 2007;21:706-711.

25. Borem K, et al. Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises. Int J Sports Phys Ther. 2011;6: 206-223.

26. Maloney W, et al. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004;107:475-482.

27. Beaulieu M, et al. Lower-limb biomechanics during gait do not return to normal following total hip arthroplasty. Gait and Posture. 2010;32:269-283.

28. Ewen A, et al. Post-operative gait analysis in total hip replacement patients – a review of current literature and meta-analysis. Gait and Posture. 2012;36:1-6.

29. Klein G, et al. Return to athletic activity after total hip arthroplasty. J Arthroplasty. 2007;22:171-175.

30. Jacobs C, et al. Sport activity after total hip arthroplasty: changes in surgical technique, implant design, and rehabilitation. J Sports Rehabi. 2009;18:47-59.

31. Wong M. Pocket Orthopedics: Evidence-Based Survival Guide. Jones and Bartlett Publishers. 2010.

32. Copstead L, et al. Pathophysiology. 3rd ed. Lippincott, 2005. 33. Altman R. Criteria for classification of clinical osteoarthritis. J Rheumatol Suppl.

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34. Currier LL, et al. Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization. Phys Ther. 2007;87:1-14.

35. Richmond J, et al. Treatment of Osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009;17:591-600.

36. American Academy of Orthopaedic Surgeons. Facts on Knee Replacements. 2014. Accessed April 17, 2016.

37. Kurtz S, et al. Projections of primary and revision hip and knee arthroplasty in the US from 2005-2030. J Bone and Joint Surg Am. 2007;89:780-785.

38. Lawerence R, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the US. Part II. Arthritis Rheum. 2008;58:26-35.

39. Murphy L, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59:1207-1213.

40. Cross W, et al. Agreement about indications for total knee arthroplasty. Clin Orthop. 2006;446:34-39.

41. Lavernia C, et al. Is postoperative function after hip or knee arthroplasty influenced by preoperative functional levels? J Arthroplasty. 2009;24:1033-1043.

42. Froimson M, et al. Joint Anatomy In: Garino J et al eds. Adult Reconstruction Arthroplasty, Core Knowledge in Orthopedics. Philadelphia, PA. Mosby; 2007:61-78.

43. Jung Y, et al. Comparison of the modified Subvastus and medial parapatellar approaches in total knee arthroplasty. Int Orthop. 2009;33:419-423.

44. Bade M, et al. Surgical management and rehabilitation of knee arthroplasty. In Joint Arthroplasty Advances in Surgical Management and Rehabilitation. APTA 2010.

45. Van den Boom L, et al. Retention of the posterior cruciate ligament versus the posterior stabilized design in total knee arthroplasty: a prospective randomized controlled clinical trial. BMC Musculoskelet Disord. 2009;10:119-125.

46. Misra A, et al. The role of the posterior cruciate ligament in total knee replacement. J Bone Joint Surg Br. 2003;85:389-392.

47. Jacobs W, et al. Retention versus removal of the posterior cruciate ligament in total knee replacement: a systematic literature review within the Cochrane framework. Acta Orthop. 2005;76:757-768.

48. Hayashi A. Modes of failure can predict outcomes after revision TKA. AAOS Now. 2009. http://www6.aaos.org/news/PDFopen. Accessed April 23, 2014.

49. Pellegrini V, et al. The Mark Coventry Award: prevention of readmission for venous thromboembolism after total knee arthroplasty. Clin Orthop. 2006;452:21-27.

50. Xing K, et al. Has the incidence of deep vein thrombosis in patients undergoing total hip/knee arthroplasty changed over time? A systematic review of randomized controlled trials. Thromb Res. 2008;123:24-34.

51. Walsh M, et l. Risk factors for acute pulmonary embolism following total hip and knee arthroplasty. J Orthopaedics. 3005;5:e10.

52. Alfonso D, et al. Nonsurgical complications after total hip and knee arthroplasty. AM J Orthop (Belle Mead NJ). 2006;35:503-510.

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53. Wells P. Advances in the diagnosis of venous thromboembolism. J Thromb Throbolysis. 2006;21:31-40.

54. Yercan H, et al. Stiffness after total knee arthroplasty: prevalence, management and outcomes. Knee. 2006;13:111-117.

55. Gonzalez Della Valle A, et al. Etiology and surgical interventions for stiff total knee replacements. HSS J. 2007;:3:182-189.

56. Schiavone Panni A, et al. Stiffness in total knee arthroplasty. J Orthop Traumatol. 2009;10:111-118.

57. Nelson C, et al. Stiffness after total knee arthroplasty. J Bone Joint Surg Am. 2005;87:264-270.

58. Topp R, et al. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. PMR. 2009;1:729-735.

59. Bozic K, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop. 2010;468:45-51.

60. Moyad T, et al. Evaluation and management of of the infected total hip and knee. Orthopedics. 2008;31:581-588.

61. Kurtz S, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop. 2010;468:52-56.

62. Yacub J, et al. Nerve injury in patients after hip and knee arthoplasties and knee arthroscopy. Am J Phys Med Rehabil. 2009;88:635-641.

63. Dobbs R, et al. Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am. 2005;87:37-45.

64. Steffen T, et al. Age and gender related test performance in community dwelling elderly people: Six-minute walk test, berg balance scale, timed up and go test and gait speed. Phys Ther. 2002;82:128-137.

65. Kennedy D, et al. Assessing recovery and establishing prognosis following total knee arthroplasty. Phys Ther. 2008;88:22-32.

66. Larsen K, et al. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop. 2008;79:149-159.

67. Lenssen A, et al. Efficiency of immediate post-operative inpatient physical therapy following total knee arthroplasty: an RCT. BMC Musculoskelet Disord. 2006;7:71-80.

68. Milne S, et al. Continuous passive motion following total knee arthroplasty. Cochrane Database Syst Rev. 2002;2:CD004260.

69. Denis M, et al. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther. 2006;86:174-175.

70. Smith C, et al. TNS and osteoarthritic pain. Preliminary study to establish a controlled method of assessing transcutaneous nerve stimulation as a treatment for pain caused by osteoarthritis of the knee. Physiotherapy. 1983. 69:266-268.

71. Lewis D, et al. Transcutaneous electrical nerve stimulation in osteoarthrosis: a therapeutic alternative? Ann Rheum Dis. 1984:43:47-49.

72. Laskin R, et al. Stiffness after total knee arthroplasty. J Arthroplasty. 2004;19:41-46.

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73. Yoshida Y, et al. Examining outcomes from total knee arthroplasty and the relationship between quadriceps and knee function over time. Clin Biomech (Bristol, Axon.) 2008;23:320-328.

74. Valtonen A, et al. Muscle deficits persist after unilateral knee replacement and have implications for rehabilitation. Phys Ther. 2009;89:1072-1079.

75. Stevens, J et al. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty. A RCT. Phys Ther. 2012;92:210-226.

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BONY ANATOMY (Schuenke et al,

2016 Thieme Atlas of Anatomy)

Hip (Coxal) bone o Ilium

o Ischium

o Pubis

Ilium: ASIS, AIIS, PSIS, PIIS

Ischium: ischial spine and tuberosity

Pubis: inferior/superior pubic ramus, pubic tubercle

Acetabulum o Cartilage, labrum

Femur o Head, neck

o Greater and lesser trochanters

o Intertrochanteric line, crest

o Linea aspera

o Pectineal line

ANTERIOR

POSTERIOR

R

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LIGAMENTOUS ANATOMY

Iliofemoral ligament o AIIS to intertrochanteric line

o Taught with hip extension and ER

Ischiofemoral ligament o Ischium to greater trochanter

o Taught with hip extension and IR

Pubofemoral ligament o Acetabulum to pubic ramus

o Taught with hip extension and AB

BLOOD SUPPLY

Femoral artery

Profunda femoral artery

Medial and lateral circumflex femoral vessels

NERVE SUPPLY

Femoral nerve

Obturator nerve

Superior gluteal nerve

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TIBIOFEMORAL JOINT

Stable

Convex femoral condyles

Concave tibial plateaus

Stability o Passive

o Active

Condyloid joint PASSIVE STABILITY

Bony fit

Capsule

Menisci

Ligaments o ACL

o PCL

o MCL

o LCL

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ACTIVE STABILITY

Anterior Thigh Muscles o Iliopsoas

o Rectus femoris

o Vastus lateralis

o Vastus medialis

o Vastus intermedius

o Sartorius

o Tensor fascia latae

o Pectineus

Medial Thigh Muscles o Adductor longus

o Adductor brevis

o Adductor magnus

o Gracilis

o Obturator externus

Posterior Thigh Muscles o Gluteus maximus

o Gluteus medius

o Gluteus minimus

o Piriformis

o Superior gemellus

o Obturator internus

o Inferior gemellus

o Quadratus femoris

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NEUROANATOMY Lumbar Plexus

L1-L4 ventral rami main nerve roots

T12 inconsistent

L5 inconsistent

Iliohypogastric

Ilioinguinal

Genitofemoral

Lateral femoral cutaneous

Femoral o Saphenous

Obturator

Sacrococcygeal Plexus

L4-S4

Cluneal nerves

Posterior femoral cutaneous

Superior gluteal

Inferior gluteal

Nerve to obturator internus

Nerve to quadratus femoris

Sciatic

Pudendal

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INDICATIONS AND PREVALENCE OF HIP ARTHOPLASTY (CDC / AAOS, 2016)

OA most common indication for THR

Osteoarthritis is no longer considered a degenerative wear and tear disease, but rather complete joint failure with an inflammatory component (Ackerman et al, 2017,

Berenbaum et al, 2013)

More and more data are demonstrating OA affecting younger individuals, with hip OA prevalence increasing steadily with advancing age (Cross et al 2014)

OA affects 13.9% adults 25yo or older

OA affects 33.6% adults 65yo or older

26.9 million adults in the US with OA

2006 in the US o 231,000 primary THR o 251,000 hemi-THR o 38,000 revision THR

2030 o 570,000 primary THR o 96,700 revision THR in the US

Direct and indirect costs of OA are astronomical, and in a recent study in

Australia, leaving the workforce early cost the system over 7 million dollars

annually (Shofield at al, 2016)

PROGNOSTIC INDICATIONS FOR HIP ARTHROPLASTY

Excellent outcomes: pain relief, improved joint mobility, function, patient satisfaction

Pre-operative function dictates post-operative walking ability in primary and revision THR

Older individuals > 70 have lower functional outcomes, longer acute care admission, and are more likely to be referred to an inpatient rehab facility

RISK ASSOCIATED HIP ARTHROPLASTY

Mortality 0.15-2% THR; 2.4% hemi-THR; 0.87-2.6% revision surgery

Greatest factors associated with adverse outcomes o Advanced age o Medical co-morbidities: CHF, CRF, DM

Needing revision procedure (increase fracture) o 90% TKR last 10 years, many last 20 years o 97% hip resurfacing lasts 8-10 years o Rate of revision 3x higher younger males

George et al, 2008; Santaguida et al, 2008; Husted et al, 2008

Santaguida et al, 2008; McBryde, et al, 2008

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SURGICAL TECHNIQUES Total Hip Arthroplasty

Most common hip surgery in adult population

These patients will have most predictable post-op management

Fixation o Cemented (acrylic)

Elderly o Noncemented (biologic

fixation)

Younger, more active

All femoral components metal stem inserted into medullary canal (longevity)

o No single system better than others

o Selection based on multitude of factors?

Most cases cementless acetabular component is the device of choice

o Cementless designs are porous over the entire surface that makes bony contact

o Various methods of initial fixation, but all rely on ingrowth of bone for long-term stability

Implant materials o Metal on polyethylene

Longest history of use because of minimal short-term complications

Prominent choice for less active individuals < 65yo o Ceramic on ceramic

Effectively resist wear

Used for younger, active patients

Higher incidence of squeaking and breaking o Metal on metal

Used for anterior approach and hip resurfacing

Younger, athletic population

Criticized for release of metal debris that can cause inflammation and osteolysis and lead to a revision procedure

Metal ions can be absorbed by a fetus and therefore are NOT an option for women of child-bearing age

Heislein, 2010; deSouza et al, 2012; Chen et al, 2013; Enseki et al, 2017

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SURGICAL APPROACHES Posterior approach

Most common approach in US still

Incision posterior aspect greater trochanter

Detachment of short ER, incise posterior capsule

Sparing of gluteus medius

Advantages: technically easier, optimal intra-articular visualization

Major disadvantages: higher rate hip dislocation, but meticulous repair of short ER and capsule has suggested decreased rates

Lateral approach

Incision over the greater trochanter through gluteal fascia, ITB, insertion glut med to release glut min and gain capsular access

Advantages: reduced risk of hip dislocation since no damage to short ER or post capsule, reduced injury to sciatic nerve

Major disadvantages: abductor weakness, superior gluteal nerve

Anterior approach

Between the TFL and sartorius

Advantages: low rate of dislocation, less muscle disruption, no FORMAL hip precautions

Disadvantages: technically difficult, MAY have hip extension limitations initially (neutral extension)

Anterior approach has been shown to have shorter LOS, and better outcomes at 3 and 6 month follow ups on the Hip Harris Score compared to a traditional posterior approach. (Sibia et al, 2016, Balasubramaniam et al, 2016.)

Heislein, 2010; Chen et al, 2013; Enseki et al, 2017

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COMPLICATIONS

Days/weeks o DVT or PE (Homan’s sign, Wells CPR) o Pulmonary/cardiac issues: atelectasis, pneumonia, orthostatic

hypotension, anemia, arrhythmias, MI o Acute care PT: screening and prevention

Auscultation of the lungs, BP, HR LE alignment checking for hip dislocation usually accompanied by

increased pain CPR for assessment of DVT

Hip dislocation: related to surgical approach

Hip precautions vary from surgeon to surgeon

Consensus is 4-12 weeks

Causes of dislocation with posterior approach o Bending forward while putting on shoes o Twisting the trunk sit/standing with feet planted o Rising from a low toilet with hip in ADD/IR position

Infection: staph aureus most common

Brander et al, 2006

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COMPLICATIONS CONTINUED

Most common long-term complication of THA is implant failure from instability and mechanical loosening

Aseptic loosening accounts for 75% implant failures o Debris from polyethylene wear accumulates in the femoral-bone-cement

interface causing an inflammatory process and ultimate osteolysis o Ceramic prevents this, brittle with high loads o Hip resurfacing

Weakness can contribute to loosening

Younger age and being male increase the risk for revision THA o Surgeons hesitant to recommend < 60yo

PREOPERATIVE REHABILITATION

Educational programs (1-2 weeks prior) o Patients who fully understand post-operative expectations and clinical

care protocols have demonstrated better coping strategies

Exercise programs o Address impairments associated with OA o Exercise prior to surgery demonstrates improved strength and functional

recovery more quickly o Overall evidence is inconclusive

ACUTE CARE REHABILITATION

Average length of stay 2-3 days (Europe 1 day; at times same day)

PT interventions begin either POD 0 or POD 1 (Masaracchio et al, 2017) o Education: THR precautions o Functional training: ambulation 100 feet; independent transfers, stair

negotiation o Therapeutic exercise to improve motor control

Important to document physiological status o Low hematocrit o Fever o Elevated anti-coagulation levels o Orthostatic hypotension

ACUTE CARE REHABILITATION CONTINUED

Therapeutic Exercise o Quadriceps isometrics, heel slides o SLR and gluteal isometrics should only be initiated if there are no

WB restrictions since they create high contact pressures in the hip o Progress to standing hip exercises when there is good postural control

and FWB

Wang et al, 2002; Wang et al, 2016

Bozic et al, 2009

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Quadriceps isometrics

Extremely important to initiate quad return

Patients should be instructed to perform 100 reps a day

Need to watch for substitution from the glutes

Heel needs to be lifted off the table

Quadriceps Progression

SAQ, SLR

Patients should be instructed to perform 50 reps a day

Ensure quad set first before SLR or SAQ

Do NOT perform if there is an extension lag

WB exercises when FWB permitted and adequate control

Patients should be instructed to perform 30 reps a day

Sit to stand concentric/eccentric glute activation

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ACUTE CARE REHABILITATION CONTINUED

D/C to either inpatient facility or home? o Independent transfers (bed, chair, toilet) o Independent ambulation of at least 100 feet with AD o Independence in stair climbing o Adherence to hip dislocation and WB precautions

Comprehensive Care Joint Replacement (CCJR) o Medicare 2016 o Short-term rehab

SUBACUTE REHABILITATION

Length of stay inpatient facility 7-10 days with D/C home occurring at POD 14

Exercises can be increased with weights and bands

Aerobic exercises are important to overcome deconditioning

OUTPATIENT REHABILITATION (Sizer et al, 2016)

Goal: return to previous level of function o Improve muscle weakness o Improve postural stability o Normalize gait deviations

Persistent weakness and/or altered motor patterns contribute to decreased balance, altered gait patterns, and fear of falling

Outcome measures: HHS, WOMAC o Harris Hip Score (HHS)

Functional change and status following THA

Combines pain, functional capacity, deformity correction, and hip ROM are assessed and combined for a total of 100.

MCID 15-18 points for minimal improvement; > 39 moderate improvement (Singh et al, 2016)

o Western Ontario McMaster Universities Osteoarthritis Index (WOMAC)

Pain, stiffness, and functional disability in hip and knee OA patients

96 points is the highest indicating maximum disability

MCID 12-22% change following intervention (Cibulka et al, 2009) C&M ORTHOSPORTS OUTPATIENT HIGH PRIORITY CHECKLIST

1. Hip extension ROM 2. Neuromuscular control of gluteal muscles 3. Lumbopelvic control 4. Balance and proprioception 5. Gait considerations

How long should all of this take? Should the order matter? Clinical reasoning? Progression and sequencing within and between sessions?

Heislein, 2010

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GAINING HIP EXTENSION

Essential for terminal stance of the gait cycle (at least 10 degrees), increasing step length, cadence, and overall efficiency

Allows proper function of gluteal group

Elongates anterior soft tissues

Unloads the lumbar spine (anterior pelvic tilt/lower cross syndrome)

PSOAS RELEASE

Add hip ROM, pelvic rocking during soft tissue mobilization

Can perform soft tissue mobilization during stretch

JOINT MOBILITY ASSESSMENT

Therapist position

Patient position

Clinical reasoning? o Grade? o Dosage?

Goal of the mobilization

Lateral Glide Posterior Glide

Anterior Glide Anterior Glide

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GLUTEAL NEUROMUSCULAR CONTROL

Must overcome deleterious effects of surgical approach, longstanding deficits (i.e., from OA)

Expect autogenic inhibition early after surgery

Begin with simple exercises

Patience is important – don’t assume exercises are too easy; don’t progress too quickly

Enhance muscle recruitment

GLUTEAL ACTIVATION DURING THE GAIT CYCLE (Neumann, 2016)

GLUTEAL NEUROMUSCULAR CONTROL

Therapeutic exercises (Sets? Reps? Weight?) o Glute sets, supine or standing abduction o Side lying AB, bridging, and clam shells o CKC exercise as strength improves, no WB restrictions o Step ups, lunges, mini- squats

Research demonstrates significant improvement in strength and stability 12-24 months after THR

Unlu et al, 2007; Galea et al, 2008

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THERAPEUTIC EXERCISES GLUTEUS MAXIMUS AND MEDIUS (Boren et al, 2011)

EMG activity o Front plank hip extension: max: 106.22; med: 75.13 o Side plank DL up: max: 72.87; med: 88.82 o Side plank DL down: max: 70.96; med: 103.11 o Single leg squat: max: 70.74; med: 82.86

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LUMBOPELVIC CONTROL

Improve lumbopelvic dissociation

Improve lumbopelvic rhythm

Start simple, progress accordingly

Incorporate into functional activities o Supine/quadruped is a great way to teach abdominal

hollowing/bracing and pelvic neutral, but it is not functional o Move to functional positions when the patient is independent in

spinal neutral and maintaining transversus abdominus contraction without substitution

o The addition of UE and LE movement patterns on a stable base will set the foundation for exercises sitting on a physioball, as well as standing with theraband

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BALANCE / PROPRIOCEPTION

Balance training is important to facilitate ambulation without AD o Begin bilateral activities o Progress to unilateral activities o Progress to unstable surfaces o Progress to multi-plane directions

Gait training to increase symmetrical step length and stance time

Leg length discrepancies?

GAIT CONSIDERATIONS

Loss of gait speed o Normal 1.2-1.4m/s o < 1.0m/s require rehab o < 0.6m/s increase fall risk

Decreased stride length

Decreased step length

Hip abductor weakness

Lateral trunk lean to involved side

Decreased hip extension

SPORT PARTICIPATION RECOMMENDATIONS

Permitted: golf, swimming, walking, stationary bike, dancing, elliptical, bowling, stationary skiing, treadmill, low-impact aerobics, speed walking, road bicycling, hiking, stair climber, doubles tennis, rowing, weight machines

Permitted with experience: pilates, cross country skiing, weight-lifting, ice skating, roller blading, downhill skiing,

Not permitted: baseball/softball, racquetball/handball, football, basketball, snowboarding, jogging, high impact aerobics, contact sports, singles tennis, martial arts

Maloney et al, 2004

Beaulieu 2010, Ewen 2012

Klein et al, 2007; Jacobs et al, 2009

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OSTEOARTHRITIS KNEE Prevalence

Women > men

> 50 years old

27 million Americans

Symptoms

Pain with WB

Morning stiffness < 30 minutes

Diffuse tenderness Systemic risk factors

Age and sex

Genetics

Decreased estrogen levels

Increased bone mineral density

Obesity

Acute injury

Repetitive injury

Joint deformity

Copstead, 2005; Arden et al, 2006; Lawerence et al, 2008; Murphy et al, 2008; Wong, 2010

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PREVALENCE OF KNEE ARTHOPLASTY

516,000 TKAs 2006

3.48 million 2030 o Increasing use of this surgery o Epidemic of obesity o Ageing population

Knee OA and RA account for over 90% TKAs o OA 72.7% o RA 21.2%

Revision rates < 1%/yr, at 10yrs 90% still functional CRITERIA FOR CLASSIFICATION OF KNEE OSTEOARTHRITIS

Age > 50 years old

Knee crepitus

Palpable bony enlargement

Bony TTP

Morning stiffness that improves in < 30min

TREATMENT

Manual therapy and exercise combined

Exercise o Hip, knee, OKC, CKC

Gait training o Lack of TKE

Hip mobilization o CPR for patients with knee OA likely to benefit from hip mobilization

OSTEOARTHRITIS TREATMENT

Recommendations for nonsurgical OA Tx o Self-management education programs (B) o BMI > 25 encouraged lose weight (A) o Low impact aerobic fitness (A) o Quad strengthening (B) o Patellar taping (B) o Glucosamine not be Rx (A) o Meds (B) o Steroid injections (B) o Synvisc injections (B) o Against Arthroscopic lavage, debridement (A)

AAOS 2016; Kurtz et al, 2007

Altman et al,1991 Copstead, 2005 Wong, 2010

Currier et al, 2007

Richmond et al, 2009

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INDICATIONS/CONTRAINDICATIONS TKA

Indications (no clear consensus) o Can no longer stand the pain (however higher levels of pain at time

of surgery dictate poorer outcomes) o Radiographic severity not an indicator

Contraindications (no clear consensus) o Major psychiatric disorder (dementia) o Poor soft tissue coverage o Infection o PVD o Poor motivation o Alcohol and drug abuse

PROGNOSTIC INDICATIONS/TIMING TKA

Patients with more pain

Lower self-reported function

Lower scores on 6MWT, TUG, SCT

Other factors: o Female o Older age o Lower socioeconomic status o Co-morbidities o Depression o Poor pain coping strategies o Unrealistic expectations

TKA SURGERY OVERVIEW

Techniques range from gold standard median parapatellar to the new minimally invasive computer-assisted TKA

Goal of any TKA o Restore the mechanical axis of the TFJ through bony cuts, soft

tissue mobilization, and ideal component implantation with proper patellar tracking

All surgical approaches involve 3 steps o Skin incision o Arthrotomy o Mobilization of the extensor

mechanism

COMMON SURGICAL APPROACHES

Medial parapatellar

Subvastus

Midvastus

Lateral

Cross et al, 2006;

Lavernia et al, 2009

POORER OUTCOMES

Froimson et al, 2007

27

MEDIAL PARAPATELLAR

Advantages o Gold standard o Familiar among surgeons o Allows for adequate exposure and clear visualization

of the joint o Can be adapted for extensor mechanism mobilization

by adding secondary incisions o Protects neurovascular structures

Disadvantages o Extensive incision through the quadriceps tendon o Usually results in post-op quadriceps inhibition o When combined with a lateral release (not common)

has been associated with reports of patella AVN o This approach detaches the vastus medialis from the

remainder of the extensor mechanism, reducing blood flow to the patella

SURGICAL DETAILS

Incision splits the quadriceps tendon

A release of the rectus and vastus medialis from the patella

Patella eversion (flipping)

Correction of varus/valgus deformity

Removal of menisci, ACL and any remaining osteophytes taken out

PCL may or may not be spared o Very controversial (no long-term difference) o Based on surgeon’s comfort level currently o Posterior stabilized design, PCL is sacrificed and the function is replaced

by a cam and post mechanism o Better arthrokinematics, better ROM?

Place prosthesis and assess patella tracking

COMMON SURGICAL ELEMENTS

Prepare the tibial and femoral surfaces

Remove the menisci and ACL

PCL may or may not be removed

MCL/LCL are preserved

Femoral component is metal

Tibial component is metal

Spacer on top of tibia is plastic

Patella spacer

Fixated with or without cement o WB restrictions

Bade et al, 2010

Verra et al, 2013; Nikolaou et al, 2014

Froimson et al 2007; Van de Boom et al, 2010

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REVISION TOTAL KNEE ARTHROPLASTY

Longevity TKA prosthesis depends on o Age o Gender o Type of implant o Type of fixation o Design of the patellar component

90% TKA 10 years; 78% 20 years

Two primary reasons leading to revisions o Aseptic failure (82%)

Instability 28.9% Tibial bone lysis 27.5% Polyethylene wear 24.5% Femoral bone lysis 22.5% Tibial loosening 22.5%

o Septic failure (18%) Infection

Symptoms: pain, decreased ROM, instability, swelling, paresthesias

Biggest challenge bone loss

COMPLICATIONS

DVT/PE o Most common reason readmission after TKA o Greatest week 1st week after surgery o Estimated annual incidence 67/100,00 in the general population o TKA population estimated incidence 36% o Incidence DVT in TKA 35.92% o Incidence of DVT in THA 23.23% o Symptomatic DVT THA 2.81% o Symptomatic DVT TKA 1.31%

Symptoms o Pain, swelling, redness of the leg, dilation of the surface veins o Post-op DVT higher in women, all patients of increased age and BMI o 15% higher risk DVT every decade after 50; twice as likely for

someone in their 80s versus the 60s o Common test clinically Homan’s test o Patients with a DVT have a positive test 8%-56% o Proximal DVT superficial femoral or popliteal vein more serious potential

fatal PE o Signs and symptoms PE o Chest pain o Respiratory symptoms w/wo hemoptysis o Tachycardia

Hayashi, 2009

Pellegrini et al, 2006; Wells et al, 2006; Walsh et al, 2008 Xing et al, 2008

29

STIFF KNEE

Definition? Varies widely

Yercan et al o Flexion contracture equal to or > 10 degrees o Total arc of motion < 95 degrees

Arthrofibrosis is used when both flexion and extension are limited secondary diffuse scar tissue

o Incidence between 1-15%

Pre-op predictors of knee stiffness o Soft tissue restrictions i.e., DM, lung disease, RA, smoking, pre-op

ROM, h/o multiple surgeries o Mechanical contributions i.e., post-traumatic OA, previous high tibial

osteotomy o Intra-operative i.e., errors in soft tissue balancing, wrong size implants,

PCL mismanagement o Post-operative i.e. arthrofibrosis, infection, patient motivational issues,

rehab, pain control

Interventions for stiff knee o Intensive PT o Splinting o Injections o Closed manipulation (MUA) o Arthroscopic debridement (only after MUA fails) o Revision surgery (components fail)

Pre-op ROM most important predictor post-op stiff knee

Studies suggest favorable outcomes with pre-op PT before undergoing TKA

Post-op PT plays crucial role in assessing a stiff knee early on (alert surgeon early 4 weeks)

Conservative versus manipulation o Manipulation works best within 3mo surgery (first time most useful) o Late manipulation can be riskier with complications as quad and

patella tendon rupture, femur fracture, and hematoma formation o More successful for flexion gains then extension gains

Patients receiving intra-articular steroid injections showed better results

Timing of MUA is variable in the literature – Does not gain 75° w/in 10 days – Or fails to progress with ROM w/in 2-3 months – < 90° knee flexion; > 15° flexion contracture; an arc < 70-80° w/in 6

weeks

Previous research suggests patients manipulated w/in 3 weeks had an average ROM of 121° 1 yr post-op; compared to 112° for individuals manipulated 3 weeks-3 months

Yercan et al, 2006

Nelson et al 2005, Brander et al, 2006; Gonzalez Della Valle et al, 2007; Schiavone Panni et al, 2009

Nelson et al 2005; Schiavone Panni et al, 2009; Topp et al, 2009

30

INFECTION

Higher in TKA compared to THA due to decreased blood supply to the knee versus hip during surgery

Most frequent reported reason for revision

Revision surgery highest risk factor for infection

Other factors o RA o DM o Obesity o Poor nutrition o Immunosuppressive medication

Incidence deep infection 1-2% primary TKA

Two-three times risk for revision surgery

Infection in the Medicare population 1.55% incidence w/in 2 years and 0.46% incidence 2-10yrs post TKA

Signs and symptoms infection: o Low grade fever o Night sweats o High skin temperature of the knee o Redness or drainage from incision

with/without red streaks o Severe pain, swelling, malaise

Delayed healing, hardening of the incision

Infection diagnosed by combination o Symptom history o Objective examination o Blood analysis (ESR, C-reactive protein) o Radiographs

Additional information may be gotten through joint aspiration and culture

PERIPHERAL NERVE INJURIES

Rare after TKA

Yacub et al studied the incidence of lower limb neuropathy w/in 90 days TKA in patients < 65 years old and established a 0.01% rate

Nerve injury rates 10X higher in diabetics (0.11% versus 0.01%) o Most common nerve injury deep fibular nerve

Moyad et al, 2008; Bozic et al, 2010; Kurtz et al, 2010

Yacub et al, 2009

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EXTENSOR MECHANISM RUPTURE

Quad tendon rupture after TKA rare 0.1% o Location usually patella tendon-tibial tubercle avulsion

MOI: trauma or high loading end-range flexion

Poor outcomes following repair in patients with TKA

Serious complications and delays to rehabilitation OUTCOME MEASURES

WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index

KOOS: Knee Injury and Osteoarthritis Outcome Score BEST for TKR o Pain subscale MDC 22.39 o Stiffness subscale MDC 29.12 o Physical function subscale MDC 13.11

FUNCTIONAL OUTCOMES

AGE SEX MEAN 6MWT (m) MEAN TUG (s)

60-69 Male Female

572 538

8 9

70-79 Male Female

527 471

9 9

80-89 Male Female

417 392

10 10

REHABILITATION

Purpose TKA surgery: o Pain relief and return of function o Rehabilitation should focus on these goals o Must restore ROM, muscle strength, gait, and functional activities

Kennedy et al o Greatest improvement LEFS and 6MWT occurs in the first 12 weeks o Slower improvements weeks 12-26 o No further improvement past 26 weeks

Perioperative o 2000 inpatient stay average length 4 days o 1990 inpatient stay average length 9 days

Primary pre-operative goals o Pain control o Education on restrictions o Safety with walking and stairs o Self-care and incision management o Understand home exercises o Meeting appropriate knee flexion milestones

Steffen et al, 2002

Roos et al, 1998

Dobbs et al, 2005

Kennedy et al, 2008

Larsen et al, 2008; Masaracchio et al, 2017

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OUTPATIENT REHABILITATION

Continuous passive motion (CPM): 2003 Cochrane Review stated short-term benefits from CPM and PT, but no long-term benefits

o Denis et al newer study found no benefit with 2 hours CPM with PT on length of stay, active knee ROM in flexion or extension, TUG, or WOMAC scores

o Lenssen et al, found no long-term differences again with the use of CPM in a group of patients who demonstrated decreased knee flexion <80° when being DC from hospital

C&M ORTHOSPORTS HIGH PRIORITY CHECKLIST 1. Edema 2. Knee extension ROM 3. Quad control 4. Knee flexion 5. Hip neuromuscular control 6. Balance and proprioception

EDEMA CONTROL

Elevation is key, knee above the heart

Ice early and often to decrease the effects of joint effusion and subsequent muscle inhibition

Consider using a compression stocking (18-22mm/hg)

Retrograde massage

Kinesiology tape CLINICAL PEARLS

Constantly re-assess gains w/in session and between session; ask lots of questions (i.e. – where do you feel pain/stiffness?)

Determine where limitation is coming from

Hamstring length/hypertonicity

Patella hypomobility (superior mobilization)

Incision mobility as soon as it is healed

If one mode of stretching is not working, try another; stress importance of the HEP for stretching

As range progresses, must strengthen in new range

TENS has shown some effect in two studies

If full extension is not achieved in the OR, it is unlikely it will be achieved in PT

QUADRICEPS CONTROL

Deficits 20-65% seen long after discharge

Many patients get categorized as having good outcomes because of the focus on pain and ROM

Normally see improvements 25-70%

Pre-op strength one of the greatest predictors

Milne S, et al, 2003; Lenssen et al, 2006; Denis et al, 2006

Smith et al, 1983; Lewis et al, 1984

Yoshida et al, 2008; Valtonen et al, 2009

33

Post-op strength is more predictive of functional compared to pain or ROM

Deficits are multimodal in nature consisting of atrophy, activation failure, and effusion

CLINICAL PEARLS

Constantly re-assess gains w/in session and between session using HHD

If one mode of strengthening is not working try another (OKC, CKC, eccentrics)

Vary reps, sets, and intensity of strengthening

Begin with quad sets, then SLR (when no lag)

Step downs, leg press, and functional training

NMES demonstrated good results with increased quad strength 6 months after use

KNEE FLEXION ROM

Stairs require 85 - 110° knee flexion

Rising from a chair requires 95° knee flexion

Kneeling and squatting require 125-135° knee flexion

Surgeons predict knee flexion to be w/in 5-10° of intra-operative measures or w/in 10-15° of pre-operative knee flexion

OUTPATIENT REHABILITATION

Joint mobility o High risk of PF joint disruption following TKA o Mobilization can be added both in clinic and at home prior to stretching o Role of TF joint mobilization is unclear

Anterior to posterior mobilizations not indicated in PCL-sacrificing techniques at 90 degrees of knee flexion, OK in 0 degrees of extension

Joint mobilization to increase extension o This can also be done with a valgus force or a

varus force to maximize results o 5 x 30 second bouts

Joint mobilization to increase flexion o This can also be done with a valgus force or a

varus force to maximize results 5 x 30 second bouts

Stevens et al, 2012

Bade et al, 2010

34

JOINT MOBILIZATION TO INCREASE TIBIAL IR Patient: supine with the treating LE in 90 degrees of knee flexion, with the hip flexed to 90 degrees Clinician: standing on the side being treated Instructions

Clinician places one hand on the bottom of the

heel and locks the ankle into DF

The other hand has the thumb on the lateral

aspect of the tibial tubercle

The clinician exerts a force into tibial IR

Dosage?

NOTE: patients with limited tibial IR also commonly have limited calcaneal EV

JOINT MOBILIZATION TO INCREASE TIB-FIB MOBILITY

Patient: supine with the treating LE in 90 degrees of knee flexion, with the foot on the table Clinician: standing on the side being treated Instructions

Clinician places one hand on the medial

aspect of the knee of the stabile

The other hand takes up the soft tissue slack

and using the thenar eminence the clinician

exerts an AP force

Dosage?

NOTE: be careful for the common fibula nerve

35

JOINT MOBILIZATION TO INCREASE MOBILITY

OF THE PATELLA

Patient: supine with the treating LE in 20 degrees of knee flexion, with the heel on the table Clinician: standing on the side being treated placing the knee under the patient’s knee, or use a half foam roll Instructions

The clinical places both thumbs on the

lateral aspect of the patella

Fine tuning his/her hands the clinician

makes sure the patella is NOT tilted

The clinician delivers a pure medial glide of the patella

This can also be done in different degrees flexion to maximize results

Dosage?

MEDIAL

GLIDE

INFERIOR

GLIDE

SUPERIOR

GLIDE

36

EXERCISES

Three different exercises to increase ROM

Seated knee flexion good for HEP every single hour awake

Self-extension with weight or bag must maintain PF of ankle to keep gastroc on slack

Low load prolonged stretching better than shorter more aggressive bouts

Need to figure out shortest to get increases in ROM

SPORTS PARTICIPATION RECOMMENDATIONS

Allowed: bowling, stationary cycling, ballroom dancing, golf, horseback riding, shuffleboard swimming, normal walking, canoeing, road cycling, square dancing, hiking, speed walking

Allowed with experience: rowing, ice skating, cross-country skiing, stationary skiing, doubles tennis, downhill skiing

Not allowed: basketball, football, jogging, soccer, volleyball

No consensus: fencing, roller skating, weight lifting, baseball, gymnastics, handball, hockey, rock climbing, racquetball/squash, singles tennis, weight machine