Total Joint Replacement
Management of Orthopedic Problems
TOTAL JOINT REPLACEMENTS
Joints that can be replaced: orthopedic physicians can replace virtually
any peripheral joint, including the hip, knee, shoulder, elbow, wrist,
metacarpal-phalangeal joints, and the ankle.
The goal of arthroplastic surgery is to improve the person's function,
achieved by decreasing the pain and biomechanical deficiencies associated
with the person's problem.
The goal of rehabilitation is to improve the person's function in their
various occupational roles, as dictated by the persons's desired outcome.
The Therapist's Responsibilities:
Composition: metallic and polyethylene (National Institutes of Health,
- Be familiar with the person, their history, and their desired outcome;
- Know protocol of the orthopedic surgeon;
- Be familiar with surgical technique as it relates to rehab;
- Be aware of untoward pt. responses, and prosthetic failure;
- Goal setting;
- Discharge planning.
Constraint: the degree of physical connection between the components of a
prosthesis. Prosthetic joints have a very limited ability to resist rotary
and shear forces. The capsule and ligaments of the joint provide the
greatest resistance to these forces (Coomey, 1993). The components of the
prosthesis accommodate axial loads much more effectively.
With advances in prosthetic designs, there are fewer indications for
constrained devices. However, surgeons still use them in some cases, such
as with total shoulder arthroplasties when the rotator cuff muscles are of
insufficient strength to support the joint. Many orthopedic surgeons tend
to prefer constrained elbow prostheses as well.
- Unconstrained prosthesis: no physical connection holds the components
together. The joint capsule, ligaments, muscles, and other structures
of the joint maintain the contact between the articular surfaces of
the prosthesis. Unconstrained prostheses reproduce the anatomy of the
joint as much as possible, (Cooney, 1993, p.62).
- Constrained prosthesis: a component physically joins the prostheses.
Orthopedic physicians choose constrained prostheses when the
surrounding joint structures are unable to provide stability. The
component that joins the prostheses tends to absorb the majority of
joint stresses, which increases the potential for loosening or
fracture of prosthesis or the surrounding bone (Cooney, 1993, p.62).
Design: the goal of a well-designed prosthesis is reproduction of the
anatomy with greater conformity of the surfaces, resulting in decreased
wear on the prosthesis. Routinely, one can make the assumption that the
greater the stability of a prosthesis, the less the available range of
General indications for TJA:
- Cemented: either one or both components are bonded to the bone via
polymethylmethacrylate bone cement. The surgery involves an osteotomy
into subchondral bone, which provides the appropriate porous interface
for the cement. Ideal for people who are unable to ambulate post-op
with decreased weightbearing (National Institutes of Health, 1994,
p.8; Sledge, 1990, p.3614).
- Porous coat: microscopic Titanium wires are bonded to the prosthesis,
which allows for biologic ingrowth of bone into the prosthesis.
Components become better-anchored, with a decrease in the forces at
the biologic interface between bone and prosthesis. The person must be
nonweightbearing for 4 to 8 weeks postoperatively (National Institutes
of Health, 1994).
- Press-fit: the surgeon literally pushes the prosthesis into the
prepared medullary canal for a snug fit. Used more in the
"nonweightbearing" joints, and to a limited extent, at the acetabulum
- Loss of function;
- Severe pain;
- Rheumatoid Arthritis or Osteoarthritis;
- Severe fracture or avascular necrosis involving articular region
(National Institutes of Health, 1994, p.5).
General restrictions :
- active sepsis of the joint
- severe osteoporosis
- Charcot joint
- obesity (greater than 200 pounds)
- person is bedfast
- Poor cognition (unable to understand
- Lesser surgical procedure would be as or more effective (ie:
- Children with active growth plates (National Institutes of Health,
The replaced joints have lost the ability to absorb shock, therefore it is
important to avoid impact loading: therefore no running or jumping for
weightbearing prostheses, and no heavy lifting.
General exercises :
For the involved joint the exercise should take into consideration the
sacrificed or incised structures. If lower extremity joints are replaced,
therapists should strengthen the unoperated extremity. Critically evaluate
what interventions work best, and reevaluate routinely for other more
optimum exercises. Treatment may begin with isometrics, progressing to
active or active-assisted range of motion very quickly, ending with the
patient performing functional activities. Therapists will want to be very
cautions in performing resisted ROM. Be sure to write the program down, and
perform with the person. Respiratory exercises should be a part of any
exercise program (Lewis & Bottomley, 1994, p.329).
SPECIFIC JOINT SURGERIES
The therapist's responsibilities:
Apply this knowledge to the rehabilitation and education of the patient.
- Familiarize yourself with the surgical approach.
- Know the contraindicated motions.
- Know the anatomy of the operated area, which structures were incised
and repaired, which were sacrificed.
- Know the desired outcome, and how it relates to the person's premorbid
functional status, and the effects of the surgery on their current
TOTAL HIP ARTHROPLASTY (THA):
Specific Indications include avascular necrosis of the femoral head, and
fractures or non-union fractures of the hip.
Surgical approaches :
- most common;
- Incision at upper border of gluteus maximus;
- ext.rotators and quadriceps femoris are detached from the greater
trochanter for prosthesis insertion, then reattached;
- Contraindicated movements: adduction, hip flexion beyond 80, internal
rotation (Pellegrini & McCollister, 1990, p.2746).
- anterior capsule incision;
- Contraindicated movements: extension, external rotation, adduction
past neutral (Pellegrini & McCollister, 1990, p.2738).
- osteotomy of greater trochanter;
- Contraindicated movements: adduction, internal rotation, hip flexion
past 80, active abduction (Pellegrini & McCollister, 1990, p.2741).
equipment: abductor wedge, athrombic pumps, poss. I.V. antibiotics.
Progression varies from case to case, but routinely the person is sat at
the side of bed on the first post operative day, possibly progressed to
standing and short-distance ambulation on that same day.
Educate the patient in contraindicated movements, and initiate an exercise
program. Antigravity SLR's are difficult for the person, and place
considerable forces at the femur. Decrease these by using gravity neutral
positions. Make plans for discharge from day one, and pay specific
attention to the person's home environment.
Considerations: once ambulatory, avoid internal L/E rotation with the
person should recline when sitting.
Avoid low surfaces that cause greater than 80 degrees of hip flexion: use
elevated commode seat. Also, avoid extremely soft cushions, which would
facilitate int. rotation. Alter or adapt the patient's dressing technique,
practice ADL's, while observing precautions.
Signs of prosthesis failure :
Pain with movement, usually at the anterior groin and medial thigh;
Frequently an audible pop can be heard with dislocation, patient knows
"something isn't right"; Abnormal positioning/shortening of limb;
Inability to weightbear (Pellegrini & McCollister, 1990, p.2752).
TOTAL KNEE ARTHROPLASTY (TKA)
Specific indications: Correction of knee deformities or instability that
interfere with ADL's.
In most surgeries, physicians excise the anterior cruciate ligament (ACL),
and in about half of the surgeries they remove the posterior cruciate
ligament (PCL) as well. If the ACL or PCL are sacrificed, the prosthesis
must make up for the loss of ligamentous stability, usually via pegs in the
prosthesis (Sledge, 1990, pp3611-3612).
The PCL is more important functionally than the ACL in that it checks
backward movement of the tibia on the femur, and functionally sustains
greater forces, such as with stair climbing and with stand to sit transfers
The surgeon will take an anterior surgical approach, excising the ACL,
giving easy access to the joint interior. The surgeon performs an almost
complete osteotomy of the tibial plateau with the exception of a small
square of the posterior intercondylar eminence. The surgeon assesses
ligament balance, makes any corrections, then performs a femoral osteotomy,
then patellar resurfacing, if indicated. Successful surgeries retain the
biomechanics of the joint as much as possible, including a knee Q-angle of
7 - 10 degrees (Sledge, 1990).
Contraindicated Movements :
None. Be cognizant of weightbearing status, and any additional corrective
surgery that the orthopod may have performed.
Equipment: CPM - Continuous Passive Motion, Athrombic Pumps, Cryo-sleeve,
possible I.V. antibiotics.
CPM efficacy is debatable: some studies show that use of the CPM doesn't
increase ROM or decrease edema in individuals who are performing an active
exercise program routinely. However, the machine will definitely have an
impact on people who have difficulty performing exercises on their own
volition. Also, the machine can at times better work within the person's
pain tolerance, by spreading out the increases in PROM over a greater
period of time (Malone, 1993).
Day one post-op, the person is sits at the side of the bed, then progresses
to standing, transferring to chairs, and short ambulation at the
therapist's discretion. Therapists should initiate an exercise program on
day one, with treatment strategies emphasizing function as it relates to
the person's occupational roles.
Usually the last 5 degrees of extension, and from 90 to 100 degrees are the
toughest to obtain. Physicians usually want 0 to 90 degrees ROM before
Tips for acquiring full extension: place the person's heel on a pillow,
with a cold pack on the knee. This applies as a force couple, slowly moving
the knee into extension. Therapists can combine this with quad-sets as
Tips for increasing flexion: work on closed chain flexion, such as stand to
sit transfers. With the person sitting in a chair, use tape markers on the
floor, and give the person a goal to actively bend the knee backward to the
tape marker before going back to bed.
Signs of prosthesis failure:
- ROM for PCL-spared TKA: patient may acquire 110 degrees of flexion;
- ROM for PCL-sacrificed TKA: may acquire 100 degrees of flexion
(Sledge, 1990, p.3634).
Less incidence than for THA's. Very difficult for joint to dislocate, but
loosening may occur. The person will have pain more with weightbearing than
movement. Pain may refer along the bone of the defective component.
TOTAL SHOULDER ARTHROPLASTY (TSA)
Surgeons will use an unconstrained prosthesis if the rotator cuff
musculature is intact. The rotator cuff and the labral capsular
ligamentous complex maintain joint stability (Rockwood, 1990).
- avascular necrosis of humeral head;
- impending or pathologic fracture of humeral head;
- destruction of proximal humerus or glenoid fossa.
They will use a constrained prosthesis for torn or paralysed
rotator cuff. In this case, the prosthesis must provide the
fulcrum for humeral movement, increasing the potential for
fracture at the insertion of the prosthesis, as well as
dislocation of the joint (Rockwood, 1990).
Surgical approach :
The surgeon uses an extended deltopectoral incision from the outer
one-third of the clavicle across the coracoid, extending distally across
the coracoid and curving laterally along the pectorals and the anterior
border of the deltoid. The subscapularis is detached from its insertion at
the lesser tubercle, occasionally the pectoralis major is detached as well.
The joint capsule is incised anteriorly, and the humeral head is dislocated
anteriorly via external rotation and extension, and is removed via
osteotomy just above the tubercles, to preserve the insertion of the
rotator cuff (Rockwood, 1990).
Contraindicated movements :
Combination of abduction and external rotation, or extension and external
rotation. Avoid inferior glide of the humeral head. The person should avoid
rolling onto operated side, and should not use operated extremity to move
Equipment: possible CPM, sling and swath.
Progression varies from physician to physician. Routinely, the person wears
the sling for the first week, removing it for therapies and hygiene. On
post-op day one, the patient performs active elbow, wrist, and hand range
of motion with the therapist. On Day 2, the therapist initiates pendulum
exercises, with the patient performing these 4 - 6 times a day. Day 2 - 3
begins supine active shoulder flexion and rotation, gentle ADL's such as
eating, brushing teeth, and writing. (NOT hair combing). At one week, the
patient can remove the sling during the day, except when the person is out
of his/her home. The therapist initiates isometrics at this time. The
patient can begin RROM at 6 weeks, plus resume hair washing and combing.
The patient can discontinue the sling and swath fully at or before this
time. The patient usually achieves full function with the exception of
lifting greater than 20 pounds by 6 months (Gristina, Roman, Kammire, &
Considerations: the person should have approximately two-thirds normal
range of motion after 6 months. (30 - 40 degrees of external rotation,
95-100 degrees flexion, 100 - 110 degrees abduction).
Signs of prosthesis failure:
TOTAL ELBOW ARTHROPLASTY
- Loss of active range of motion;
- Shoulder pain with or without movement;
- Indications of rotator cuff tear.
Majority of people have Rheumatoid Arthritis (RA);
Primary goal is relief of pain. Restoration of motion is rarely an
indication for surgery.
Varying approaches. One of the collateral ligaments must be released to
dislocate the joint; the surgeon inserts the prostheses into the capitellum
and trochlear notch of the humerus and the proximal ulna . Prostheses are
cemented or press-fitted. The prosthetic components must restore the center
of rotation of the joint, which is located at the center of the trochlea
and capitellum, and approx. 30 degrees anterior to the axis of the humerus.
The normal carrying angle of 5 - 7 degrees valgus is obtained as much as
possible. Rarely do surgeons replace the radial head (Sledge, 1990, p.62).
Surgeons use unconstrained and constrained prostheses equally:
Unconstrained prostheses have a higher dislocation rate.
Constrained prostheses have a higher ultimate loosening rate.
The surgeon applies a posterior leaf splint in 70-80 degrees flexion and
neutral forearm rotation. Therapists remove the splint 5-7 days post-op and
begin gentle active and passive ROM. The patient will wear the splint
between therapy sessions.
3 weeks post-op, AROM continues and the therapist begins general soft
8 weeks post-op, the therapist discontinues the splint unless major
ligamentous instability is present. The physician or therapist usually
impose lifting restrictions on the patient.
TOTAL WRIST ARTHROPLASTY
- High incidence of ulnar nerve problems;
- High failure rate after 6 years;
- High incidence of sepsis.
Most orthopedic physicians prefer fusion of the joint over arthroplasty.
Most patients prefer ROM over fusion, obviously. The deciding factor is the
patient's persistence and range of motion requirements of occupational
The most commonly used prosthesis is semiconstrained;
Allows 90 degrees palmar flexion - extension;
Allows 50 degrees radioulnar deviation;
Does not allow rotational movement (Volz, 1984).
The surgeon excises the distal end of the radius to the level of Lister's
tubercle and resects the head of the capitate distally. The surgeon then
cements or press-fits the prosthesis into the distal radius, and through
the capitate and the third metacarpal. Centering is critical. The axis of
motion at the wrist is at the proximal pole of the capitate and vertically
in line with the long axis of the third metacarpal. The surgeon aligns the
proximal component is along the ulnar border of the distal radius, and the
distal component in the third metacarpal.
The primary difficulty with surgery is post-operative balancing of the soft
tissues and musculotendinous forces crossing the joint between the wrist
flexors and the extensors (Volz, 1984).
The wrist is splinted for 7-10 days, then the therapist begins Active and
passive ROM with the patient. The splint is continued if the therapist
notes muscle imbalances. The therapist may use a dynamic splint to correct
The prosthesis is a "finger joint silicone elastomer intramedullary stemmed
Implants are rarely cemented.
- flexible hinge
- dynamic joint spacer
- internal mold around which a new capsuloligamentous system develops, also
guides bone formation (Swanson, de Groot, Swanson, Leonard, & Boozer,
The surgeon resects the metacarpal heads perpendicular to the shaft,
preserving the collateral ligaments. The surgeon then corrects tendon
imbalances and joint deformities (Swanson, et al., 1990).
The most frequent complication is post-operative instability. This is
easily avoided via surgically correcting deformities and ligamentous laxity
during the implant procedure.
The patient is in a bulky post-op dressing, with hand elevated for 3-5
days. At 3 - 5 days, the therapist begins guided active and passive motions
with the patient, usually via an adjustable dynamic splint, (which guides
the motions in the desired planes of movement: flex-ext, and ab-adduction).
The goal of therapy is to acquire a balance between good healing of the
scar tissue, and an application of tension to the scar to get the desired
At 5-7 days, the patient begins active range of motion with joint blocking,
performing motions in isolated planes. With the removal of the sutures, the
therapist can begin friction massage.
The therapist should keep an eye on all joints and their ranges of motion.
The person may substitute one joint for another, more painful one. The
patient will routinely substitute PIP motin for MP motion. The ideal ROM
for a replaced joint is 0-70 degrees flexion.
COMPLICATIONS OF TOTAL JOINT REPLACEMENTS:
Remember, a prosthetic joint is never as good as the one it has replaced.
- Deep vein thrombosis (DVT): positive Homan's sign, exquisite
tenderness to palpation in deep calf, which is warm and/or red to the
touch (Sledge, 1990);
- Pulmonary Embolism;
- Dislocations: possible surgery to re-locate, the person may have to
wear a brace;
- Loosening of the prosthesis: related to age of prosthesis and activity
of the owner;
- Fracture of bone around the prosthesis;
- Polyethylene wear: Polyethylene is inert in the prosthesis form,
however the shavings caused by wear become toxic to the system;
- Elderly people may become confused from anesthetic;
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