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chapter
16
Therapeutic
Exercise for Joint
Replacement
History
• Partial joint replacement began in late 1800s
• First successful total joint replacement (TJR)
– Dr. John Charnley
– Total hip
– Metal ball, Teflon socket secured with dental cement
Today’s Total Joints
• Metal alloys
– Chromium
– Cobalt
– Titanium
• Polymers
• Cement and cementless
Longevity and Candidates
• Early versions lasted:
10 years
• No one under 70
years old
• Today’s version last:
>20 years
• Hips: as young as
30s
• Knees: as young as
50s
Terminology
• Arthroplasty = total joint procedure
• Also, arthroplasty = replacement, so
– THR = THA = total hip
– TKR = TKA = total knee
– TSR = TSA = total shoulder
Arthritis
• Many kinds
• Most often candidates for total joint
replacements have:
– Osteoarthritis
– Rheumatoid arthritis
– Aseptic necrosis
Progression of Arthritis
Injury or disease  fraying, thinning  surface
degeneration  exposure of bone  pain,
disability, deformity
Weakness,
motion loss
Pain,
disability,
deformity
Arthroplasty Risks and Their
Management
• Risk of embolism (deep vein thrombosis)
– Management includes thromboembolic disease
(TED) hose, early exercise, and ambulation
• Risk of dislocation
– Management includes restricted motion during first
postoperative weeks, use of protective splints, and
braces
Prearthroplasty Treatment Options
1. Medications
1. Non-steroidal anti-inflammatory drugs (NSAIDS)
2. Glucosamine and chondroitin
2. Articular cartilage treatment options
1. Cleaning: arthroscopic debridement
2. Reparative:
1. Abrasion arthroplasty
2. Arthroscopic subchondral drilling
3. Microfracture
3. Restorative:
1. Osteochondral plugs
2. Autologous chondrocyte transplantation
Prearthroplasty Candidates
• Severe joint degeneration
• Excessive, continual pain
• Reduced function that interferes with daily
activities
• Muscle weakness and atrophy
• Loss of motion
• Pathological gait (for lower extremity)
• Weakness in other extremity segments
Arthroplasty Surgical Procedure
• Remove articular surface section of each joint
end.
• Select appropriate prosthesis size.
• Prepare bone for prosthesis.
• Align prosthesis parts.
• Cement or cementless introduction of
prosthesis to bone.
• Reapproximate joint ends.
Postoperative Care
•
•
•
•
•
•
Continuous passive motion (CPM) is an option.
TED hose for lower extremity
In-bed exercises no later than first day post-op
Gait (for lower extremity) on first day
Active exercises for non-excised muscles
Rehabilitative environment progression
– In hospital
– At home or in extended care facility
– Outpatient program
Figure 16.2
THA Precautions
• If gluteus medius was cut, no active abduction
for 6 weeks
• No sitting at 90° or less for first 2-3 months
• Use abduction pillow in bed for first 2-3 months
• No crossing of legs
• No medial rotation of hip beyond 0° (with
posterolateral approach)
• Avoidance of hip extension and lateral rotation
(with lateral or anterolateral approach)
Figure 16.3
TKA Precautions
• Patient may be able to bear full weight even with a
cementless procedure; must be indicated by surgeon
• Patella dislocation or subluxation may occur.
• Patient is not to drive car for first 8 weeks.
• Post-op results are better with patella resurfacing.
• Quadriceps will be excessively weak, but rehabilitating
it is secondary to the following concerns:
Pain
Prolonged weakness (premorbidly)
Edema
Surgical procedure
Figure 16.4a
Figure 16.4b
TSA Precautions
• If rotator cuff is not viable or reparable, reverse
TSA (rTSA) may be required.
• Results for full function with rTSA are less
optimal.
• Deltoid is split, and subscapularis and
pectoralis major are excised; therefore, no
active exercise for shoulder abduction and
medial/lateral rotation for first 4-6 weeks.