Extract
Although most patients who undergo total hip or knee joint
arthroplasty have an excellent clinical result with routine postoperative
interventions, substantial dysfunction develops in 15% to 20% of patients for
various reasons1.
These patients do not respond to standard physical therapy modalities and need
a very aggressive regimen of management that may include both invasive and
noninvasive therapeutic options. The purpose of this study was to identify
these patients with functional limitations and to assess the results of
treatment with a customized regimen. We defined soft-tissue problems as those
not directly related to the implant. Implant-related problems due to
malalignment or loosening were ruled out radiographically or by specialized
testing by two of the authors (M.M. and G.E.). We identified several
functional problems following total hip arthroplasty and total knee
arthroplasty that were related to muscle weakness, muscle tightness,
limb-length differences, and nerve problems
(Table I).
Although most patients who undergo total hip or knee joint
arthroplasty have an excellent clinical result with routine postoperative
interventions, substantial dysfunction develops in 15% to 20% of patients for
various reasons1.
These patients do not respond to standard physical therapy modalities and need
a very aggressive regimen of management that may include both invasive and
noninvasive therapeutic options. The purpose of this study was to identify
these patients with functional limitations and to assess the results of
treatment with a customized regimen. We defined soft-tissue problems as those
not directly related to the implant. Implant-related problems due to
malalignment or loosening were ruled out radiographically or by specialized
testing by two of the authors (M.M. and G.E.). We identified several
functional problems following total hip arthroplasty and total knee
arthroplasty that were related to muscle weakness, muscle tightness,
limb-length differences, and nerve problems
(Table I).
After identification of the problems, management was initiated with either
noninvasive treatment such as physical therapy, customized bracing, electrical
stimulation, or iontophoresis or with invasive treatment such as injections of
Botox (botulinum toxin type A; Allergan, Irvine, California), intraarticular
injections, nerve blocks, or muscle-lengthening procedures. For patients
exhibiting joint stiffness, a lack of extension, or a lack of flexion
(<90°) following total knee arthroplasty, we developed a special
customized protocol utilizing a customized hinged cast and adjunctive physical
therapy. We identified problems with the soft-tissue envelope that were
directly related to the joint in the majority of patients. In addition, some
patients had problems affecting an adjacent joint that resulted in poor gait
and function, such as malalignment of the knee joint in a patient who had had
a total hip arthroplasty or malalignment of the foot in a patient who had had
a total knee arthroplasty.
Our study group consisted of 118 patients who had been treated with a
unilateral arthroplasty. Rehabilitation was difficult in this group, and in
most cases a standard postoperative regimen of physical therapy had failed.
Sixty-seven patients had undergone a total hip arthroplasty and fifty-one, a
total knee arthroplasty. Seventeen of the sixty-seven total hip arthroplasties
were revisions performed because of either component loosening or a previous
infection at the hip. Thirteen of the fifty-one total knee arthroplasties were
revisions secondary to loosening, infection, or joint stiffness. The study
group represents about 5% of the patient population at our center. There were
fifty men and sixty-eight women, and the age range was forty-seven to
seventy-two years (mean age, 65.3 years).
Patients were screened carefully for radiographic evidence of loosening.
Additional assessment included a detailed physical examination, isokinetic
strength testing, videotaped gait analysis, assessment of balance, and, for
the few patients with malalignment, a three-dimensional gait study. Patients
with neuropathic pain underwent sensory nerve testing and electromyography,
and superficial nerve blocks were used to identify specific etiologies in some
patients. On the basis of these detailed examinations, we identified certain
functional problems associated with total hip arthroplasty and total knee
arthroplasty. Functional limitations due to range-of-motion deficits in the
patients who had had a total hip arthroplasty were most commonly identified
around two to 2.5 months after the surgery, usually during the second or third
follow-up visit. Problems related to joint stiffness in the patients who had
had a total knee arthroplasty were typically detected at six to nine weeks
postoperatively and also coincided with the second or third follow-up visit.
All of the other functional limitations were detected late in the follow-up
period. Problems related to malalignment were usually discovered much later
than the other functional deficits (approximately one year after the
surgery).
We questioned all patients regarding their ability to participate in light
recreational sports and whether they had been active prior to the surgery. We
also posed specific questions regarding their activities of daily living,
including stair-climbing, showering, dressing and undressing, and walking
various distances, as well as other relevant activities, including sexual
relations.
Hip Functional Deficits
On the basis of a thorough examination as outlined above, we identified hip
functional deficits and classified them into four major categories
(Fig. 1): muscle weakness,
muscle contracture, limb-length difference, and malalignment. We analyzed hip
abductor strength with the patient both in the side-lying position and
standing, and we assessed walking for the presence of a Trendelenburg gait. Of
the patients treated with a total hip arthroplasty, thirty-six had abductor
weakness: the gluteus medius was weak in all thirty-six
patients2,3,
the gluteus minimus was weak in twenty-eight (78%) of the thirty-six, and the
tensor fasciae latae were weak in four (11%).
A muscle contracture was present in twenty-one of the sixty-seven patients
who had had a total hip arthroplasty. A hip flexion contracture resulting from
iliopsoas tightness was identified in seventeen patients, who walked with a
lack of hip extension in terminal stance, with increased lordosis of the
lumbar spine, and with trunk rotation. Some of these patients also had deep
groin pain on active flexion of the hip joint. We found a rectus femoris
contracture in sixteen patients. The rectus femoris contracture reduced
swing-phase knee flexion in two of these patients, and the remaining patients
reported stiffness of the hip joint.
Fifteen patients with a total hip replacement had tightness of the tensor
fasciae latae. In four of them, the contracture was >10°, which
resulted in apparent lengthening of the affected limb
(Fig. 2). All of these patients
felt that the surgically treated side was longer. A careful evaluation of the
radiographs in this group determined that none of the cases of lengthening
were caused by the implant.
We identified four patients with a hip adductor contracture. Three of them
lacked full abduction, and one had a substantial adduction contracture that
resulted in apparent shortening of the ipsilateral limb.
Nine of the sixty-seven patients treated with a total hip arthroplasty had
a limb-length discrepancy. The discrepancy was caused by true ipsilateral
lengthening from the prosthetic fit in two of these patients, apparent
ipsilateral lengthening due to tightness of the tensor fasciae latae in four,
apparent ipsilateral shortening due to hip adductor tightness in one, and
ipsilateral shortening of 1.5 and 2.5 cm due to multiple total hip
arthroplasty revisions in two.
Ten of the sixty-seven patients had malalignment, not of the prosthesis but
of a more distal joint. Five patients had malalignment of the ipsilateral knee
joint due to a genu valgus deformity, and one had ipsilateral genu varum with
a flexion contracture that resulted in gait and functional abnormalities. Four
patients in this group did not have symptoms in the knee until after they
underwent the total hip arthroplasty, even though the knee deformity had been
long-standing. Thus, the biomechanical abnormality may have been unmasked by
the total hip arthroplasty. Two patients had malalignment of the contralateral
knee; both had a substantial genu varum deformity that resulted in increased
knee pain with walking. Two patients had an ipsilateral planovalgus
abnormality of the foot. These two patients had constant foot pain and a gait
disturbance related to the collapsed longitudinal arch.
Knee Functional Deficits
The knee functional deficits were broadly divided into six categories:
weakness, peroneal nerve symptoms, flexion contracture, limb-length
difference, knee flexion deficit, and malalignment
(Fig. 3). Twenty-one of the
fifty-one patients who had had a total knee arthroplasty had a clinically
relevant quadriceps strength deficit as demonstrated by an isokinetic test
with a Biodex dynamometer (Biodex Medical Systems, Shirley, New York).
Quadriceps weakness was defined as an active extension lag exceeding 15°
in the early postoperative phase or <50% of the strength of the
contralateral limb as shown by isokinetic testing in the later stages of
recovery.
There was a high rate of knee flexion contracture (defined as a lack of
extension of =10°), which was identified in twenty-three of the
fifty-one patients who had had a total knee arthroplasty
(Fig. 4). The common causes of
the knee flexion contractures were adaptive muscle-shortening, exuberant
scar-tissue adhesions, quadriceps inhibition and hamstring overactivity,
unrecognized tightness of the gastrocnemius, limb-length difference, and
peroneal nerve entrapment. A knee flexion deficit (defined as knee flexion of
<90°) was present in nine of the fifty-one patients. The common causes
of the knee flexion deficits were joint effusion, abnormal pain response,
quadriceps scarring, tightness of the patellar tendon, tightness of the rectus
femoris, and tightness of the iliotibial band.
We identified several nerve problems related to peroneal nerve entrapment
as well as neuromas of the sciatic and superficial nerves in this group. Three
patients had peroneal nerve entrapment that produced burning pain down to the
dorsum of the foot, paresthesias of the foot, increased foot pain, mild
weakness of the extensor hallucis longus, and a positive Tinel sign (in one
case). Two patients had a history of sciatica that resulted in increased
peroneal nerve symptoms postoperatively. In addition, two patients had a
superficial neuroma involving the saphenous nerve, with symptoms that resolved
with nerve blocks.
Four of the fifty-one patients who had had a total knee arthroplasty
demonstrated a limb-length difference, with the side of the arthroplasty
longer than the contralateral side. These discrepancies resulted in a flexed
knee posture and a resultant flexion contracture. We determined that these
flexion contractures had developed as compensation for the limb-length
difference. Two of the four patients who had a limb-length difference after
the unilateral total knee arthroplasty had preoperative bilateral genu varum
deformity. The discrepancy occurred in those two patients when the surgical
side gained length as a result of the correction of the varus deformity.
There was malalignment on the side of the total knee arthroplasty in four
patients, three of whom had substantial planovalgus deformity of the foot. Two
of the three had a dysfunctional posterior tibial tendon with hindfoot valgus
and a pronated hindfoot, and one had a tarsal coalition and a planovalgus foot
deformity. The fourth patient had substantial ligamentous laxity of the knee
in both flexion and extension. This patient was dissatisfied with the result
and went on to have a revision total knee arthroplasty to improve the
stability of the joint.
Correlation of Functional Impairment with Symptoms and Physical
Findings
We attempted to correlate the physical impairments with the symptoms in the
patients in our study. In the population treated with a total hip
arthroplasty, we identified four major impairments: hip flexion contracture,
hip abduction contracture, hip abductor weakness, and a true or functional
limb-length difference (Table
II). The major symptoms in the patients who exhibited a
contracture included anterior hip pain or groin pain, abnormal gait, and low
back pain. These impairments were found in most of the patients. Many
patients, especially younger ones, reported that their sexual relations had
been altered. The main symptoms in the patients with hip abductor weakness
were increased energy consumption during gait, as suggested by the patient
tiring too easily, and an abnormal appearance. The weakness also resulted in
an inability to participate in light sports or recreational activities such as
golf, tennis, dancing, or gardening. The main problems associated with a
limb-length difference were low back pain and abnormal gait.
In the population with a total knee arthroplasty, we identified five
impairments: knee flexion contracture, knee flexion deficit, quadriceps
weakness, peroneal nerve entrapment syndrome or nerve symptoms, and
malalignment (Table III). Knee
flexion contractures frequently resulted in anterior knee pain or
retropatellar pain with quadriceps fatigue pain, back pain, limping gait,
difficulty walking long distances, or the inability to participate in light
sports. A flexion deficit did not result in a clinically relevant gait
abnormality but did result in difficulty sitting in a chair or rising from a
seated position, difficulty ascending or descending stairs, inability to use a
bicycle for recreation, and difficulty with sexual relations. Patients with
quadriceps weakness had quadriceps fatigue pain, buckling, or a giving-way
sensation, especially those who demonstrated a quadriceps lag of >15°
when they were tested in a seated or straight-leg-raise position. These
patients lacked quadriceps control at the initial stance phase of the gait
cycle and experienced some instability with a giving-way sensation. Quadriceps
weakness also resulted in difficulty with walking on uneven ground and on
ramps, difficulty climbing stairs and walking long distances, and the
inability to participate in sports.
Peroneal nerve symptoms caused difficulty with sleeping at night, radiating
pain to the dorsum of the foot, and difficulty walking long distances,
especially at heel-strike during the gait cycle, with tripping or stumbling
occurring in severe cases. Malalignment usually resulted in knee pain and
laxity with buckling at the knee. Patients also needed to use braces, which
some found cumbersome.
Muscle Contractures
In our study, we identified hip flexion contractures due to
tightness of the iliopsoas, rectus femoris, sartorius, adductors, and
sometimes the tensor fasciae latae. Our initial strategy for treatment of hip
flexion contractures involved manual therapy. This included an aggressive
customized stretching protocol with at least seven to ten stretches of each
affected muscle during each physical therapy session, at a frequency of four
or five times a week for the first two to three weeks followed by a frequency
of three times a week (Fig. 5).
All patients were also provided with a home exercise regimen, which they
performed either by themselves or with assistance from family members. In
addition to aggressive physical therapy to stretch the hip flexor contracture,
we injected 2 mL of triamcinolone with 3 mL of 1% lidocaine into the iliopsoas
tendon with image-intensifer-guided assistance
(Fig. 6). Tendinitis was
diagnosed when resisted hip flexion was found to be painful in a seated
position. Stretching was initiated forty-eight hours after the injection.
Of our four patients with adductor tightness, one responded well to
standard manual therapy, one underwent adductor lengthening surgery, one
received a Botox injection into the adductor muscle, and one had resolution of
the adductor spasm after a revision total hip arthroplasty. Of the fifteen
tensor fasciae latae contractures, four resulted in an apparent limb-length
difference, with the tight side being longer by 1 to 2.5 cm. The patients with
this complication responded well to a specific tensor fasciae latae stretching
regimen as shown in Figure 7.
Stabilizing the hip with the patient in either the prone or side-lying
position stretched the tensor fasciae latae, after which the therapist
performed extension and adduction mobilization of the hip joint to increase
tension in the tensor fasciae latae. In addition to stretching, manual massage
and soft-tissue mobilization techniques involving deep massage had good
results in patients with tightness of the tensor fasciae latae. All of the
patients with muscle contractures were asked to perform home-stretching
regimens daily. We avoided giving a shoe lift initially to patients in whom
the limb-length difference was due to tightness of the tensor fasciae latae;
instead, we instructed them to walk in order to stretch the tensor fasciae
latae. In our opinion, a shoe lift would have prevented effective
stretching.
Abductor Weakness
Hip abductor weakness was a major problem in a large proportion (54%) of
our patients. Our treatment strategies depended on the degree of weakness. If
the muscle weakness was less than grade 2 (of 5), we always began with aquatic
therapy4. Aquatic
therapy improves muscle performance by utilizing buoyancy to reduce
gravitational forces, and the warm temperature of the water increases blood
flow to the affected muscles. Once muscle strength was increased to at least
grade 3, we began a land-based strengthening regimen. We used electrical
stimulation to augment the strengthening program for the gluteus minimus and
medius muscles (Fig. 8).
Instead of completing a standard hip-abduction exercise program with use of
resistance, we focused mainly on muscle pattern techniques that strengthened
hip abduction through the use of correct positioning to enhance muscle
performance. For example, the gluteus medius is best strengthened in the
side-lying position with the hip in about 10° of extension and external
rotation while the abduction motion is completed. This maneuver specifically
addresses the role of the gluteus medius in abduction. The gluteus minimus was
strengthened in pure abduction with the patient in the side-lying position,
whereas the tensor fasciae latae was strengthened with the patient in the
supine position with the hip held in external rotation and abduction completed
in a 45° arc. As the muscle performance increased, we applied weights,
first at the knee and then at the ankle, to increase the lever arm of the
resistance. The maximum weight used with this specific regimen never exceeded
10 lb (4.5 kg). In addition to hip abductor strengthening with the patient in
the side-lying position, we utilized functional retraining with the Balance
Master System (NeuroCom International, Clackamas, Oregon).
Once the patient graduated from treatment with these techniques, balance
enhancement with use of functional exercises, such as standing on one leg in
front of a mirror to obtain biofeedback and use of the BAPS (Biomechanical
Ankle Platform System) board (Spectrum Therapy Products, Jasper, Michigan)
were encouraged to increase the total limb function and pelvic stability in
single-limb stance. This was the progression of hip abductor strengthening for
all patients who had major hip abductor weakness. After most revision total
hip arthroplasties, and some primary arthroplasties, the average duration of
the exercise program with and without a supervised physical therapy regimen
was three to six months until the patient returned to full function. In two
patients in this series, the hip abductor weakness was extensive and did not
respond to the treatment regimen described above. When we found no improvement
in these two patients, we referred them for electromyography and nerve
conduction studies. Both demonstrated L4-L5 radiculopathy, and they were
referred to spine physicians for specific interventions. One patient underwent
surgical decompression of the spine with fusion, and had improvement, and the
other patient refused additional treatment.
We always attempted to address apparent limb-length differences due to
tightness of the hip abductors with aggressive stretching and manual physical
therapy techniques to improve the length of the tensor fasciae latae. One
patient had no improvement with this treatment, and one patient did not comply
with our program and chose to have a surgical lengthening. Patients who had a
true limb-length difference, with the surgically treated side longer than the
uninvolved side, had trochanteric pain and pain around the total hip
arthroplasty incision. These symptoms appeared to be due to a pelvic tilt
compensation that placed the long limb in adduction and the short limb in
abduction. This problem resolved only after an appropriate shoe lift was worn
on the contralateral side, and it did not resolve in all patients. The
patients with a longer limb on the contralateral side than on the surgically
treated side and some stiffness of the hip joint were always given a shoe lift
that was 0.5 to 1 cm shorter than the true limb-length difference in order to
aid in foot clearance.
Ten patients had malalignment that was not directly related to the hip
joint but rather was in the knee or foot and resulted in pain or an abnormal
gait. Two patients with a pronated foot on the surgically treated side were
treated with a medial wedge and corrective footwear that improved the gait and
reduced the pain in the foot. Two patients had substantial genu varum on the
contralateral side, which was corrected with a high tibial osteotomy in one
and with a total knee arthroplasty in the other. Five patients had substantial
ipsilateral genu valgum. Three of them also had substantial abductor weakness
and, as a result of positioning of the trunk over the foot in order to reduce
the abductor lurch, the lateral knee pain was considerably increased. As the
abductor lurch was reduced with improvements in strength, the lateral knee
pain was reduced as well. The other three patients had no resolution of
symptoms; substantial pain in the lateral compartment continued. Two patients
had an osteotomy of the distal part of the femur to correct the mechanical
axis, and one patient used an off-loader brace and was satisfied with the
outcome.
We identified five types of impairment that resulted in substantial
dysfunction following total knee arthroplasty. A knee flexion contracture was
found in twenty-three of the fifty-one patients. The causes of the knee
flexion contracture were preoperative loss of motion with muscle-shortening,
previous surgery with exuberant scar formation, knee effusion resulting in
pain and quadriceps inhibition causing hamstring overactivity, unrecognized
gastrocnemius tightness, a limb-length difference with the side of the total
knee arthroplasty being longer and resulting in a flexed-knee posture,
periarticular remodeling, joint subluxation, and peroneal nerve
entrapment.
Our preferred method for treatment was aggressive and customized. All
patients with a knee flexion contracture were assigned to be treated with our
aggressive regimen, which was carried out five times a week for the first few
weeks. In addition, they were all fitted with a customized knee device that we
had developed5. This
device allows knee-extension positioning with use of a Theraband attached in a
figure-of-eight fashion to produce an extension moment at the knee
(Fig. 9). We used
polyester-based casting tape (Dynacast PII; BSN Medical, Charlotte, North
Carolina) to fabricate the splint. This material is lightweight and conforms
well. At the same time, it is rigid enough to transmit optimal force. Patients
wore the customized knee device at maximally tolerated tension for thirty to
forty-five minutes three times a day. The heel was propped up on a pillow to
utilize gravity and promote knee extension with the patient in a long-sitting
or supine position.
In addition, we used an aggressive adjunctive therapy consisting of
application of moist heat and soft-tissue mobilization at the posterior aspect
of the knee (at the distal hamstring insertion and the proximal gastrocnemius
insertion) with the patient prone and the knee in maximal extension.
Anterior-posterior joint mobilization of the femur while the patient was in
the supine position, and the proximal part of the tibia was supported by a
bolster, was used to promote end-range knee extension. Gastrocnemius
stretching with the patient supine, the heel propped, and the knee in maximum
extension was also used. Neuromuscular electrical stimulation involved
applying electrodes to the quadriceps over the vastus medialis obliquus
fibers, and over the proximal part of the vastus lateralis. It was used for
twenty to thirty minutes with a five-second on-time and a fifteen-second
off-time and a waveform at 70 to 90 pulses per second with 400-microsecond
pulse duration. The intensity of the stimulation was the maximum that could be
tolerated6. We
instructed patients to complete a quadriceps set when the electrical
stimulation was active. Closed-chain weight-bearing exercise with use of a
leg-press to promote end-range knee extension was also utilized
(Fig. 10).
The majority of the patients responded well to this regimen, but we used
Botox injections into the hamstring and gastrocnemius muscles to reduce muscle
spasm in two patients. This resulted in the resolution of symptoms, and
aggressive therapy could continue. Three other patients were not doing well
because of persistent effusions of the joint, and they responded to the
vigorous physical therapy and bracing only after aspiration of the joint
followed by intra-articular injections of 1 mL of triamcinolone with 4 mL of
1% lidocaine. One patient underwent arthroscopic lysis of adhesions followed
by a continuous epidural block and continuous passive motion with aggressive
manual therapy to increase knee extension. This patient went on to have a
persistent knee flexion contraction of 5° but was functioning well.
Another patient in this group did not respond to any of these interventions
and chose to have a revision total knee arthroplasty and scar-tissue
release.
As stated, our treatment regimen for flexion contracture was successful in
the majority of cases. It was aggressive to address joint positioning with
careful assessment of joint subluxation (if any) and use of an anterior drawer
maneuver to mobilize the knee into extension. A customized knee device was
used for prolonged knee-extension positioning at home and sometimes at night.
Aggressive mobilization of the joint and electrical stimulation of the
quadriceps muscle were used to increase the passive range of motion achieved
with active extension. Gait training was employed to improve active heel
strike at initial contact once the flexion contracture had resolved, and any
limb-length difference was managed with an appropriate shoe lift (used for two
patients).
Knee flexion deficits (<90° of flexion) resulted in functional
deficits in the ability to ascend and descend stairs, rise from and sit in a
chair, sit for a prolonged period of time, and sexual activities. These
problems were mainly related to tightness of the rectus femoris, patellar
tracking problems, and tightness or inflammation of the patellar tendon. Four
patients in this group required manipulation under anesthesia followed by
aggressive physical therapy to improve knee flexion. We also devised a
customized knee device to increase knee flexion
(Fig. 11), as we had to
increase extension. The patients were instructed to use the device for thirty
to forty-five minutes three times a day to improve knee flexion. In addition,
careful knee joint mobilization with posterior glides of the tibia
(Fig. 12), inferior patellar
mobilization (Fig. 13), and
mobilization of the quadriceps tendon and the patellar tendon were all
techniques that were applied to increase knee flexion. Treatment with physical
therapy and customized bracing alone was successful in five of the nine
patients. The other four patients required manipulation under anesthesia as
outlined above, and one of the four also required arthroscopic lysis of
adhesions. With this combination of invasive and noninvasive modalities, all
of the nine patients had an increase in knee flexion and most had an increase
of at least 30°.
We defined quadriceps weakness as either an active extension lag of
>15° or quadriceps strength, in the available range of motion tested
isokinetically, that was <50% of that on the contralateral side. For
patients with quadriceps weakness, we used the muscle-stimulation protocol to
augment the muscle contraction during strengthening. This regimen is more
effective than are voluntary contractions alone, presumably because of the
neural overflow produced by the electrical stimulation. Use of this regimen
improved quadriceps strength in most patients.
Three patients had peroneal nerve entrapment resulting in a lack of knee
extension. These patients had no frank motor involvement except for mild
weakness of the extensor hallucis longus in one patient. Knee extension made
the foot pain worse, and knee flexion made it better. Sensory testing with use
of a pressure-specified sensory device and additional testing with
electromyography in both the extended-knee and the flexed-knee position were
used to test the sensitivity of the peroneal nerve at the fibular head. Frank
electromyographic changes with knee extension or substantial clinical symptoms
were present in these three patients. Two underwent surgical release
(Fig. 14), and one responded
well to medications. Two patients with sciatica had less severe symptoms and
could be treated with medications; the symptoms resolved within three months.
A saphenous neuroma was found in two patients. One underwent excision of the
neuroma followed by release of scar tissue and had an excellent outcome. The
second patient refused further treatment for this problem.
Three patients had planovalgus malalignment of the foot, which resulted in
maltracking at the knee. The changes in the pressure distribution on the foot
were managed with appropriate shoe modifications, and all three patients had
substantial improvement of gait and decreased pain after that intervention.
One patient had ligamentous laxity of the knee, which required a revision
total knee arthroplasty with an adjustment in the height of the spacer. This
patient eventually had 0° to 110° of motion with a substantially
improved gait pattern.
Overall, our aggressive, customized, invasive and noninvasive
treatment protocols that addressed limitations following total hip or knee
arthroplasty reduced symptoms and restored function in 92% (108) of the 118
patients in the series. The 8% for whom this treatment failed required a major
surgical intervention.
Although such an aggressive regimen is not required following most total
hip and knee arthroplasties, some patients do require, to a lesser degree, a
structured program. A careful physical examination of selected patients can
help the clinician to identify specific physical findings and impairments,
which can then be treated with the noninvasive or invasive therapeutic
modalities described above. ?
Ranawat CS, Ranawat AS, Mehta A. Total
knee arthroplasty rehabilitation protocol: what makes the difference? J
Arthroplasty.2003;18(3 Suppl 1):
27-30.1827
2003
[PubMed][CrossRef]
Sicard-Rosenbaum L, Light KE, Behrman
AL. Gait, lower extremity strength, and self-assessed mobility after hip
arthroplasty. J Gerontol A Biol Sci Med Sci.2002;57:
M47-51.57M47
2002
[PubMed]
Bertocci GE, Munin MC, Frost KL, Burdett
R, Wassinger CA, Fitzgerald SG. Isokinetic performance after total hip
replacement. Am J Phys Med Rehabil.2004;83:
1-9.831
2004
[PubMed][CrossRef]
Ruoti R, Morris D, Cole A, editors.
Aquatic rehabilitation. Philadelphia: Lippincott Williams and
Wilkins; 1997.
1997
Bhave A, Mont M, Brown C, Tennis S,
Etienne G. New cost-effective customized knee device for knee flexion
contractures after total knee arthroplasty. Presented as a podium presentation
at the Annual Meeting of the American Academy of Orthopaedic
Surgeons; 2005 Feb 23-27; Washington, DC.
2005
Stevens JE, Mizner RL, Snyder-Mackler L.
Quadriceps strength and volitional activation before and after total knee
arthroplasty for osteoarthritis. J Orthop Res.2003;21:
775-9.21775
2003
[PubMed][CrossRef]