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 With the advent of joint replacement or arthroplasty, new materials technology and minimally invasive techniques, surgeons have created a wave of older patients looking for sports medicine rehabilitative services. From the most recent data available from the National Center for Health Statistics and the U.S. Department of Health and Human Services, there are 231,000 total hip replacements (THRs), 542,000 total knee replacements (TKRs) and 18,300 total shoulder replacements (TSRs) performed annually. In addition, although numbers are not yet available, surgery for total disc replacements (TDRs) are being perfected.
Arthroplasty on the Rise
No longer a surgery reserved for patients older than 65 years of age, the success of joint arthroplasty over the last 10-20 years has created more general acceptance and thus expanded opportunities for younger patients suffering from joint failure. Rather than avoiding activities and awaiting later age with weight gain from inactivity and a greater risk of co-morbidities, younger patients are eager to elect surgery sooner rather than later. Perioperative mortality approximates a low 0.5 percent, and patients who undergo joint replacement demonstrate a relatively rapid and substantial improvement in their conditions of pain, functional status and overall health-related quality of life. Data suggest that these improvements in patient-reported outcomes persist in both short- and long-term studies. Research has shown that 54 percent of all patients with THR actually improved their levels of sports activities 5 years after surgery compared to before surgery.1
Following a Consensus Development Conference on TKR, the National Institutes of Health produced a summary of four decades of data since the inception of modern arthroplasty. The success rate for patients who elect joint arthroplasty is 90-95 percent, with few contraindications other than infection, peripheral vascular disease and/or neurological conditions. Fortunately, obesity is not a contraindication to TKR, as individuals with high body mass indexes suffer from higher rates of osteoarthritis, a leading cause for election of this type of surgery.
Arthroplasty, regardless of its location, has potential complications following joint replacement. These include surgical wound-healing problems; infection; deep-vein thrombosis and subsequent risk for pulmonary embolism; pneumonia; myocardial infarction; joint instability; stiffness; malalignment; and nerve and vascular injuries. Other complications include excessive post operative edema, inability to effectively manage pain and difficulty with bowel management regimens due to narcotics used perioperatively. Clinicians should be aware of patients who elect arthroplasty who also have rheumatoid arthritis, diabetes mellitus, obesity or use glucocorticoids, as these may influence wound healing. One of the most important factors leading to successful TKR is proper surgical technique; the rate of success is directly related to both surgeons' and hospitals' volume of operations per year.
New Technologies
Part of the rush to joint replacement has been a surge of new technologies being developed. Joint replacement prosthetics are more durable and can be customized to a patient's anthropometics more accurately. For physical therapists, knowledge of the different types of techniques is also important.
For hip replacement, there is the familiar posterior approach; however, other surgeons prefer a lateral approach, anterolateral and an anterior approach. The Zimmer Minimally Invasive Solutions (MIS) anterolateral hip replacement is a design that allows a prosthetic implantation through a smaller incision without dividing the abductor muscles or violating the posterior capsule and thus, patients generally have no precautions for dislocation.
There are also new names, like the Birmingham Hip arthroplasty and the Mayo hip arthroplasty. The Birmingham Hip arthroplasty is actually a hip resurfacing technique, where the acetabular component is metal, but only the head of the femur is replaced. The Mayo hip is a minimally invasive mini-stem that is inserted anteriorly through the patient's joint capsule. Special postoperative precautions for these patients include avoiding positions of extreme extension and abduction with external rotation.
In addition to the hip joint, advances in knee arthroplasty have contributed to the popularity of this type of surgery. With TKR, the distal femur, proximal tibia and portions of the patient's patella are all replaced. A polyethylene insert, typically cross-linked to improve its durability, is placed within the two metallic prostheses.
Common prostheses include the fixed bearing unit, where the polyethylene cushion is attached to the tibial stem. Newer prostheses allow 155 degrees range of motion, while others, such as the Medial pivot, the Rotating Platform and Mobile-Bearing types, allow for the rotation that is normally found in an unoperated knee. Other types of prostheses are made to spare the posterior cruciate ligament (PCL) or substitute for the PCL allowing for more stability of the replaced knee. Partial knee joint arthroplasties, such as unicompartmental or patellofemoral knee resurfacing procedures, are also performed to minimize bone loss. To improve the accuracy of the surgical procedure computer-assisted navigation equipment may be used, and some orthopedic doctors will design a customized prosthesis from medical imaging studies prior to the surgery to produce a prosthesis with a more compatible fit.
Research in Practice
Research has shown that the largest gains occur in the first 12 weeks following surgery.2 At Harvard Vanguard Medical Associates (HVMA) in and around Boston, MA, clinicians at all levels are involved in the new Sports Medicine phenomenon. Dr. John Zimmer, who focuses his orthopedic practice on pathologies of the hip and knees, relates the case of a patient who underwent a left TKR in March 2009. Prior to TKR, the patient was a very athletic individual who relates a knee injury requiring open knee surgery "the old way" 31 years prior. Throughout the years he participated in basketball, volleyball, skiing, tennis, rock climbing, marathon running and his favorite sport: surfing.
The year before his surgery he had given up running and was hobbling through tennis once a week. He postponed his TKR surgery primarily because he believed, as many others in the same situation, that joint replacement would help relieve the pain but would prevent him from participating in the activities he had enjoyed before. His recovery included a short hospital stay, 4 weeks of home care followed by 2 more months in an outpatient physical therapy clinic.
At first, he recalled, "bending seemed impossible, then holding my knee straightened was the exercise I dreaded the most." But an exercise that seemed impossible "became a goal." Two months after surgery, he was bicycling again. Three months later, he was surfing. His proudest accomplishment to date was a nine pitch 1000-foot rock climb in November 2009.
When asked to provide advice for patients considering joint replacement, he offered two suggestions: "Get in shape for the surgery" and "Don't cut corners on the rehab from the PT".
"The reward is unbelievable," he added, as he plans for a cross-country ski adventure.
Dr. Steve Hollis, an orthopedic physician at the Peabody HVMA, is himself an individual who has had both hips replaced. He continues to bicycle, walk and has gone skiing in Utah. He recommends that patients have a realistic timetable for recovery. A 45-year-old when he had his first hip surgery, Dr. Hollis advocates early return to walking but recommends a more conservative 6 months before returning to sports.
Rehabilitation following joint replacement is not the only sports medicine approach offered by physical therapy professionals. At the HVMA clinics in the Boston area, PTs have been trained in the "Strong Woman Stay Young" strength training program for osteoporosis prevention. At the HVMA in Watertown, Nuala Heespelink, PT, leads an 8-week program of strength training for older female patients who have chosen to adopt a more proactive, less sedentary approach to health. These are women who want to initiate or continue a weight lifting program specifically adapted to the needs of older females at higher risk for osteoporosis. Her focus has been on upper and lower extremity strength training and balance activities that target functional needs and ADLs. The exercise routine she teaches is easy to learn and consistent, which leads to better carryover for gym programs and home maintenance.
The confluence of Baby Boomers and medical technology has ushered in a new era for managing the health of geriatric patients. However, younger patients undergoing arthroplasty are looking for a higher level of functional returns and an earlier return to a more active lifestyle. The next phase of technology will emphasize programs for the revision generation. Modular prostheses designed for easy replacement--much like tires changed on a car--will be the next new wave. Either way, physical therapy will be a necessary ingredient in the preoperative preparation, rapid recovery and early return to function for these patients.
Joseph "Jay" Cigna, PhD, MSPT, is a physical therapist for Harvard Vanguard Medical Associates in the metropolitan Boston area. He has more than 20 years experience in healthcare practice, teaching and research, with interests in gerontology and the role of rehabilitation in the management of chronic diseases.
References
1. Annals of the Rheumatic Diseases 2005; 64:1715-20
2. Physical Therapy 2008; 88:22-32
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