Secondary Logo

Journal Logo

CAQ Review

Rehab Considerations for Recovery after a Prosthetic Joint Placement

Kiel, John DO, MPH, CAQ-SM1,2; Washington, Johnny MD1

Author Information
Current Sports Medicine Reports: August 2020 - Volume 19 - Issue 8 - p 279-280
doi: 10.1249/JSR.0000000000000733
  • Free

Introduction

Prosthetic joint replacement surgery of the knee and hip is a common surgical procedure performed across the United States. This procedure is intended to treat the symptoms associated with osteoarthritis and rheumatoid arthritis, including pain and decreased mobility (1). Currently, more than 700,000 total knee and roughly 400,000 total hip arthroplasties are performed across the country each year (2,3). These numbers are projected to increase rapidly over the coming decades (2). Many factors go into creating a successful outcome after these procedures. Proper physical rehabilitation is one of the most crucial.

General

The general goals of rehabilitation after prosthetic joint replacement are to improve joint motion, enhance muscle strength, and enhance patient mobility to allow a safe transition to functional independence (4). Achieving these goals requires a multidisciplinary approach among physicians, nurses, physical therapists, and case management staff. Physicians recommend a treatment plan based on the procedure performed. Nurses and physical therapists monitor and assist the patients throughout the treatment plan. Case management staff assure that the patients' discharge needs are met, including assistive walking devices, bedside commodes, and, if necessary, arrangements for subacute rehab facility placement.

Preoperative

The best approach for most patients is to begin outpatient rehabilitation during the preoperative phase. Patients can attend an instructive class presented by nurses and physical therapists to familiarize themselves with the surgical procedure, postoperative program, and general rehabilitation progression. Patients can receive lessons on the following: general exercises: how to walk with assistive devices, such as crutches or a rolling walker; and setting expectations regarding pain management. These sessions should provide ample time to have their questions answered.

Immediate

During the hours after the procedure, the surgical team will evaluate the limb circulation, sensation, movement, range of motion, and strength. Physical therapists will often come to see the patient the same day of surgery to begin education and mobilization. Prosthetic joints are sturdy enough to bear weight immediately after surgery; however, it is strongly recommended that patients do so with assistance. This early ambulation is not only beneficial for the joint itself but also helps decrease the likelihood of postoperative complications, including atelectasis, pneumonia, urinary retention, and venous thromboembolisms.

After knee arthroplasty, patients must meet several milestones before discharge to home or a subacute rehab facility, including achieving independence with a home exercise program (HEP), knee flexion to 90 degrees or more, independence with transfers from bed, and independence with walking 200 ft to 250 ft with an assistive device. If a patient has stairs at home, the therapist also will ensure patient safety for navigating stairs.

There are similar discharge criteria for patients after hip arthroplasty, including the ability to comply with hip dislocation precautions, perform bed mobility and functional transfers independently, safely ambulate household distances of 50 ft to 100 ft on even and uneven surfaces with an assistive device, and improve hip range of motion and strength.

The average length of stay varies among patients and can be determined based on the patient's age, comorbidities, and preoperative functional status. The vast majority of patients stay in the hospital for 2 d to 3 d. The decision for discharge to home versus subacute rehabilitation is best determined before surgery to allow the patient and the staff to make necessary arrangements ahead of time. Although most patients prefer to go home after surgery, a patient might be better served in a rehab facility if he/she has limited family support, a home not conducive to a mobility-challenged individual, or an unforeseen postoperative complication. Coordinated arrangements for a safe discharge involve the patient, physician, therapist, and case managers.

Short Term (0 to 12 wk)

Short-term goals include performing safe transfers, ambulating with an assistive device, progressing sustained distance to 0.5 mile, restoring range of motion, participating in a HEP, reducing pain, and improving function.

For the knee, the range of motion should increase at each visit toward a goal of full extension to 125 degrees of flexion. Quadricep muscle strength should improve such that a patient can perform a straight leg raise without any lag. Between weeks 3 and 6, patients should be able to transition to use a cane or a single crutch. They should be encouraged to walk short distances without an assistive device. At this point, patients also should be able to climb stairs with alternating gait for at least one to two flights with or without using the handrails.

The short-term goals after hip arthroplasty differ to some degree. The normal anatomy of the hip joint is less constrained, when compared with the knee, leading to a higher propensity for dislocation. In addition, the structures that hold the hip joint reduced are compromised during surgery. Some of the goals of rehabilitation after hip arthroplasty are, therefore, centered around prevention of this devastating complication. Hip precautions have been prescribed by arthroplasty surgeons in an attempt to limit certain motions that might place the arthroplasty construct in a position at increased risk for dislocation (5). Proper education about at-risk hip positions is a crucial component of rehabilitation. In addition, the patient should be comfortable with bed mobility (i.e., rolling over in bed) and transferring from bed to chair with assistance. They are encouraged to ambulate 20 ft to 100 ft with an assistive device. If patients have stairs at home, they will be instructed on how to navigate stairs properly. Strength and motion parameters include the ability to perform a straight leg raise independently and to regain at least 80 degrees active and passive hip flexion.

Long Term (12 wk and Beyond)

By 12 wk, the patient should be able to resume normal activities, such as exercising, returning to work, and participating in air travel.

There are some general limitations to physical activity, which will differ between knee and hip recipients. Acceptable physical activities after knee replacement include the following: unlimited walking, swimming, and low impact sports (bicycling, golf, light tennis) (6). Weight training is acceptable but should be limited to 50 lb or less. In addition, emphasis should be on continuing fitness activity for weight loss purposes and for maintaining a healthy body composition.

The acceptable activities after hip replacement mirror those for total knee (7). The limitations specific to the hip are directed at preventing hip dislocation. The precautions are typically prescribed to protect the joint during the early phase of soft tissue healing, during the early recovery period, which is approximately 3 months. They can typically be discontinued thereafter (5); however, patients should remain mindful of the precautions for life. Some examples include the following: avoid leaning forward while sitting down, avoid reaching to pick up an item off the floor while seated, and avoid bending at the waist more than 90 degrees.

The authors declare no conflict of interest and do not have any financial disclosures.

References

1. Meier W, Mizner RL, Marcus RL, et al. Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches. J. Orthop. Sports Phys. Ther. 2008; 38:246–56.
2. Inacio MCS, Paxton EW, Graves SE, et al. Projected increase in total knee arthroplasty in the United States: an alternative projection model. Osteoarthr. Cartil. 2017; 25:1797–803.
3. Amanatullah DF, McQuillan T, Kamal RN. Quality measures in total hip and total knee arthroplasty. J. Am. Acad. Orthop. Surg. 2019; 27:219–26.
4. Ghazinouri R, Rubin A. Total knee arthroplasty protocol. The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services, 2012. [cited 2020 March 1]. Available from: https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/knee-tkr-protocol-bwh.pdf.
5. Brown ML, Ezzet KA. Relaxed hip precautions do not increase early dislocation rate following total hip arthoplasty. J. Am. Acad. Orthop. Surg. 2020; 28:e440–7.
6. American Academy of Orthopaedic Surgeons. Orthoinfo. Activities After Knee Replacement. [cited 2020 March 1]. Available from: https://orthoinfo.aaos.org/en/recovery/activities-after-knee-replacement/.
7. American Academy of Orthopaedic Surgeons. Orthoinfo. Activities After Hip Replacement. [cited 2020 March 1]. Available from: https://orthoinfo.aaos.org/en/recovery/activities-after-hip-replacement/.
Copyright © 2020 by the American College of Sports Medicine