Exploring Advances In THA
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This document provides an overview of a physical therapy course on total hip rehabilitation. The course objectives are to understand hip surgery and exercises, describe hip biomechanics, and effectively progress patients through rehabilitation. The schedule covers topics like evidence-based practice, anatomy, exercises, and outcome measures. Recent advances in hip rehabilitation include smaller incisions, reduced hospital stays, and early mobilization leading to better short-term outcomes. Assessment tools for hip function include the Lower Extremity Function Scale and Harris Hip Score.
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Exploring Advances In THA
- 1. Total Hip Rehabilitation:The latest advances
- 2. Bridgit Finley, PT, DPT, M.Ed., OCSBoard Certified in Orthopaedicsbfinley@ptcentral.orgwww.ptcentral.orgFacebook
- 3. Physical Therapy CentralChoctaw Chickasha Newcastle NormanOKC Pauls Valley Stillwater
- 4. ObjectivesCourse Objective:The course participants will be able to:Understand the surgical procedures and contraindications with specific exercises.Describe normal biomechanics for the hip joint.Implement the use of outcome measures for patient’s that have had hip surgery.Utilize the internet to access information in regards to evidence based practice.Effectively progress patients through the rehabilitation protocol.
- 5. Course ScheduleEvidence Based PracticeAnatomyBiomechanicsHip O-A & SurgeryManual TherapyTherapeutic ExercisesOutcome Measures
- 6. Vision 2020 The first, best choice in musculoskeletal care.ResourcesAPTAJOSPTPhysiopediaEvidence in MotionAAOMPTPEDroNAIOMTLife Long LearnersPatient AccessAutonomous ExpertsTake our game to the next levelSpecialty CertificationsManual Therapy CertificationsDPT
- 7. Evidence Based PracticeIntegration of the best research evidence with clinical expertise and patient values.Levels of EvidenceSystematic ReviewsCase SeriesExpert Opinion
- 8. American Physical Therapy AssociationConsumersProfessional DevelopmentAdvocacyReimbursementLearning CenterHooked on EvidenceDatabase current researchEarn CEU’s
- 9. JOSPTJournal of Orthopaedic & Sports Physical TherapySearchedHip Arthritis20 AbstractsFull Text Articles
- 10. NAJSPTSports Physical Therapy SectionHip ArthritisNorth American Journal of Sports Physical Therapy
- 11. Overview of the Hip
- 12. OSTEOARTHRITISIn US, 100 Billion Health Care $ by 2020Progressive loss of articular cartilage with variable subchondral bone loss.Prevalence – 10 to 25% in adults age 55 and older.43 Million people in USStandard of care is THA
- 13. Total Hip ArthroplastyThe most common surgical procedure for end-stage hip osteoarthritis.Primary reason for surgery is pain which interferes with ambulation.
- 14. American College of RheumatologyClassification Hip OACluster 1Pain in the hip< 115 hip flexion< 15 IRCluster 2Pain with IR< 60 minutes morning stiffness> 50 yrs. oldCurrent guidelines focus on pharmacological and surgical management
- 15. X-RayDemonstrate loss of joint space, osteophytes and sclerosis.Dysplasiatears are more common in individuals with acetabular dysplasia.
- 16. In US, between 1990 and 2002, THA rose from 119,000 to 193,000 annually.62% increase600,000 THA Procedures Performed Annually
- 17. Total Hip ArthroplastyThe first joint replacement, a total hip arthroplasty, was performed in 1936.Most widely performed orthopedic procedure performed on adults.In 2008, the average hospital and physician charge for a THA totaled $ 45,000.
- 18. ProsthesisMaterialsGlassPyrexIvoryPlasticsDr. Charnley in 1960 developed a low frictionAll new designs are adapted from his design.
- 19. Artificial JointTitanium hip prosthesisCeramic headPolyethylene acetabular cup
- 20. Zimmer
- 21. Health Care CostsPhysical Therapy12 visitsManual Therapy and exercise$1,200THR$45,000Surgery, hospitalization and rehabilitation
- 22. Risks and ComplicationsMedical Risks Heart AttackStrokeVenous Thromboembolism 1%PneumoniaUTIInfection 0.2 – 1%Intra-operativeMal-positioningShort/Long 1%InstabilityLoss of ROMFracture 2-5%Nerve Damage 1%Dislocation 4-10%
- 23. Long Term RisksOsteolysisLoosening of the componentsCement breaks downWear debrisInflammatoryPainPolyethylene wear rate is 0.3mm yearWear debrisBody will absorb the metal
- 24. OsteolysisCascade starts from particlesThe body creates an inflammatory response.Re-absorbs the bone. 12 months
- 25. A Squeaking hip ?StrykerHighly durable ceramic hips in 2003.7% of patients from 2003-2005 developed squeakingSqueaky Walk
- 26. Trendelenburg (+) for weakness in Abductor musclesTendinous avulsionSonography used to diagnosisTestGait
- 27. Glut Medius controls Adductor MomentHip Abductor function in closed chain is to maintain a level pelvis.
- 28. Trendelenburg GaitHave patient stand on one leg and assess if the pelvis drops.(+) Trendelenburg Sign
- 29. Subjective HistoryDJD (> 50)Usually no specific mechanism of injuryGroin pain; behind greater trochanter, anterior thigh to kneeStiffness in the morningLoss of ROM (Flexion, IR)Increased pain with WB (bony)
- 30. Functional LimitationsWalkingStair climbingPutting on shoesShaving legsRising from a chair
- 31. Causes of Hip OA Congenital DysplasiaGenetics Disease Process Trauma CompensationLeg length, lumbar pathology
- 32. X-RayGold StandardJoint Space NarrowingOsteophytesSubchondral Bony Change
- 33. Femoroacetabular Impingement (FAI)Contact between the femoral head-neck junction and the acetabular rim.Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.
- 34. Precursor to early hip O-AAcetabular labral pathology secondary to femoroacetabular impingement (FAI)Acetabular labral pathology is frequently present in highly active individuals 20-40 yo.Gradual on-set with repetitive microtrauma.
- 35. Diagnosis of FAIScour TestFADIR – anterior-superior labrumEABDER – posterior-inferior labrumLog Roll Test
- 36. Scour TestThe examiner moves the patient’s hip through a range of motion from hip flexion and adduction to hip extension and abduction, while adding a compressive force through the hip joint as well as movement into hip internal and external rotation. The test is considered positive if there is a reproduction in hip pain and/or intraarticular joint clicking.
- 37. Log Roll TestThe examiner passively moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B).Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity
- 38. Impingement TestThe examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation. A positive test is reflected by increased hip or groin pain.
- 39. FABER TestThe examiner passively positions the testing limb in a position of hip flexion, abduction, and external rotation. The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table. A decrease in this distance or pain, when compared to the uninvolved side, issuggestive of intra-articular hip pathology.
- 40. Hip Impingement
- 41. Hip Special TestsMartin et alJOSPT July 2006Intra-articular TestsFABER TestScour TestResisted SLRLog Roll TestDistractionFAI
- 42. Hip Arthroscopy
- 44. Clinical Prediction RuleChilds September 2008Loss of IR< 15 degrees Loss of Flexion< 115 degrees(+) Scour Test(+) FABER Test(+) Hip Flexion Test Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.395% confidence interval: 4.4-142.1, increasing the probability of hip OA to 91%.
- 45. Diagnosis Hip O-AMade with certainty on the basis of history and physical exam.X-ray is definitive CPR – Child’s et al.Hip Guidelines – CibuklaPhysiopedia
- 46. 1975 Management THAPhase I – immobilization. If unstable will use hip spica cast x 3 weeks. (2-5 days)Phase II – mobilization. Isometric, isotonic (AAROM, AROM). Trochanter detached and transplanted distally. 2-3 week and D/C to home. Crutches x 8 weeks. Walk day 7 - WBATROM goalsFlexion 90, ER 15, Abd 15, IR 0, Add 0
- 47. 2010 THA ManagementHospital 1-3 days/Out-patientAmbulate day 1 – FWBAROM day 1Isotonic week 1C-V by day 10ROM goalsFlexion 125, Add. 30, ER 50, IR 30 by week 12
- 49. Muscles
- 50. Gluteus MediusGluteus Medius – main hip abductorPrimary stabilizer of hip and pelvisTrendelenburg sign
- 51. Gluteus MaximusTFL envelops the muscles of the thighCounteracts the backward pull of the gluteus maximums of the ITB.Hip extensors are 3 times as strong as the flexors
- 52. PsoasIliopsoas bursa – present in 98% of adults.Lies under the psoas tendonOveruse and impingement syndromes
- 53. SLR ExercisesMust have excellent core strengthThis is a core exercise, If neutral pelvis is not maintained
- 54. Hip External RotatorsHip capsule is cut and the ER are retracted so that the joint can be exposed.THA – now most repair the capsule
- 56. Journal of Orthopedic Surgery Chung, et al. Smaller incisionOperating timeBlood lossNarcotic useLength of StayAssistive deviceHarris Hip Score20049.2 2049 55136 2002.2 2.644.4 5.421 2595 93
- 57. Metal-on-Metal Hip Resurfacing Arthroplasty
- 58. ResurfacingMain advantage is bone conservation for younger patientsEarly resurfacing failed because of polyethylene5 year follow-up excellent resultsComplicationFemoral neck fractureOsteonecrosis
- 59. High Failure Rate1970, materials available at the time had insufficient wear resistanceIncorrect patient selection1999, re-introduced Same revision rate as THA at 4 yearsWomen 2 x than men1-3%
- 60. DesignMetal on MetalCause release of inflammatory cytokinesMetal allergyLarge ball – decrease wear rateCementedTHA - Cementless acetabular fixation – bony in growth
- 61. Patient SelectionYoung and activeIsolated hip diseaseExcellent bone qualityNormal kidney functionContra-indicatedSevere acetabular dysplasiaObesity
- 62. SurgeryHigh learning curvePosterior approach Capsulotomy – preserve lateral muscles but sacrifice medial circumflex arteryImplant positioningLimited candidates
- 63. Outcomes94-99% survival rates at 5 years446 hips, patients < 55 yrs oldPrimary diagnosis of OANo difference in ROMGait analysis – no difference THAHip impingement
- 65. Traditional THA
- 66. Floyd LandisWon the Tour de France in 2006Stripped of his titleRoad with Lance 2002-2004Osteonecrosis – crash in 2002Sept 2006 Surgery
- 67. Tour de France
- 68. Birmingham Hip ResurfacingPart 1Part 2Part 3Part 4Part 5
- 69. Rehabilitation ConsiderationsSurgical ApproachSelection of appropriate hip precautionsCemented vs. non-cementedWeight bearing precautionsEarly mobilization (prevent DVT)Early rehab can improve short term outcomes.
- 70. Bioengineering
- 71. ViscosupplementationInjection of artificial lubricants into the joint.Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymaltem cells.
- 72. Biomechanics
- 73. Hip DysplasiaDisplacement of femoral head in acetabulumLeft hip is more often involved80 % FemalesBreech birthFirst born
- 74. Hip DysplasiaLess degress of femoral head coverageDecreased joint surface areaNormal 30-40%Angle of inclination >125 degreesIncreased femoral anterversionAcetabular retroversionMcCarthy & Lee found 72% of patients with dysplasia had labral tears
- 75. Ball and Socket JointFlexion to 110-120Extension 10-15Abduction 30-50Adduction 25-30ER 30-45IR 20-35Rolls anterior glides posteriorRolls posterior glides anteriorRolls laterallyRolls mediallySpins anteriorly and laterallySpins posteriorly and medially
- 76. MobilizationFlexionExtensionAdductionInternal RotationPosterior / Inferior GlideAnterior GlideLateral GlideLateral Glide
- 77. DistractionGeneral joint mobilityCan be diagnosticGentle let offPlace in open packed positionDon’t grab ankle
- 78. PosteriorGain FlexionAdductionBe careful not to create impingement
- 79. Exercise Posterior MobilizationPsoas & TFL ReleaseFollow with psoas stretch
- 80. Psoas StretchAvoid lumbar extensionHave patient posterior pelvic tileCan flex or extend the knee
- 82. Lateral MobilizationTo gain adduction Can also work on ER
- 83. Lateral MobilizationPatient self mobMust stretch lateral structuresITBDon’t let hip IR
- 84. Inferior MobilizationExcellent technique to use with hip impingementTest – re-test
- 85. Caudal/Inferior MobilizationMulligan technique – mobilization with movement.Measure flexion or IR and mobilize and re-measure
- 86. Anterior MobilizationAssess gaitPelvic winkTo gain extension and external rotationStress the anterior labrumIf had labral repair
- 87. Anterior MobilizationMobilize anterior capsuleSelf stretch and exercises – army crawl
- 88. Anterior Self StretchKneeling MobilizationPsoas and TFL stretching
- 89. CyriaxCapsular pattern – specific and proportional loss of movementMost common cause of capsular pattern is arthritis
- 90. Capsular PatternCyriaxIRFlexionAbductionIf capsular pattern of restriction; joint is arthritic.If non capsular pattern; not joint.Cyriax listed in ascending orderLoss of internal rotationMore than flexionMore than abduction
- 91. Noncapsular RestrictionsFracturesOsteomiylitisLabral tearsCancerBursitisCapsular IrritationSynovitisImpingement
- 92. Resting Closed PackedFlexion 30 degreesAbduction 30 degreesExternal Rotation 10-15 degreesExtensionAdductionInternal RotationStable position of the jointTighten capsule
- 93. Muscle ImbalancesTightnessPsoasAdductorsQuadratus LumborumTFLPiriformisWeaknessGlut MaximusGlut MediusQuadsHip ERCore MuslcesAbsErrector spinae
- 94. FACILITATED MUSCLESIliopsoasRectus FemorisTFLQLHip AdductorsPiriformisHamstringLumbar Erector Spinae
- 95. Medial Hip MobilizationMakofsky, et al. Journal of Manual and Manipulative Therapy 2007Increase in abductor muscle forcePrior to exercise
- 97. OutcomeMeasures
- 98. Lower Extremity Function ScaleOrdinal Scale 0 “extreme difficulty” to 4 “no difficulty”Patient rate ability to perform 20 different activities0 to 80 scale, 80 no limitations.Minimum detectable change 9 scale points
- 99. Harris Hip ScoreScores on 10 different variablesPainROMGaitADLsScore range from 0 “worst” to 100 “best”.Harris Hip Score
- 100. Hip Outcomes MeasuresValidityReliabilityIncludesPainROMFunctionSurgeon & Patient disagree on outcomesHarris Hip ScoreCharnley ScoreOxford Hip ScoreThe Hip Disability and Osteoarthritis Outcome Score
- 101. Patient Based ScalesSite SpecificOxford Hip ScaleHealth StatusDesigned for RA20 TasksSF-12Disease-SpecificHip & Knee OAWOMACOxford12 item questionnaireTHRValidated against SF-36Short, practical and valid
- 102. Activity Limitation6 Minute Walk TestHow far a person can walk in 6 minutes. Can use walking aids.Treadmill is good.Stair MeasurePatients are instructed to ascend and descend 9 stairs (step height 20cm) Timed measure in seconds
- 103. Rehabilitation ProtocolAgeHealth StatusControl pain and swellingBody WeightBody Build -
- 104. Week 2-3GoalsPatient EducationDecrease EdemaIncision HealingIndependent HEPROM: flexion 90, abduction 35, ER 35, IR 20, adduction 20
- 105. TreatmentModalitiesMFR/ MassagePROMTransfer and gait trainingRhythmic StabilizationMET / Manual Stretching
- 106. ModalitiesUSAt incision and piriformis/ITBNMSGlut Medius with isometric ABD.IFC & CPControl swelling and painAt the end of treatment
- 108. Hip PROMWatch for compensation at the pelvis.Capsular pattern?End-feel?Pain?
- 109. PROM
- 110. Hip RotationPROM of left hipLoss of IR > loss of hip EREnd-feel usually empty and painful.
- 111. MET – manual stretchingSoft tissue and capsular tightnessHave not moved hip though this motion in years
- 112. GaitHip extension15-20 degreesPelvicRotationSide bendingMost patients will have LBP
- 113. Rhythmic StabilizationNeutral PositionManual resistance in ER and IR
- 114. Muscle Energy TechniqueHamstringsPsoasLumbar Spine
- 115. Hamstring StretchLumabr spine is protectedIncrease stretch with APTContract quads will inhibit hamstrings
- 116. ExercisesExercise Pro Handout Week 2-3
- 117. Week 5-6Hip Flexion 100-110, add. 40, ER 40, IR 30Quad/Ham strength 70%(-) TrendelenburgInitiate Hip PRENeutral alignment lumbar spine
- 118. TreatmentMyofascial ReleasePsoasPosterior Hip CapsulePROM/Jt. MobilizationCore Stabilization
- 119. Thomas TestPsoas StretchThigh off the tableTight iliopsoas and rectus femoris muscle (knee flexion)
- 120. MobilizationLeg traction – inferior glideDistraction – inferior or caudal glide.Mobilization with movementBeltMET to restore IR/ER or hip flexion
- 121. Joint Mobilization
- 122. Whitman & ClelandSeptember 2007Hip OA when treated with manual therapy (mobilization)5 PT sessionsTotal PROM increases 82 degreesHarris Hip Score 25 points
- 123. Case Report JOSPT Dec. 2007Vol. 37, Num. 1273 yo female with THA revision2 yrs s/p revision admitted to hospital 10/10 hip pain after lifting her foot to put on her shoeX-ray normal d/cPT – manual therapy – 4 PT visits4 year follow up
- 124. ProprioceptionArthritic hips lose input secondary to loss of articular cartilage.THR – no input from the hip joint. Must retrain neuromuscular system.Balance activities.
- 126. Therapeutic ExerciseTHA Protocol Exercise Pro HandoutWeek 5-6
- 127. Week 6-12Walk 1 mileC-V Endurance 20-40 minutesPain FreeEqual strength between legsFlexion 130, ER 45, IR 35
- 128. S.E.R.F. StrapPulls the hip into ERJOSPT September 2008 Vol 38, N 950% self report decrease painDecreases hip impingement
- 129. TreatmentD/C all modalitiesManual techniques if necessaryExercise Pro Week 6-12
- 130. 10 days S/P 12 Weeks
- 131. ContraindicationsHome exercises. Exercises were commenced following manual physical therapy in the clinicUpright bicycle: 10 – 20 minGluteus medius clamshell exercises: 3 sets of 12Hip abduction in sidelying: 3 sets of 12Core transverse abdominus: 2 sets of 20 in supine with hips flexed to 45°Bridge with straight leg raise: 3 sets of 10Hip flexor stretch kneeling or sidelying: 30 sec × 3Single leg balance: up to 60 secTandem stance eyes open or closed: up to 60 sec Recumbent Bike
- 132. SLR
- 133. Aggressive Glut Medius StrengtheningQuestions
Editor's Notes
- We are in private practice, we are not owned by a hospital or any physicians. I want to try and take back our profession – when you work for yourself you have to become a better clinician. Look at the work that has come from Austrailia – Diane Lee, Maitland, McConnell, Jim MeadowsIt is my goal today to make you a better clinician, and I challenge you to use that knowledge to reclaim our profession.
- The health care bill just passed. I got up the next morning and log on to APTA web site to gain more information. I also get emails from the OPTA listserve. APTA members – this is my other soap box today, if you are not a member you need to join. The APTA is fighting for our rights. You need to get active in the OPTA, the PAC. Things are changing and you can either get involved and fight for your profession or your profession may drastically change.
- Research – read your journals. CE courses – Clinical Expertise – clinical skill and formulated educationWhen I graduated, we tried to selective isolate the VMO for improving patellar mechanics – the literature has proven this ineffective.
- Increaseing at a rate of 10% a year.
- Sensitivity was 86% and specificity was 75% with a LR+ of 3.44
- This was a low friction arthroplasty. Smaller femoral head 7/8 inch which has a decreased wear rate. However, it had a poor stability. This prosetesis used cement.Stems are typically made of titanium alloys or chrome cobalt – very strong and most biocompatible. New heads are ceramic or cobalt-chromium alloy.
- FDA issued a warning. Recalled ceramic hip parts.
- Most patients are diagnosed with snapping hip or psoas muscle strain or bursitis
- This is a non-specific test – internal hip pathology (intra-capsular).
- Feel end-feel. Should be capsular, not empty or painful.
- Used to assess FAI – exactally like the shoulder impingement test. Same ball and socket joint. Always test this prior to having a patient stretch the piriformis muscle
- Mitchell et all reported that the presence of hip pain during the FABER test was 88% sensitive for intra-articular hip pathology.
- JOSPT July 2006
- College of Rheumatology has criteria – so why did Childs develop a CPR?
- X-ray will show joint space narrowing, osteophytes.
- Do the exercise. How to correctly stretch the psoas.
- Surgical approach used is one of the main determinates to rehabilitation. The posterior lateral approach is the most common, although as new techniques of minimally invasive THA are evolving, the anterior-lateral approach is becoming more common for younger, active patients.Posterior lateral approach – cuts posterior capsule and gluteus maximus – posterior dislocation.Anterior-lateral approach involves take-down of the gluteus medius, which can limit post-op weight bearing.
- Surgery done in Europe for over 17 years. Birmingham Hip Resurfacing device was approved by the FDA in May 2006
- Fracture rate at about 4% compared to 1% in THA. Have preserved the bone in the femur.
- 2009 returned to cycling after his ban and finished 17th overall in the Tour of New Zeland.
- FDA approved in 1997 – hyaluronan acid – extracellular matrix, contributes to cell proliferation.Molicular goo. Syovial fluid – increase the viscosity. Lubrication. Using in wound healing.