• Rehabilitation requires coordinated effort from
    • orthopaedic surgeon
    • physical therapist
    • occupational therapist
    • case manager
    • nursing staff
    • patient and patient's family
  • Care can be broken down into different phases including
    • preoperative teaching
    • inpatient acute care (hospital)
    • inpatient extended care (rehab/SNF)
    • outpatient home care
Preoperative Teaching
  • Physical therapy
    • preoperative physical therapy has not been shown to improve postoperative outcomes
  • Hip precautions
    • useful if discussed before surgery
    • types of hip precautions
      • posterolateral approach  
        • avoid
          • flexion past 90 degrees
          • extreme internal rotation
          • adduction past body's midline
      • anterolateral approach  
        • avoid
          • extension
          • extreme external rotation
          • adduction past the body's midline
      • direct anterior approach        
        • avoid  
          • bridging
          • extension
          • extreme external rotation
          • adduction past body's midline
Inpatient Acute Care (Hospital)
  • Pain management
    • preoperative
      • NSAIDS and opioids given immediately before procedure reduce postoperative pain
    • intraoperative
      • regional anesthesia (spinal and/or epidural) 
        • preferred over general anesthesia
      • periarticular multimodal drug injection
        • decrease postoperative pain with minimal risks
    • postoperative
      • multimodal oral drug therapy
        • gold standard
  • Physical therapy goals
    • sitting upright -->
    • gait training, ambulation with walker, out of bed to chair -->
    • transfers, gait normalization -->
    • independence
  • Discharge home criteria
    • independent ambulation with assistive device
    • independent transfers
    • independent ADLs
    • stairs with supervision
    • appropriate home assistance (spouse, family, visiting nurses)
Inpatient Extended Care (Rehab)
  • Earlier discharge to rehab from hospital associated with improved outcomes
  • Discharge criteria to home similar to those in hospital
Outpatient Care
  • Return to sport
    • low-impact exercises are preferred
      • golf
        • handicap shows minimal change after THA
        • handicap shows increase after TKA 
    • high-impact exercises increase revision rates in patients less than 55 years-old
  • Driving recommendations
    • 3-4 weeks after a right total hip
    • less than 3-4 weeks after a left total hip
  • Return to work
    • within a month if no manual labor

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Questions (2)

(OBQ11.16) A 68-year-old right handed male golfer presents with significant left knee pain which has not been amenable to conservative management. A radiograph is shown in Figure A. He is interested in pursuing total knee arthroplasty (TKA). What can this patient expect with regards to his golf game after undergoing this procedure? Review Topic


A significant rise in his handicap




No change in his drive distance




Decreased pain compared to undergoing a right TKA




A significant chance of having severe pain during play




Patients are required to use a cart while golfing



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Active golfers who undergo total knee arthroplasty (TKA) typically have a significant increase in their handicap when they return to the game.

Mallon et al studied 83 (80 of which were right handed) active golfers who underwent TKA and found that they invariably experienced a significant rise in their handicap (mean +4.6 strokes) and also a decrease in the length of their drives. Approximately 15% of the cohort experienced a mild ache while playing, and golfers with left TKA's had more difficulty with pain during and after play than did golfers with right TKA's. It also should be stated that statistically significant increased pain ratings occur in golfers with a TKA on the target-side knee. Finally, almost 90% of the patients in this study utilized a cart while playing post-operatively.

Mallon et al also evaluated the effect of total hip arthroplasty (THA) on the game of avid golfers. They found that hybrid and uncemented primary THA's had lower rates of radiographic loosening in active golfers when compared to cemented THA's. However, symptoms of pain while playing or after playing did not differ among these groups.

Arbuthnot et al sent golfing habit questionnaires to 750 consecutive avid golfers who had undergone total hip arthroplasty. They found no significant change from their predisease state to their 1-year postoperative golf performance and level of participation.

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(OBQ07.84) A 60-year-old female underwent hybrid total hip arthroplasty with good position of implants and post-operatively is instructed not to extend, adduct, and externally rotate the hip to prevent dislocation. What approach was likely performed? Review Topic






Stoppa approach








Kocher Langenbach




Pfannenstiel approach



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The position to dislocate a hip anteriorly is extension, adduction, and external rotation which is the position at risk after an anterior approach. Hips are most likely to dislocate the direction of the approach assuming the implants are correctly positioned. Other important variables to THA stability include: component design, component alignment, soft-tissue tensioning, and soft tissue function.

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