ARE WE BOOMER READY?

Transcription

1 ARE WE BOOMER READY? Today s total Joint Replacement is not like the one your grandparents had- Patient expectations are higher and surgical/rehab techniques must match the expectations

2 CURRENT AND FUTURE CONCEPTS FOR TOTAL JOINT REPLACEMENTS Earlier facilitation of function Emphasis on Balance Return to Activity/Sports- Review of the literature

3 BONE AND JOINT DECADE 1 st Decade of the 21 st Century Are we ready? Seniors are and will continue to express a desire to stay active with their sports participation

4 Left Hip Replacement at age 38 (2005) Goal: be able to get on the floor to play with kids Biomet s M-2-a-Magnum Hip Replacement Metal on metal Large femoral head Greater ROM Decreased risk for dislocation 3 Month Recovery * Mary Lou Retton

5 Precautions-The Textbook Hip Precautions Posterior Approach No hip flexion > 90 o No hip adduction beyond neutral No hip internal rotation beyond neutral Anterior Approach No hip extension beyond neutral No hip external rotation beyond neutral No prone lying No bridging Knee Precautions None Precautions are based on surgeon s preference and the surgical procedure *Brigham and Women s Hospital

6 Advantages of Athletic Activity Increased maximal walking speed, stride length, & cadence Increased power output Increased cardiovascular fitness Increased maximal O 2 consumption Increased quality of life Increased function Better overall health Increased bone density *Nicholls M, Selby M, Hartford J

7 Benefits of Joint Replacements Pain Relief Improved Function Increased Mobility Increased Psychological Well-being Patient Satisfaction Long-term Results *Kuster, M.

8 Factors Affecting Outcomes of Joint Replacements Wear of total joint replacement Joint load and moments during sport activities Intensity: recreation vs. exercise Type of prosthesis Activity desired Co-morbidities Previous skill level and experience of patient *Kuster, M.

9 Recommendations Following THA Survey sent to members of the Hip Society and American Association of Hip and Knee Surgeons (2007) 549 respondents (72%) 30 groups of activities; 37 specific sports Allowed Allowed with experience Not Allowed Undecided * Klein et al.

10 Allowed Activities Following THA Golf Swimming Doubles Tennis Walking Speed Walking Hiking Stationary Skiing Bowling Road Cycling Stationary Bicycling Low-impact Aerobics Rowing Dancing (ballroom, jazz, square) Weight Machines Stairclimber Treadmill Elliptical *Klein et al.

11 Previously in the not allowed category Downhill skiing, weightlifting, ice skating and in-line skating have recently been upgraded to the Activities Allowed with Experience category per the AAHKS- Feb 2007

12 Activities Allowed With Experience Following THA Downhill Skiing Cross-country Skiing Weightlifting Ice Skating/Rollerblading Pilates *Klein et al.

13 Activities Not Allowed Following THA Racquetball/Squash Jogging Contact Sports Football, Basketball, Soccer High-impact Aerobics Baseball/Softball Snowboarding *Klein et al.

14 Undecided Activities following Martial Arts Singles Tennis THA *Klein et al.

15 Research- Tennis-USTA men 5 women Mean age 64 7 years post TKR all were playing singles and doubles tennis 3X/wk Only 21% of the patients surgeons approved tennis, 45% approved doubles **AJSM 30;163,2002

16 Research Why did snowboarding get a not allowed grade while other sports like skiing and inline skated were upgraded to allowed with experience?

17 Snowboarding is a less familiar activity and biomechanically surgeons are concerned with the torque created around the hip when the feet are fixed to the board

18 TOTAL KNEE RECOMMENDTIONS Survey of the Knee Society in Members of the Hip Society and the Knee Society Based on surgeon recommendations *Kuster, M.

19 Allowed Activities Following TKA Low-impact Aerobics Stationary Bicycling Bowling Golf Dancing Horseback Riding Croquet Walking Swimming Shooting Shuffleboard Horseshoes *Kuster, M.

20 Allowed With Experience Road Bicycling Canoeing Hiking Rowing Cross-country Skiing Speed Walking Tennis Weight Machines Ice Skating Following TKA *Kuster, M.

21 Not Allowed Following TKA Racquetball Squash Rock Climbing Soccer Singles Tennis Volleyball Football Gymnastics Lacrosse Hockey Basketball Jogging Handball *Kuster, M.

22 Undecided Following TKA Fencing Rollerblade/inline Skating Downhill Skiing Weight Lifting *Kuster, M.

23 Time Frame Return to athletic activity in 3-6 months after THA 71% of Hip Society 60% of American Association of Hip & Knee Surgeons (Klein et al.) 10% of American Association of Hip & Knee Surgeons allowed return to sports in the first 3 months (Klein et al.) TKA should avoid athletic activities until the quadriceps and hamstring muscles are rehabilitated (Nicholls M, Selby J, Harford J.)

24 Long Term Results Average: years of function after TKA or THA (Nicholls M, Selby J, Harford J.) Failure of THA do not occur until 10 years postoperatively Revision rate twice that of inactive patients (Nicholls M, Selby J, Harford J.) Dubs et al: revision rate 1.6% in 61 athletic patients, & 14.3% in 49 non-athletic patients (Huch et al) Strempel et al: loosening rate of 5% in sports group & 10% in non-sports group (Huch et al) Widhalm et al: loosening in 18% in sports group & 57% in non-sports group (Huch et al) Cementless acetabular prosthesis have better long-term results in younger, more active patients (Huch et al, Nicholls et al)

25 Activities 5 Years After TKA or THA Questionnaire to 636 Patients < 76 years old at baseline and 5 years follow-up Athletic Activities Hiking, riding, dancing (ballet, & jazz), aerobics, swimming/aqua jogging, soccer/handball/volleyball/basketball, downhill skiing, cross-country skiing/jogging, boxing, wrestling Commonly named: golfing, bowling, tennis *Huch et al.

26 5 Years Following TKA or THA 97% of hip & 94% of knee patients had participated in sports in lifetime 36% of hip & 42% of knee maintained sport activity until surgery 5 years after surgery Hip patients increased to 52% Knee patients declined to 34% Biking, hiking, & swimming Pain was limiting factor in TKA Precaution was limiting factor in THA *Huck et al.

27 Risks of Athletic Activity Following Joint Replacement Osteolysis Catastrophic implant failure Periprosthetic fractures Dislocation * Nicholls M, Selby M, Hartford J.

28 THERAPEUTIC TIPS Balance is under rehabbed and critical to improve gait and stability Core Awareness Eccentric weight shifting etc for femoral internal rotation control

29 Workers Compensation- Rehabilitation THR Data Return to ADL s, Driving, Work Time to MMI, Impairment, Permanent Restrictions Long Term Follow up and Risks

30 Work Restrictions Seated work with frequent changes in positions at 4-6 weeks Standing 8 hr/day, lifting to months

31 MMI, PPI, Permanent Restrictions MMI at 3-4 months Permanent restrictions: poly cup/small head: limit ROM, NO squat, jump 40 lb freq lift, 50 lbs Occ Metal on Metal: more motion (15 deg) Occ run, jump, and heavy lift. Freq 50 lb lift

32 Follow-up THR Annual x-rays for first 5 years and then every other year for life

33 DISLOCATIONS 2-4% primary THR in USA, up to 20 % of revisions Why? Small head, improper version, short neck-infection (joint swells and head slips out) Behavior: violated precautions

34 Future Research Long-term results of athletic activity with TKA & THA Younger patients with TKA & THA Update of TKA recommendations from surgeons Comparison of various protocols and treatment approaches

35 Total Shoulder Replacement- generally accepted post-op guidelines Typical progression of ROM phases first 6 weeks. Early on ER to neutral Avoid IR actively until 6 weeks High reps and GOOD AROM for multiple reps as early strengthening PRE s HEP:2 oz-8 oz s, table knife>tuna can>soup can> 1 lb etc

36 Total Shoulder Function Acceptable ROM-AAOS Golf in 3 months-hit off a tee for a year (Neer)

37 References 1. Biomet, Inc. Accessed 4/11/ Brigham and Women s Hospital. Total Hip Replacement Protocol. Boston, Massachusetts. 3. Nicholls M, Selby J, Hartford J. Athletic activity after total joint replacement. Orthopedics. Nov 2002; 25,11: Kuster, M. Exercise recommendations after total joint replacement: A review of current literature and proposal of scientifically based guidelines. Sports Med. 2002;32(7): Klein G, Levine B, Hozack W, et al. Return to athletic activity after total hip arthroplasty: Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J of Arthroplasty. 2007;22(2): Huch K, Muller K, Sturmer T, Brenner H, Puhl W, Gunther K. Sports activities 5 years after total knee or hip arthroplasty: the Ulm Osteoarthritis Study. Ann Rheum Dis. 2005;64;