Comparison of two different rehabilitation

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Rehabilitation programmes for thrust plate prosthesis 91. Brotzman SB ed. Clinical orthopaedics rehabilitation. Missouri: Mosby-YearBook, 1999: 278–311.
Clinical Rehabilitation 2004; 18: 84–91

Comparison of two different rehabilitation programmes for thrust plate prosthesis: a randomized controlled study Bayram Unver School of Physiotherapy, VasŽ Karatosun, Izge Gunal Department of Orthopaedics and Traumatology, School of Medicine and Salih Angin School of Physiotherapy, Dokuz Eylül University, Izmir, Turkey Received 15th November 2002; returned for revisions 18th March 2003; revised manuscript accepted 24th July 2003.

Objective: Weight bearing after total hip arthroplasty is postponed in order to prevent early loosening, but this negatively affects the rehabilitation programme. For the force transfer characteristics of thrust plate prosthesis (TPP), a new type of hip prosthesis used without cement is similar to the normal hip. We evaluated the possibilities of early weight bearing after TPP by comparing early partial with early full weight bearing. Design: Randomized controlled study. Setting: Department of orthopaedics and traumatology in a university hospital. Subjects: Sixty hips of 51 patients who underwent total hip arthroplasty with TPP were randomly assigned into two groups. Interventions: Both groups received accelerated rehabilitation programmes: group 1 with early partial weight bearing and group 2 with early full weight bearing. Main outcome measures: Patients were evaluated by a blind observer preoperatively, at three months after surgery by clinical (measurement of range of hip motion (universal goniometry), muscle strength (Manual Muscle Test), functional test (6-minute walk test), hip function (Harris Hip Scoring System) ) and radiographical parameters and one year after surgery by clinical (Harris Hip Scoring System) and radiographical parameters. Results: Group 2 performed transfer activities earlier, had more walking distance at the time of discharge and shorter hospital stay than group 1. At three months, Harris Hip Score, muscle strength, 6-minute walk test, and duration of crutch use were signiŽcantly (p < 0.05) in favour of group 2. None of the patients in either group showed signs of loosening one year after the operation. Conclusions: These results suggest that patients with TPP can tolerate an accelerated rehabilitation programme with early weight bearing and will gain the goals of rehabilitation earlier.

Address for correspondence: Bayram Unver, Korutürk Mahallesi, Mes,e Sokak Çam Apt. No: 7/3, Balçova, Izmir, TR-35340, Turkey. e-mail: [email protected] © Arnold 2004

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Rehabilitation programmes for thrust plate prosthesis Introduction The ultimate goal of rehabilitation after total hip arthroplasty is to maximize functional performance and improve an individual’s ability to perform daily activities earlier and for shorter hospital stay.1,2 The femoral component of total hip arthroplasty can either be cemented or cementless.3–6 In the protocols for rehabilitation following cementless total hip arthroplasty, partial weight bearing for six weeks after surgery is generally recommended.1,7–11 It was thought that early weight bearing might increase micromotion and result in Žbrous in-growth at the implant–bone interface, resulting in early loosening of the prosthesis.1,2,7,8,10,11 However, it is well known that weight-bearing restrictions can negatively affect the rehabilitation programme1,7,8,10,11 and there are no outcome studies supporting the empiric weight-bearing restrictions that are used in common clinical practice.1,7,8,10 The thrust plate prosthesis (TPP) is a relatively newly designed femoral prosthesis, 5,12–15 which is implanted without cement to the metaphysis of the proximal femur and secured to the lateral

Figure 1

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cortex of the femur with a plate and two screws. The principle of the TPP is to transfer the resulting forces from the hip joint via a thrust plate directly to the femoral neck and above all to the cortical bone of the calcar.13 This force transfer is as close to physiological (without prosthesis) as possible, according to the results of the biomechanical experiments of Jacob14 and Bereiter et al.12 With the TPP, a more physiological functional loading of the bone than with conventional stem Žxation is expected.12–14 Careful review of the literature revealed no study concerning the rehabilitation protocols applied to patients with TPP. By taking into account the load transferring characteristics of TPP, we compared two accelerated rehabilitation regimens: one with partial the other with full weight bearing. Methods Subjects The series consisted of 60 hips of 51 patients who were operated on using the TPP (Figure 1). The indication was primary coxarthrosis in 25

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and secondary in 35 hips. The inclusion criteria were: (a) patients younger than 65 years old, (b) patients who had received at least six months of physical therapy before surgery, (c) severe pain and limitation of hip movements restricting daily activities. The exclusion criteria were: (a) arthritis in other joints necessiting treatment, (b) neurological or medical conditions causing loco motor disability, and (c) revision hip prosthesis. Procedure The patients were allocated into two groups using a table of random numbers from a computer program (Excel 2000). All operations were performed by the same surgeon (VK) using the lateral approach. Group 1 (control group) received accelerated rehabilitation with partial weight bearing, identical to that applied after cemented type hip prosthesis. 1,9 Group 2 (study group) received accelerated rehabilitation with full weight bearing. Group 1 consisted of 30 hips of 27 patients; group 2 consisted of 30 hips of 24

Table 1

patients. In bilateral cases there was an interval of at least four months between operations. The details of the rehabilitation protocols are displayed in Table 1. All these interventions were provided by four physical therapists, with 3–8 years of experience, one of whom was involved in the study (BU). The postoperative rehabilitation of the patients was initiated the day after surgery and repeated twice a day. On each occasion exercises were repeated 10 times. The patients were discharged from the hospital when they could walk independently with crutches, these were discontinued two weeks after full weight bearing for group 1 and at six weeks for group 2. All patients were encouraged in transfer activities on the third day postoperatively. After discharge from the hospital, the patients were instructed to perform the exercises, and were visited every two weeks for examination and instruction of new exercises.

Details of the rehabilitation programmesa

Activities Deep breathing, cough Calf exercise Isometric quadriceps and gluteal sets Strengthening exercises to unaffected extremities and trunk muscles Hip precautions Passive, assisted range-of-motion exercises Transfers to unaffected side Out of bed, stand or walking with walker Transfers (bed to chair, toilet) Use appropriate dressing and toileting equipment Walking with crutches Stair training Active isotonic exercises in standing position Active abduction exercises Resistive hip exercises Stretching exercises for hip musculature Endurance training for hip musculature Weight bearing Partial Full Duration of use of crutches Resume normal daily activities

Group 1 Postoperative

Group 2 Postoperative

day day day day

day day day day

1 1 1 1

day 1 day 2 day 2 day 2 day 3 day 3 3–7 days 5–7 days 3–4 weeks 4–6 weeks 6–8 weeks 6–8 weeks 8–10 weeks

day day day day day day 3–7 5–7 2–3 3–4 4–6 4–6 6–8

1 2 2 2 3 3 days days weeksb weeksb weeksb weeksb weeksb

day 2 6–8 weeks 8–10 weeks 8–10 weeks

– day 2b 6 weeksb 6–8 weeksb

1 1 1 1

All activities were added to the following, except for deep breathing and cough (discontinued at four days) and passive exercises (discontinued when active exercises were initiated). b Differences between the rehabilitation programmes. a

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Rehabilitation programmes for thrust plate prosthesis Table 2

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Clinical parameters used in the study

Parameters

Method of evaluation

Hip function Manual muscle strength for gluteus maximus and gluteus medius Hip range-of-motion (exion, extension, abduction, adduction, external and internal rotation) Functional capacity

Harris Hip Score16 Lovett’s concept17

Outcome measures All patients were evaluated preoperatively by a blinded observer who had six years of experience in physical therapy, and at three months postoperatively using the clinical parameters displayed in Table 2, and by Harris Hip Score at one year after the surgery. Harris Hip Score is commonly used to follow patients after an operation for a degenerative disorder of the hip and contains questions about pain, function, absence of deformity and range-of-motion. The best possible score is 100 points. 16 Range-of-motion was determined with a universal goniometer by evaluating range of hip exion, extension, abduction, adduction, external rotation and internal rotation.17 The gluteus maximus (while in prone position, patient was instructed to extend the hip, with the knee in exion) and gluteus medius (while in side-lying position, patient was instructed to abduct the hip) muscles were evaluated manually against gravity and resistance.17 The 6-minute walk test was performed as follows: the patient was asked to walk up and down a 30metre-long corridor and cover as much distance as possible in 6 minutes. The physical therapist gave the patient standard encouragement, such as ‘You’re doing well’, every minute. The patient used whatever aid, such as a cane, was needed to perform the test. The outcome measure was the distance in metres that the patient was able to walk in 6 minutes.18 The stability of the components was determined by radiographs with special reference to change in the position of the implant or the presence of radiolucent lines around the prosthesis. This was done by two authors (VK, IG) who were blinded to the rehabilitation programme, at three months and one year after the operation. The study protocol was approved by the local ethical committee and all patients gave their informed consent.

Universal Goniometer17 Six-minute walk test18

Data analysis The statistical analyses were performed using independent samples t-test (age, weight, height, Harris Hip Score, range-of-motion, 6-minute walk test, duration of crutch use, duration of hospitalization, walking distance and transfer activities) and Mann–Whitney U-test (manual muscle test) where appropriate. p-values less than 0.05 were accepted as signiŽcant. Results Details of randomization and follow-up are provided in Figure 2. Preoperatively there were no signiŽcant differences (p < 0.05) between the groups when compared with the parameters listed in Table 2 and the demographic data (Table 3). None of the patients were lost to follow-up. There were 20 and 16 women in groups 1 and 2 respectively. When the groups were compared as they were discharged from the hospital, the patients in group 2 had signiŽcantly greater walking distance than group 1 (p = 0.001). In reality, the signiŽcance is more, for the patients in group 2 were discharged from the hospital about four days earlier than group 1 (Table 4). All patients in both groups were re-evaluated three months postoperatively. Although there were no statistically signiŽcant differences between the groups with respect to range-ofmotion, all other parameters were signiŽcantly in favour of group 2 (Table 5). None of the patients in either group showed signs of early loosening, either clinically or radiographically. At the latest follow-up, one year postoperatively, dislocation of the components or signs of loosening were not recorded in any patient, and there was no signiŽcant difference between the groups when evaluated by the Harris Hip Score

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(group 1: 94.7 ± 5.5; group 2: 96.9 ± 4.1, t = –1.746, p = 0.086). Discussion Total hip arthroplasty is a safe and effective treatment for advanced arthritis of the hip that has not responded to nonoperative treatment. The efŽcacy in reducing pain and improving func-

tion has been reported as greater than 90%.1,11,19 Subsequent rehabilitation is an integral part of joint replacement surgery in order to increase function and return to daily activities and most beneŽts are achieved by 3–6 months after surgery.1,4,11,20 Weight bearing restrictions after cementless total hip arthroplasty may slow a patient’s rehabilitative process or may negatively affect the rehabilitation programme.1,7,8,10,11 Gait training

Patients with osteoarthritis of hip joint

Exclusion – Arthritis in other joints necessitating treatment – Locomotor disability – Revision of hip arthroplasty

Patients suitable for study (N = 51)

Block randomization (N = 51)

Study group (N = 24)

Control group (N = 27)

Assessment at discharge (N = 24)

Assessment at discharge (N = 27)

Assessment at the end of third month (N = 24)

Assessment at the end of third month (N = 27)

Assessment at the end of one year (N = 24)

Assessment at the end of one year (N = 27)

Figure 2

Progress through the trial. Downloaded from cre.sagepub.com at Univ of Salford Hold Account on November 5, 2014

Rehabilitation programmes for thrust plate prosthesis

Table 3

Comparison of the groups preoperatively

Age (years) Height (cm) Weight (kg) Hip exion (°) Hip extension (°) Hip abduction (°) Hip adduction (°) Hip external rotation (°) Hip internal rotation (°) Gluteus medius strength Gluteus maximus strength Six-minute walk test (m) Harris Hip Score

Group 1

Group 2

X ± SD

X ± SD

48.9 ± 12.9 160.8 ± 7.9 66.5 ± 9.7 85.3 ± 18.5 6.5 ± 5.8 26.6 ± 12.9 11.1 ± 7.7 18.6 ± 11.2 15.3 ± 14.3 3.8 ± 0.6 3.5 ± 0.7 128.6 ± 53.1 48.7 ± 17.9

49.9 ± 163.0 ± 69.5 ± 81.0 ± 5.1 ± 30.3 ± 11.3 ± 18.6 ± 17.3 ± 3.9 ± 3.5 ± 139.1 ± 44.1 ±

10.0 9.7 13.7 31.1 6.7 14.1 7.9 13.7 14.7 0.7 0.8 60.1 15.3

t/Z

p-value

0.333 0.985 0.965 –0.654 –0.814 1.047 0.082 0.000 0.533 –1.145a –1.140a 1.083 –1.074

0.740 0.329 0.338 0.516 0.419 0.299 0.935 1.000 0.596 0.252 0.254 0.065 0.287

Values are expressed as means ± SD. a Z-value for Mann–Whitney U-test. t-value for independent samples t-test.

Table 4

Comparison of the groups at the time of discharge from the hospital

Transfer activities (days) Walking distance (m) Hospitalization (days)

Group 1

Group 2

X ± SD

X ± SD

t

p-value

6.3 ± 2.1 164.1 ± 134.8 15.2 ± 3.5

4.5 ± 1.5 290.0 ± 145.2 11.6 ± 2.7

3.722 –3.478 4.356

0.040 0.001 0.001

t/Z

p-value

–0.269 0.919 0.091 –0.127 –0.954 0.523 –3.126a –2.857a 2.328 –13.100 4.145

0.789 0.362 0.928 0.900 0.344 0.603 0.002 0.004 0.023 0.000 0.000

Values are expressed as means ± SD.

Table 5

Comparison of the groups at three-month postoperative follow-up

Hip exion (°) Hip extension (°) Hip abduction (°) Hip adduction (°) Hip external rotation (°) Hip internal rotation (°) Gluteus medius strength Gluteus maximus strength Six-minute walk test (m) Duration of crutch use (weeks) Harris Hip Score

Group 1

Group 2

X ± SD

X ± SD

99.6 ± 12.0 10.1 ± 5.1 40.3 ± 6.9 16.1 ± 4.2 27.6 ± 8.6 25.5 ± 9.8 3.6 ± 0.7 3.9 ± 0.6 182.5 ± 58.2 12.0 ± 1.5 81.4 ± 9.3

98.6 ± 11.5 ± 40.5 ± 16.0 ± 25.6 ± 26.6 ± 4.1 ± 4.3 ± 215.8 ± 7.2 ± 89.3 ±

16.4 6.0 7.2 5.7 7.5 7.2 0.5 0.7 52.5 1.2 4.6

Values are expressed as means ± SD. a Z value for Mann–Whitney U-test. t-value for independent samples t-test. Downloaded from cre.sagepub.com at Univ of Salford Hold Account on November 5, 2014

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Clinical messages • Patients with thrust plate prostheses can tolerate an accelerated rehabilitation programme with early weight bearing. • Patients with early weight bearing gain the goals of rehabilitation earlier. • Early weight bearing after thrust plate prosthesis insertion does not result in early loosening of the prosthesis.

with restricted weight bearing becomes more difŽcult,1,3,10 duration of usage of ambulatory aids is too long1,3,7,8,10 and length of stay may be prolonged.1,8,10 The inability of the patient to bear full weight on the operative lower extremity increases stress on the upper extremities and as well as on the contralateral hip.10 In addition, muscle atrophy occurs around the surgically treated hip with partial weight bearing over a sixweek period.1,10,11 The energy requirements of ambulation with full weight bearing are also signiŽcantly less than with partial weight bearing.1,10 Although TPP is a kind of a cementless type hip prosthesis, we applied an accelerated type rehabilitation programme in all patients because the force transfer characteristics of TPP were shown to be similar to those of the normal hip.12,14 The Žrst group achieved a rehabilitation programme identical to that for a cemented prosthesis and the second group also achieved a similar programme but with full weight bearing on the second postoperative day. The results of the study clearly show that there is no reason to postpone weight bearing or other activities of the patients with a TPP. Although patient transfer activities in both groups were encouraged on the third day (Table 1), what group 1 patients could perform approximately on the sixth day could be carried out by group 2 patients on the fourth day (Table 4) (p = 0.040). Similarly, group 2 patients were discharged from the hospital about four days earlier than group 1 (Table 4) (p = 0.001). Although both groups could walk further than patients with other intramedullary type prostheses, 1,21 at the time of discharge from the hospital this distance was signiŽcantly more in group 2 (Table 4) (p =

0.001). These results clearly demonstrate that the independency of both groups was good but better in the second group, probably due to early weight bearing because it is well known that the energy requirements of ambulation with full weight bearing are signiŽcantly less than those with partial weight bearing.1,10 Possible problems of early weight bearing may be early loosening or failure of the hip prosthesis22 and it has been suggested that early full weight bearing ambulation (before three months post surgery) leads to a 50% incidence of migration of the prosthesis 2 because the period of bone growth is expected to take up to three months. 11 We speciŽcally re-evaluated our patients at that critical time (three months) (Table 5). At that time, none of our patients showed any evidence of loosening or failure, either clinically or radiographically, and the results at three months were in favour of the early full weight-bearing patients (group 2). Table 5 clearly shows that group 2 patients had more muscle strength, could walk further, had used crutches less than group 1 and Žnally had better Harris Hip Scores. Although early partial and full weight bearing were not the only differences between two rehabilitation protocols (Table 1), the differences between the groups can be attributed to that part of the difference, for resistive and active exercises depend on the weight-bearing status of the patients.1 As shown in a study of a three-axis load cell implanted in a femoral head, the forces applied to the hip joint may be up to 1.8 times body weight.23 Review of the literature revealed two papers reporting the results of TPP patients three months postoperatively.5,13 In these series, Menge5 and Fink et al.13 reported mean Harris Hip Scores as 69 and 78.8 respectively at the third-month evaluation. Our results in both groups (81.4 and 89.3) were superior to the previous series, probably due to the accelerated rehabilitation programme used. The patients were again re-evaluated one year postoperatively and none of them showed any signs of loosening or failure. In conclusion, the results of the present study suggest that patients with TPP can tolerate an accelerated rehabilitation programme with early weight bearing and gain the goals of rehabilita-

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Rehabilitation programmes for thrust plate prosthesis tion earlier. These are probably due to the biomechanical principles of the TPP, in that mechanical loads are directly transmitted to the calcar and cortical bone as in the natural hip. The design of the TPP is somewhat like the angled implants that are used in the management of femoral neck fractures; in these cases full weight bearing is allowed as soon as the fracture has united. In our opinion, TPP can be considered like these implants but in cases without fracture. Although not primarily in the scope of the present study, one may expect that such an approach will reduce costs. In our opinion, larger trials with longer followup, using more reliable measures (i.e., muscle testing by isokinetic dynamometer) and with cost-effectiveness analyses are necessary for Žrmer conclusions.

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