Chapter 50

Physiotherapy Following Joint

Replacement

1 Introduction
Joint replacement surgeries, or arthroplasty, is a surgical intervention aimed at alleviating
joint pain and restoring function in cases of advanced joint pathology.. It may involve the
replacement of only part of a joint (hemiarthroplasty), such as replacing the femoral head
while preserving the acetabulum, or the complete joint (total joint replacement), where both
articulating surfaces are replaced. Common procedures include Total Hip Replacement
(THR), Total Knee Replacement (TKR), and Total Shoulder Replacement (TSR). Post-
operative physiotherapy is critical for maximizing outcomes, ensuring early mobilization,
restoring joint range, strengthening muscles, and facilitating a return to functional
independence.

Hemiarthroplasty (Partial joint replacement)

Hemiarthroplasty involves replacing one component of a joint, typically used in conditions
like femoral neck fractures where the acetabulum remains structurally intact.

Prosthetic options may include monopolar (single-piece) or bipolar (two-piece) systems.

Modular prostheses allow customization of stem and head sizes during surgery. These can be
either cemented using bone adhesive or uncemented, relying on a tight press-fit with the host
bone.

Operative technique: - The process includes exposing the hip, dislocating it, resecting its
ends, preparing the medullary canal for the prosthesis, implanting the prosthesis in the canal,
reducing the hip, and sealing the wound.

Precautions:

 To prevent the prosthesis from dislocating during a hip hemiarthroplasty, the patient
is placed in a supine posture with the limb in abduction.
 For four to six weeks, flexion and adduction should be avoided in particular because
they could cause the prosthesis to dislocate.
 Changing positions frequently to avoid pressure sores, etc.
 Partial weight-bearing crutch walking is initiated after three weeks, and full weight-
bearing is permitted after four to six weeks.
Total joint replacement
When both components of the joint are replaced, e.g., the head and the acetabulum are
replaced in a total hip replacement surgery, other examples include total knee replacement
and total shoulder replacement.

2 Goals of Post-Operative Rehabilitation

 Relieve post-operative pain and swelling
 Prevent complications (DVT, joint stiffness, muscle atrophy)
 Restore range of motion (ROM) and muscle strength
 Improve gait and posture
 Enhancing proprioception and balance
 To avoid prosthesis redislocation in the initial postoperative phase.
 Enhance functional independence in ADLs
 Promote patient education and adherence

3 General Phases of Rehabilitation

Phase Duration Key Goals
Control pain, prevent complications, and initiate
Phase I: Acute Day 1–3 weeks
gentle mobilization
Restore joint mobility, begin muscle activation,
Phase II: Subacute 3–6 weeks
and initiate basic functional tasks
Focus on muscle strengthening, balance
Phase III: Strengthening 6–12 weeks
retraining, and functional progression
Return to ADLs, work, and recreational
Phase IV: Functional 3–6 months
activities, and achieve functional independence

4 Total Hip Replacement (THR)

Total Hip Replacement (THR) involves the surgical replacement of both articulating surfaces
of the hip joint—the femoral head and the acetabulum—with artificial components. It is
primarily indicated in conditions where conservative management fails to relieve pain or
preserve joint function. Total hip joint implants come in two varieties:

1. Cemented implants (Bone cement (typically polymethyl methacrylate) is used to

secure both the acetabular and femoral components. This type is often selected for
older adults with compromised bone density, such as those with osteoporosis.)
2. Non-cemented implants (Screws are used to secure the acetabular component, and
the femoral component is firmly inserted into the femur's medullary canal. In two
to three months, bone development surrounding the prosthesis' stem will firmly
anchor its position. It is applied to young patients.)

A more recent advancement is hip total surface replacement arthroplasty. This preserves the
healthy host bone for the most part, replacing only the articular surfaces of the femoral head
and the acetabulum with thin prosthesis. For younger patients, it is recommended to produce
better and more durable outcomes.

Common Indications:

 Osteoarthritis
 Rheumatoid arthritis
 Avascular necrosis
 Fracture neck of femur
 Hemiarthroplasty failure
 Ankylosed hip
 Hip tuberculosis

Contraindications

 Infection is an absolute contraindication

 Neuropathic joints
 Poor medical risk
 Poor anaesthetic risk
 Obesity

Complications

 DVT
 Fat embolism
 Infection
 Breakages of implants
 Loosening of implants
 Osteolysis
 Periprosthetic fractures
 Dislocation
 Heterotrophic ossification
 Neurovascular injuries
Post-Operative Precautions:

 Avoid hip flexion >90° (posterior approach)

 No adduction past midline
 No internal rotation
 Avoid knee hyperextension in the first week following surgery.
 Avoid squatting, cross-legged sitting, and forward bending
 Position of flexion, adduction, and internal rotation must be avoided
 Refrain from long sitting

Physiotherapy Management:

 Day 1-7: Bed mobility, limb elevation, elastocrepe bandaging, ankle pumps (to
prevent DVT and pulmonary embolism), chest physiotherapy, deep breathing,
quadriceps setting, gluteal sets, isometric exercises of glutei, hamstrings, ankle
dorsiflexors and plantarflexors (to improve joint stability) and continuous passive
motion (CPM) can be used for small range of relaxed passive movement.
 Week 1-2: passive, active, and active-assisted movements. Increase the range of
CPM, sit with knees hanging, bed-transfers, Sit-to-stand, walker-assisted ambulation,
gentle hip abduction, heel slides
 Week 3-6: Partial weight-bearing within the parallel bars; can progress to crutch
walking, standing hip, knee, and ankle exercises, stair climbing (up with the
unaffected leg and down with the affected or operated leg), light resistance training,
and single-leg standing on the operated limb. Bicycle exercises and rotational
exercises for the hip in supine positions are initiated.
 Week 6 onwards: Gait training, balance work, and functional mobility; can come to
the single crutch usage, which can further be replaced by a cane upto 6 months (as
suggested by Beber and Covery); by 12 weeks, the patient should be functionally
independent.

Assistive Devices:

Assistive devices such as walkers, reachers, and raised toilet seats may be recommended to
enhance postoperative safety and mobility.

5 Total Knee Replacement (TKR)

Total Knee Replacement (TKR) is a surgical technique where a damaged knee joint is
replaced with a prosthesis or artificial joint.
Types of Knee Replacement Prostheses:

Knee replacement prostheses come in three varieties:

 Non-constrained prostheses: These depend primarily on the patient’s surrounding soft

tissues (ligaments and muscles) for joint stability. They are suitable for patients with
intact ligamentous support.
 Semi-constrained prostheses: They provide some stability for the knee and do not rely
entirely on the patient's ligaments and muscles to provide the stability.
 Constrained prostheses: These designs are utilized in cases of gross instability or
ligamentous insufficiency, often seen in complex revisions or severe deformities.

Types of Total Knee Replacement (TKR)

 Unicompartmental or Unicondylar or Partial knee replacement: Only one

compartment (medial or lateral) of the knee is replaced. It can be done in case of
osteoarthritis.
 Bicompartmental: Both the compartments (medial and lateral) of the knee are
replaced.
 Tricompartmental: Along with medial and lateral compartments, the patellofemoral
compartment is also replaced by prostheses. (most preferred method)

Common Indications:

 Osteoarthritis
 Post-traumatic arthritis
 Rheumatoid arthritis
 Severe pain and deformity due to any form of arthritis

Contraindications:

 Sepsis
 The extensor mechanism is insufficient
 Neuropathic joint
 Relative contraindications include a younger patient (<50 years), obesity, and those in
a physically demanding profession.

Complications:

 Infection
 Deep venous thrombosis (DVT)
 Nerve palsy
 Fractures
 Extensor mechanism complications
 Knee stiffness

Rehabilitation Milestones:

Timeline Goal
Week 1 0-90° knee flexion, independent transfers
Full extension, 90-100° flexion, gait without
Week 2-3
walker
Week 6 110-120° flexion, strength recovery

Post-operative precautions

 Avoid rotation and deep squatting during early recovery.

 The range of knee flexion should be < 40º during 1-3 days to prevent undue stress.
 Persistent pain may result from weak quadriceps and limited patellar movement.
 It is important to monitor for quadriceps lag caused by reflex inhibition.
 Avoid activities that cause undue compression at the knee joint (e.g., excessive
sitting-standing, or stair activities)

Physiotherapy Protocol:

 Early Phase: Cryotherapy, CPM machine, patellar mobilization, static quadriceps,

isometrics of glutei and hamstrings, heel slides, SLR with support, chest
physiotherapy, limb elevation, positioning of the limb with a pillow beneath the heel,
preventing rotation. Standing and ambulation with walkers.
 Mid Phase: Passive, active, and active-assisted ROM exercises for knee flexion,
Straight leg raise, mini squats, step-ups, start with partial weight bearing and
ambulation on crutches, and gradually progress to full weight bearing. knee flexion
must be 110º-120º, pedocycle and stationary bicycle, staircase walking. Quadriceps
drill, hydrotherapy. Post 45 days after surgery- ambulate with cane, shifting weight on
both knees evenly.
 Advanced Phase: Resistance band work, proprioception, functional training (sit to
stand),

Outcome Measures:

 WOMAC score
 Visual Analogue Scale (VAS)
 Timed Up and Go (TUG) Test
 Knee Society Score (KSS)

6 Total Shoulder Replacement (TSR)

This involves the replacement of the glenoid articulating surfaces and the humeral head with
prosthetic parts. The Neer prosthesis is the one that is most frequently utilized.

Types of Shoulder Arthroplasty:

  Anatomic Total Shoulder Arthroplasty (TSA):
Both the humeral head and glenoid are replaced in an anatomical configuration,
preserving the natural joint mechanics. Suitable for patients with intact rotator cuff
function.
 Reverse Total Shoulder Arthroplasty (RTSA):
The ball and socket configuration is reversed (glenoid becomes the ball; humerus
becomes the socket), providing stability and improved function in patients with
massive rotator cuff tears or cuff tear arthropathy. It relies more on the deltoid muscle
for arm elevation.
 Hemiarthroplasty:
Only the humeral head is replaced, usually indicated in proximal humeral fractures or
when glenoid preservation is required.

Indications:

 Glenohumeral arthritis
 Complex fractures
 Rotator cuff arthropathy
 Rheumatoid arthritis
 Secondary Osteoarthritis of the shoulder (uncommon)

Post-Op Considerations:

 Sling use for 3-4 weeks

 Avoid active internal rotation, lifting
 The shoulder joint is mobilized 2-3 weeks after the operation.
 Lateral rotation may be commenced by 3 weeks and permitted by the end of 6 weeks
 To prevent dislocation, avoid combining adduction with internal rotation and
abduction with external rotation.

Physiotherapy Plan:

 Phase I (0-3 weeks): Pendulum exercises, assisted ROM (flexion/ER), active

exercises of the wrist, hand, and fingers of the operated limb along with normal
movements of the unoperated limb.
 Phase II (3-6 weeks): Progress to active-assisted ROM exercises in sitting position,
scapular stabilization, shoulder shrugging, and continue with the pendulum exercises.
 Phase III (6-12 weeks): Active ROM, light strengthening
 Phase IV (3+ months): Functional strengthening, endurance exercises

Outcome Measures for TSR Rehabilitation:

 Disabilities of the Arm, Shoulder, and Hand (DASH) Score

 Constant–Murley Shoulder Score
 American Shoulder and Elbow Surgeons (ASES) Score
 Range of Motion (goniometry)
7 Patient Education
 Importance of compliance with home exercise program
 Precautions and safe joint positioning
 Use of assistive devices
 Signs of infection, DVT, or prosthetic failure
 Psychological support
 Sudden joint pain or instability, fever, swelling, and tenderness along with other signs
must be reported immediately.
 Gradual return to ADLs

8 Complications and Physiotherapy Response

Complication Physiotherapy Role
DVT Early mobilization, ankle pumps
Joint Stiffness Passive and active ROM, CPM
Muscle Weakness Progressive resistance training
Prosthetic
Reinforce precautions, avoid risky movements
Dislocation
Extensor
Ultrasound/ice contrast, stretching, and strengthening exercises of the
mechanism
quadriceps and hamstrings
complications

9 Summary
Post-joint replacement rehabilitation requires a structured and evidence-based physiotherapy
program that emphasizes pain control, mobility, and strengthening. Tailoring interventions to
the patient’s functional needs and respecting surgical precautions ensures a successful return
to independent life.

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