This document provides information on total hip replacement, total knee replacement, and postoperative ACL rehabilitation. It describes the anatomy and surgical procedures for hip and knee replacements. For hip replacement, it discusses indications, surgical approaches, complications, and pre-operative and post-operative physiotherapy management. For knee replacement, it similarly outlines indications, surgical approaches, complications, and physiotherapy management. For ACL rehabilitation, it details the phases of rehabilitation from immediate post-op to return to sport at 6 months, focusing on restoring range of motion and strengthening.

1. BY
VAISHNAVI E
BPT INTERN
TOTAL HIP REPLACEMENT
TOTAL KNEE REPLACEMENT
POSTOPERATIVE ACL
REHABILITATION

2. TOTAL HIP REPLACEMENT
 A total hip replacement [THR] – also called hip arthroplasty is a
surgical procedure that re-forms the hip joint
 Hemiarthroplasty – wherein the femoral part is replaced [ done
for fracture neck of femur ]
ANATOMY:
 The hip is a ball and socket joint . The ball is the femoral head
and the acetabulum is the socket
 The head of the femur and the inside of the acetabulum are
covered with hyaline cartilage
 Once this cartilage is worn out or damaged the underlying bone
is exposed , resulting in pain , stiffness and shortening of
affected leg . By replacing these surfaces the aim is to reduce
pain and restore an active and pain free life.

3. DESCRIPTION
 In a total hip replacement,
the damaged bone and
cartilage is removed and
replaced with prosthetic
components
 The damaged femoral head is
removed and replaced with a
metal stem that is placed
into the hollow center of the
femur. A metal or ceramic
ball is placed on the upper
part of the stem . The
damaged cartilage surface is
removed and replaced with a
metal socket.
 Screws or cements are used
to hold the socket in place . A
plastic ,ceramic , or metal
spacer is inserted between
the new ball and socket to
allow for a smooth gliding
surface

4. INDICATIONS
 Osteoarthritis
 Post-traumatic arthritis
 Rheumatoid arthritis
 Avascular necrosis
 Congenital hip dislocations and dysplasia
CONTRAINDICATIONS
 LOCAL: Hip infection or sepsis
 Remote[extra-articular]-active , ongoing infection
 Severe cases of vascular dysfunction

5. SURGICAL APPROACHES
 POSTERIOR : Most common surgical approach [Skin incision is made 10-15 cm
centered the posterior aspect of the greater trochanter ]
 Direct anterior [ Incision between tensor fascia lata and sartorius , gluteus
medius and rectus femoris ]
 Anterolateral [Violates hip adductor mechanism ]
 Direct lateral [ If nerve injured leads to postoperative Trendelenburg gait]
COMPLICATIONS:
 THA dislocation
 THA Periprosthetic fracture
 THA Aseptic loosening
 THA prosthetic joint infection
 Wound complication , Nerve injury
 Leg length discrepancy
 Heterotropic impingement

6. PHYSIOTHERAPY MANAGEMENT
 HIP PRECAUTIONS:
 POSTEROLATERAL APPROACH : Avoid hip flexion past 90 degrees
, adduction and internal rotation [extreme]
 ANTEROLATERAL APPROACH : Avoid extension ; extreme
external rotation and adduction
 DIRECT ANTERIOR APPROACH : Avoid bridging ,extension ,
extreme external rotation , adduction.
PRE-OPERATIVE MEASURES
 Chest physiotherapy and deep breathing exercises
 Isometric exercises to the glutei , quadriceps and hamstring
muscles of the affected limb
 Active ROM exercises to the unaffected limb and both the
upper limbs

7.  To prepare the patient for proper limb positioning after surgery , to teach
the method of transfer
POST-OPERATIVE MEASURES
 During the first 7 days:
 Chest physiotherapy
 To prevent PE and DVT: Limb elevation , active exercises of the ankle and
toes , preventing hyperextension at the knee
 Isometrics to the glutei , quadriceps , hamstrings , ankle dorsiflexors and
plantar flexors

8. From 7-14 days
 The passive , active and active-assisted movements are made more vigorous
 The patient should be taught how to turn in the bed and should be encouraged to
sit with the knees hanging , taught to transfer himself from bed to wheelchair to
parallel bars and back
During 21-28 days
 Patient is encouraged to bear weight partially within the parallel bars
 Vigorous strengthening exercises to the hips , knees , and ankle muscles are
continued
 Knee standing and walking ,Single leg standing on the operated side is encouraged

9. After 1 month
 All the exercises are made more vigorous
 Stair climbing is started
 Bicycle exercises and rotational exercises are initiated
 By 12 weeks the patient should be functionally independent

10. TOTAL KNEE REPLACEMENT
 Total knee arthroplasty or total knee replacement involves
replacing the articular surfaces of the knee joint with smooth
metal and highly cross-linked polyethylene plastic
ANATOMY:
 The Knee is a modified hinge joint .Three bones form the knee
joint the upper part of the tibia , the lower part of the femur
and the patella
 The knee joint is reinforced by ligaments and a tear capsule

11. DESCRIPTION
 The damaged cartilage
surfaces at the ends of the
femur and tibia are
removed along with a small
amount of underlying bones
 The removed cartilage and
bone is replaced with metal
components and the
undersurface of the patella
is cut and resurfaced with a
plastic button
 A medical- grade plastic
spacer is inserted between
the metal components to
create a smooth gliding
surface

12. INDICATIONS
 Severe osteoarthritis of the knee
 Rheumatoid arthritis
 Severe pain and deformity to any form of arthritis
SURGICAL APPROACHES
 Prepatellar approach: It provides a good view of the articular surface of the
distal femur
 Subvastus approach: It is a truly quadriceps sparing technique
 Anterior approach
 Midvastus approach
 Trivector retaining approach

13. COMPLICATIONS & CONTRAINDICATIONS
 Infection
 Nerve damage
 Bone fracture
 Persistent or chronic pain
 DVT
 Stiffness
 Loosening or fracture of prosthetic components

14. PHYSIOTHERAPY MANAGEMENT
PREOPERATIVE MEASURES:
 EVALUATION : Pain , deformity , gait analysis , muscle strength
 Isometric exercises of the affected limb , measures to counter
DVT , Edema
POSTOPERATIVE MEASURES:
DURING THE FIRST 7 DAYS:
 Chest physiotherapy
 The limb is elevated and positioned properly with a pillow
beneath the heel preventing rotation
 Isometrics to the quadriceps
 SLR
 Active or active assisted knee flexion can be commenced

15. BETWEEN 7 AND 14 DAYS
 Isometrics are made more intensive
 Active , active assisted and passive ROM exercise for knee
flexion are done
 SLR is made intense
 Partial weightbearing and ambulation is begun on crutches
AFTER 3 WEEKS
 Knee flexion above 110-120 degrees
 Partial weightbearing progressed to full weight bearing
 Staircase walking is begun , Quadriceps drill are done

16. AFTER 45 DAYS
 Patient encouraged to walk with a cane
 Patient is taught to balance his/her weight evenly on both the
knees
 By 12 weeks the cane is discarded and the patient should be
able to resume all the normal activities

17. POSTOPERATIVE ACL REHABILITATION
INTRODUCTION:
 The anterior cruciate ligament is a main stabilizing ligament of
the knee . It prevents abnormal translation and rotation of the
tibia with respect to the femur . The ACL is commonly torn
during sports and in any event that causes an undue rotational
force to the knee
 Various grafts/tissues have been used to anatomically
reconstruct the torn ACL
 The most commonly used are the autografts [ Bone – patellar
tendon- bone , Quadriceps tendon and hamstring tendon graft]
sometimes the allografts

18. WEEKS 1-2 [ IMMEDIATE POSTOPERATIVE
PHASE]
 Protect the graft ,Regular icing and elevation are used to
reduce swelling . Elevation of the knee done above the heart
level
 The goal is to restore full extension and 70 degrees of knee
flexion by the end of first week
 Keep your knee straight and elevated when sitting / laying
down
 Do quad sets , SLR [ Active assisted ] [If there is extensor lag no
need to do it ] , ankle pumps , seated assisted knee flexion are
done
 Isometric quadriceps exercise of the affected limb are done and
prone leg hang are done

19. WEEK 3-5 [ INTERMEDIATE
POSTOPERATIVE PHASE]
 Continuation of previous phase exercises ,Maintain full
extension , restore full flexion [ contralateral side ]
 Patient are taught to do wall slides , partial squats using table
for stabilization , standing hamstring curls , ball squats
 Strengthening exercises to the core , hip and calf and hamstring
are done
 Single leg balance is done

20. WEEK 6-8 [ LATE POSTOPERATIVE
PHASE]
 Maintain full ROM ,Proprioception and Coordination exercises
are given if general strength is good . This includes balance
exercises on boards and toll
 Continue partial squats [ squat to chair ] and toe raises and Leg
press , single leg standing , step up/down, forward and side
lunges , bridges are done to strengthen the lower extremities
 SLR with resistance , prone quadriceps stretching are done
WEEK 9-12 [ TRANSITIONAL PHASE ]
 Continuation of the previous phase exercises
 Resisted squats , unilateral heel raises , resisted step ups ,
planks are done
 Climbing stairs , walking uphill, skating and swimming are
started

21. UNRESTRICTED RETURN TO SPORT [ 6+
MONTHS AFTER SURGERY ]
 Continue strengthening and proprioceptive exercises
 Safely progress to full sport

22. THANK YOU