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By the late fourth century CE the river Danube had become Rome’s Calais. What we often call the “invasions” into the Roman empire of barbarian hordes (or “swarms”, perhaps) could equally well be described as mass movements of economic migrants or political refugees from northern Europe. The Roman authorities had no better idea of how to deal with this crisis than our own authorities do, and, predictably, they were less humane. On one notorious occasion, uncomfortable even for some Roman observers, they sold dog-meat as food to the asylum-seekers who had managed to get across the river (dog was off limits for human consumption then as now). It was just one stage in a series of standoffs, compromises and military conflicts that eventually destroyed central Roman power in the western part of their empire. And it was exacerbated by the calculating policy of the Romans in the east, who by this era effectively formed a separate state. Their solution to the crisis of migration was to point the migrants firmly westwards, and try to make them someone else’s problem.It’s tempting to imagine the ancient Romans as some version of ourselves. They launched disastrous military expeditions to those parts of the world where other armies have failed. Iraq was as much a graveyard for the Romans as it has been for America. And one of their worst defeats, in 53BCE at the hands of a rival empire in the east, took place near the modern border between Syria and Turkey. In a particularly ghoulish twist, uncomfortably reminiscent of the sadistic showmanship of Islamic State, the head of the Roman commander was cut off and used by the enemy as a makeshift prop in a performance of Euripides’ play The Bacchae – in which the head of King Pentheus, horribly decapitated by his mother, takes a macabre starring role.Back in Italy too, Roman life had a familiar side. Urban living in a capital city with a million inhabitants, the biggest conurbation in the west before the 19th century, raised all the usual questions: from traffic congestion (one law tried to keep heavy vehicles out of the city during the day, with the knock-on effect of appalling noise at night) to rudimentary planning problems (exactly how high were high-rise blocks allowed to be, and in what materials to make them safe from fire?). Meanwhile the political classes worried about everything from expenses scandals to benefits scroungers. There was endless, and largely unsuccessful, legislation aimed at preventing officials lining their own pockets out of the public purse. Even the famously upright Marcus Tullius Cicero –politician, poet, philosopher and jokester– left one overseas posting with a small fortune in his suitcase; he had apparently been “economical” with his expenses allowance.There was also endless debate over the distribution of free or subsidised grain to citizens living in the capital, one half of the infamous pair of “bread and circuses”, which, according to a hard-nosed Roman satirist, had sapped the political energy and independence of the people. Was this a proper use of the state’s resources and a precedent to be proud of – the first time any state in the west had decided to guarantee the basic subsistence of many of its citizens? Or was it an encouragement to idleness, and an extravagance that the exchequer could not afford? One rich Roman conservative was once caught standing in line to collect this allowance of which he vehemently disapproved and certainly did not need. When asked why, he replied: “If you’re sharing out the state’s property, I’ll come and take my cut, thank you.” This is not far from the logic of the elderly modern millionaire who claims his free TV licence or bus pass.But it is not so simple. To study ancient Rome from the 21st century is rather like walking on a tightrope – a careful balancing act, which demands a very particular sort of imagination. If you look down on one side, everything does look reassuringly familiar, or can be made to seem so. It is not just the military escapades or the problems of urban life and migrants. There are conversations going on that we almost join, about the nature of freedom or the problems of sex. There are jokes we still “get”, buildings and monuments we recognise and family life lived out in ways we understand, with all their quarrels, divorces and troublesome adolescents.Cicero’s disappointment in the first century BCE with his son Marcus, who, at university in Athens, preferred clubbing and drinking to attending lectures on philosophy, is one that many of us can share. So too is the dilemma revealed by a surviving Roman do-it-yourself fortune-telling kit. Among the many questions it lists for anxious consulters is: “Will I get caught in adultery?” And among the many possible responses you could receive (depending on how the dice fell) was the wise and realistic: “Yes, but not yet.”On the other side of the tightrope, however, is completely alien territory. Some of that strangeness is well recognised. The institution of slavery disrupted any clear idea of what it was to be a human being (neither Greeks nor Romans ever worked out whether slaves were things or people). The filth of the place was, in our terms, shocking. There was hardly any reliable system of refuse collection in ancient Rome, or in any ancient city, and there were revealing stories about stray dogs walking into posh dinner parties clutching in their mouths human body parts they had picked up in the street. And that’s not to mention the slaughter in the gladiatorial arena or the death from illnesses whose cure we now take for granted. More than half of the Romans ever born would have died before they were 10 years old. Childbirth was as deadly to women as battle was to men.Less well known are the thousands of unwanted new‑born babies who were thrown on to rubbish heaps (or “exposed” to use the modern scholarly euphemism); the boundary between contraception and infanticide was a blurred one, and disposing of children after birth was safer than getting rid of them before. Likewise overlooked are the young Roman girls, who were not uncommonly married by the age of 13 or 14, and sometimes even earlier, into what we would have little hesitation in calling child abuse. How soon these marriages were consummated is anyone’s guess, but Cicero’s response, on the eve of his second marriage, to questions about why, in his 60s, he was taking as a bride a young virgin, a child in her mid-teens, is instructive. “Don’t worry,” he said, “she’ll be a grown-up woman tomorrow” (that is, a virgin no longer). The ancient critic who quoted this answer thought that it was a brilliantly witty way of deflecting criticism, and held it up for admiration. We are likely to put it somewhere on the spectrum between uncomfortably coarse and painfully bleak – one powerful marker of the distance between the Roman world and our own.The truth is that Roman history offers very few direct lessons for us, and no simple list of dos and don’ts. We hardly need to read of the difficulties of the Roman legions on the Syrian borders to understand that modern military interventions in western Asia might be ill‑advised, or that feeding inedible food to refugees is likely to rebound. I am not even certain that those modern generals who boast of following the tactics of Julius Caesar or Hannibal really do so, in anything more than their own imaginations; most military victories in the ancient world were achieved by massive superiority in numbers or by some variety of “going round the back” of the enemy and capturing them in a pincer movement (“tactics”, in any more sophisticated sense, just weren’t in it). Besides, “the Romans” were no less divided about how they thought the world worked, or should work, than we are. There is no simple Roman model to follow, or reject. If only things were that easy.Ancient Rome still matters for very different reasons – mainly because Roman debates have given us a template and a language that continue to define the way we understand our own world and think about ourselves, from high theory to low comedy, while prompting laughter, awe, horror and admiration in more or less equal measure. Of course, western culture is not the heir of the classical past alone, nor would anyone wish it to be. There are, happily, many different influences woven into our cultural fabric: Judaism, Christianity and Islam only three of the most obvious. But since the Renaissance at least, many of our most fundamental assumptions about power, citizenship, responsibility, political violence, empire, luxury, beauty, and even humour, have been formed, and tested, in dialogue with the Romans and their writing.Detail from a fresco depicting the arrival of the Trojan Horse, from Pompeii. Photograph: RexWe see that in the vocabulary of modern politics, from “senators” to “dictators”, and in our own catchphrases and cliches. “Fiddling while Rome burns” is a reference to the emperor Nero playing his lyre while the city went up in flames in the great fire of 64CE (not, as is now often assumed, “fiddling” in the modern sense of fussing aimlessly).“Fearing Greeks even when bearing gifts” is how Virgil in his Aeneid scripted the warning of one of the Trojan elders at the appearance of the great “Trojan horse”, a treacherous present from their Greek enemies. And the single Latin word “plebs” is still an insult, whether actually uttered or not, that can force a government minister to resign. We see it too in the political geography of modern Europe. The main reason that London is the capital of the United Kingdom, so inconveniently located in many respects, is that the Romans made it the capital of their province Britannia – a dangerous place lying, as they saw it, beyond the great ocean that encircled the civilised world. Britain is in many ways a Roman creation.But even more importantly, we have inherited from Rome many of the fundamental principles and symbols with which we define and debate politics and political action. The assassination of Julius Caesar on the “Ides of March” in 44BCE was in reality a bungled and slightly seedy operation. Despite Shakespeare’s glamorising recreation of the conspiracy, it was headed by the decidedly unattractive Marcus Junius Brutus, whose previous claim to fame had been to extract an almost 50% rate of interest for loans to the unfortunate people of Cyprus (when they could not come up with the repayments he had the main council chamber on the island besieged, starving five councillors to death in the process). It caught several innocent people in what we would call “friendly fire”. And in the medium term it did more to bring about one-man rule in Rome than to eradicate it as the assassins had hoped. Yet, helped no doubt by the Shakespearean version, it has provided the model and the justification for destroying “tyrants” in the name of “liberty” ever since. It is no coincidence that John Wilkes Booth used “Ides” as the code word for the day on which he planned to kill Abraham Lincoln. Almost every assassination in western politics has been seen against the background of the Ides of March.Twenty years before Caesar’s murder there was another event that has had an equally long afterlife in western history and thought. While he held the chief office of the Roman state, the consulship, in 63BCE, Cicero uncovered what he claimed (and probably believed) to be a terrorist plot to overthrow the government and to eliminate several of its senior politicians, himself included. The mastermind was supposedly a bankrupt aristocrat by the name of Catiline, who had turned to revolution when he had failed to reach power by legitimate means. Cicero had been tipped off by his undercover agents, intelligence reports and intercept evidence, and so – displaying a breastplate under his toga (more or less the equivalent of turning up at the House of Commons with a bulletproof vest and pistol) – he denounced Catiline who quickly fled, and he rounded up the other conspirators. These he executed without trial, in the interests of homeland security. “Vixere,” he announced, in a chilling understatement, as he emerged from the prison where he had overseen their punishment: “They have lived.” That is: “They are dead.”Detail from Ara Pacis Augustae, an altar in Rome dedicated to Pax, the Roman goddess of peace. Photograph: Tristan Lafranchis/akg-imagesWe know about this incident almost wholly from Cicero’s side; in fact, four speeches that he delivered accusing Catiline of treason and revealing what he knew of the plot went on to the Roman school curriculum almost immediately, as models of persuasive oratory, and have been read and studied ever since. The speeches still have their foothold in the modern western school curriculum, albeit a considerably more tenuous one. But we also know that there was another side to the debate. Whatever Catiline was really up to (and there is still disagreement about how far the “reds under the bed” were a figment of Cicero’s conservative imagination or paranoia), every Roman citizen had the fundamental right to due process and fair trial; summary execution contravened the most basic of civil liberties, then as now. Cicero did not escape scot-free. He was shortly sent into exile, his house in Rome was demolished, and a shrine to the goddess Liberty was pointedly constructed on its site.The exile was unpleasant for Cicero, and copies of his unattractively self-pitying letters, sent back to his family and friends, still survive. Roman men did not often have the stiff upper lips of popular imagination, and Cicero wallowed in his tears. But the crying did not last long, for in a year he was recalled – in his account again – to a hero’s welcome and to the rebuilding of his house. His career, however, never fully recovered and the basic clash between, on the one hand, the obligation on the elected officials of the state to ensure its security and, on the other, the civil liberties of every citizen, no matter how criminal, continued to be debated – as it still is, whether in relation to detention without trial, Guantánamo Bay or British drone strikes against British citizens in Syria.Over the centuries Cicero and Catiline have hovered in the background of these and other political debates, and have sometimes provided an explicit template for them. Writing a play on the subject in the aftermath of the Gunpowder Plot, Ben Jonson turned Catiline into a sadistic anti-hero (though his Cicero was an almost equally unattractive droning bore), while from the other side of the political spectrum Henrik Ibsen, in the fallout of the European revolutions of the 1840s, imagined a highly principled Catiline pitted against the corruption of the world in which he lived. Even now, the very words that Cicero used in his speeches against Catiline – and especially the first line of the first speech “Quousque tandem abutere, Catilina, patientia nostra?” (“How long, Catiline, will you go on abusing our patience”) – get replayed as a signal of fundamental and principled political opposition. That goes from the hard-line Republican senator for Texas, Ted Cruz, who just last year started his attack on Barack Obama’s immigration plans with the words, “When, President Obama, do you mean to cease abusing our patience?”, to protesters against the government in Hungary a couple of years before who emblazoned banners with just the words Quousque tandem. No more needed to be said.‘How long yet?’ … a banner bears a phrase from Cicero’s speech at a protest denouncing Hungary’s new constitution, 2012. Photograph: Getty ImagesWhat is important here is the debate, not the resolution. Ancient Rome is not a simple lesson for us, nor is it a civilisation that we should gratefully admire. There is much in the classical world – both Roman and Greek – to engage our interest and demand our attention. But admiration is a different thing. After 50 years of working on, and with, the Romans, I bridle when I hear people talking, as they so often do, of “great” Roman conquerors, or even of Rome’s “great” empire. That certainly wasn’t what it looked liked from the other end of Roman swords. But admiration apart, Roman debates are embedded in our own, and they are embedded in those of our predecessors who have in turn bequeathed their own problems, solutions and interpretations to us. I am not only referring to debates on Catiline and civil liberties, but also to the lurid, largely fictional, anecdotes of Roman emperors that have framed our own views of political corruption and excess (where does autocratic excess end and a reign of terror begin?), or the justifications, bad and good, for imperial expansion and military intervention.Our own world would be immeasurably the poorer, and immeasurably less comprehensible to us, if we did not continue to interact with the Roman past. If we want, for example, to understand why John F Kennedy, like Lord Palmerston before him, chose to adopt the slogan Civis Romanus sum (“I am a Roman citizen”) – in Kennedy’s case as a defence of the freedom of West Berlin, in Palmerston’s in defence of some gunboat diplomacy – we need to keep engaged with the history of ancient Rome itself, with Roman approaches to citizenship and nationhood, and why they might underpin our own. Cynically, we should probably also wonder whether Kennedy (or Palmerston) actually knew that their cherished slogan had first become a Roman commonplace after being uttered as a desperate plea from a tragic Sicilian as he was pinned to a cross and illegally crucified by a rogue Roman provincial governor in the first century BCE – a plea that had no effect whatsoever.Inevitably, the Rome with which we engage is a moving target. Roman history has changed dramatically over the last 50 years, and even more so over the last 250 years since Edward Gibbon wrote The Decline and Fall of the Roman Empire, his idiosyncratic historical experiment that began the modern study of Roman history in the English-speaking world (and which certainly would have been on Palmerston’s desk). That is partly because of the new ways of looking at the old evidence, and the different questions we choose to put it. It is a dangerous myth that we are better historians than our predecessors. We are not. But we come to Roman history with different priorities – from gender identity to food supply – that makes the ancient past speak to us in a new, as well as an old, idiom. Whereas once the empress Livia, wife of the first emperor Augustus, was presented as a scheming manipulator and poisoner, we are now much more sensitive to the way male traditions tend to project villainy and self-interest on to women who have the fortune, or misfortune, to be married to the man in charge (think Cherie Blair). Livia may not have been a shy retiring lady innocent of all machinations, but we now realise that we would be the dupes of a tendentiously patriarchal vision to think of her simply as the wicked witch behind the throne.There have also been an extraordinary array of new discoveries –in the ground, under water, even lost in libraries– presenting novelties from antiquity that tell us more about ancient Rome than any modern historian before us could ever have known. We now have a manuscript of a touching essay by Galen, a Roman doctor whose prize possessions, kept in a lock-up store in the centre of Rome, had just gone up in flames; this resurfaced in the library of a Greek monastery only in 2005. We have discovered wrecks of Mediterranean cargo ships that never made it to Rome, with their foreign sculpture, furniture and glass destined for the houses of the rich, and the wine and olive oil that were the staples of everyone. Soundings off the coast of Sicily have even located on the sea bed the detritus of the last great naval battle in the first Punic war between Rome and Carthage in the mid-third-century BCE – including the metal rams from the prows of the ships inscribed with appropriate messages (one Carthaginian specimen has words to the effect of “Up yours, Rome”), helmets of the fighters and their day-to‑day supplies. Surprising as it may seem, the best-preserved ancient battlefield turns out be under the sea.And nowadays archaeological scientists are carefully examining samples drilled from the ice cap of Greenland to find the traces, even there, of the pollution produced by Roman industry – the mines in Roman Spain, for example, where thousands of people, children included, worked in appalling industrial conditions to produce the silver that ended up as Roman small change. Others are putting under the microscope the human excrement found in a cess-pit in Herculaneum, in south Italy, to itemise the diet of ordinary Romans, and to ask what went into – and out of – their digestive tracts, 2,000 years ago. A lot of eggs and sea urchins are part of the answer.Roman history is always being rewritten, and always has been. It is a work in progress, and the myths and half-truths of our predecessors always demand correction – as our own myths will no doubt be corrected by our successors in due course. For me, it is the one-sided thuggish image of the Romans that we especially need to re-examine. It has a harmless and humorous form, perhaps, in the tales of plucky Astérix and his struggles with the Roman legions (and that is where most of us come across it first). But it is much more misleading when it masquerades as the answer to some of the biggest questions about ancient Rome. Why did a small and very ordinary little town by the Tiber, with no obvious advantages, come to dominate first the peninsula of Italy and then most of the known world?Were they simply, as is often claimed, a community committed to aggression and conquest, built on the values of military success and little else?The Roman empire in 117CE.The fact is that Romans did not start out with a grand plan of world conquest. They did eventually parade their empire in terms of some manifest destiny, and Virgil in his national epic, the Aeneid, could in retrospect make the god Jupiter prophesy for Rome “an empire without limit”. But the motivations that originally lay behind their conquests through the Mediterranean world are far harder to pin down. One thing is certain: in acquiring their empire, the Romans did not viciously trample over innocent peoples who were minding their own business in peaceable harmony until the legions appeared on the horizon.Roman conquest undoubtedly was vicious. Caesar’s conquest of Gaul has not unfairly been compared to genocide, and was criticised by some Romans at the time in those terms. One of Caesar’s political rivals even suggested that he should be put on trial for war crimes, with the jury made up of the tribesmen he had conquered. But Rome expanded into a world not of communities living at peace with one another, but one of endemic violence, rival power bases backed up by military force (there was not really any alternative backing) and mini empires. Most of Rome’s enemies were as militaristic as the Romans, and, in our terms, as sadistic. This is where the “Astérix image” is part of the problem, with its suggestion that Caesar’s adversaries in Gaul relied on little more than wit, ingenuity and magic potion. One Greek visitor to Gaul a few decades before Caesar’s invasion reported seeing enemy heads regularly strung up as trophies outside Gallic huts – an alarming sight, he confessed, though in time one did get used to it.What cries out for explanation is not the Romans’ militaristic character or psychic aggression, but why in a world that was universally violent the Romans were so consistently more successful than their enemies and rivals. The basic answer to that has little to do with superior tactics or even with better military hardware; it has much more to do with boots on the ground. In its early centuries at least, standard Roman practice, unique in the ancient world and most of the modern, was to turn those it had defeated into Roman citizens and to convert erstwhile enemies into allies and future manpower. It was an empire built – as those desperate refugees on the Danube must have hoped, long after the policy had ceased to be feasible – on the extension of citizenship and the incorporation of outsiders.It was also an empire of which some Romans themselves were the most powerful critics. Rome was not simply the unsophisticated and badly behaved younger sibling of classical Greece, committed to engineering, military efficiency and absolutism, whereas the Greeks preferred intellectual inquiry, theatre and democracy. It suited some Romans to pretend that was the case, and it has suited many modern historians to present the classical world in terms of a simple dichotomy between two very different cultures. That is misleading, on both sides. The Greek city states were as keen on winning battles as the Romans were, and most had very little to do with the brief Athenian democratic experiment. And far from being the unthinking advocates of imperial might, several Roman writers sharply analysed the origins and effects of their interventions in the world. “They create desolation and call it peace,” is a slogan that has often summed up the consequences of military conquest. It was written in the second century CE by the Roman historian Tacitus, referring to the Roman conquest of Britain.The history of Rome lasted for well over 1,000 years (and well over 2,000 if we count the centuries of the Byzantine Romans in the east). For better or worse, Rome is ingrained in our political, cultural and literary traditions, and ways of thinking. It is a fair bet that there has not been a single day since 19BCE when someone somewhere has not been reading Virgil’s Aeneid, and it is hard to think of many other books, apart from the Hebrew Bible, of which one could say that. I am making no plea for a fan club for ancient Rome. We do the Romans a disservice if we heroise them, as much as if we demonise them. But we do ourselves a disservice if we fail to take them seriously – and if we close our long and complicated conversation with them.SOURCES:“The Guardian”Fri 2 Oct 2015 11.00 BST Mary Beard: why ancient Rome matters to the modern worldMary Beard’s SPQR: A History of Ancient Rome

Physiotherapy ManagementPrecautions and ContraindicationsPatients are at risk of hip dislocation after replacement as a result of the trauma to the hip stabilizers of the hip (capsule, ligaments and muscles) as well as due to the size difference of the prosthesis to the bones. Reduced size of the prosthetic femur head when compared to the average human femur head makes it easier to dislocate until the stabilizing tissues have healed and adapted to this smaller size[40]. This generally takes up to 6 weeks to heal.Posterior ApproachNo combination of the following hip movements on the operated side:Flexion > 90 degreesInternal rotation past neutralAdduction past midlineWeight bearing restrictions as per surgeon (mostly partial to full weight bearing for 6 weeks after surgery)Anterior ApproachHip replacements following this surgical approach is generally more stable. No specific ranges are currently linked to the precaution movements, as surgeon preference should also be taken into account.Patients are encouraged to avoid a) excessive ranges and b) combination of the following hip movements on the operated side:ExtensionAbductionExternal rotationWeight bearing restrictions as per surgeon (usually less strict than with posterior approach surgery and patients are able/allowed to mobilise unaided sooner)Pre-operativePrescribing preoperative exercise as soon as people are approved for hip surgery could play an important role towards improving preoperative quality of life, because people can wait many months for surgery and might experience further deterioration in health-related quality of life during long waits.[41] Level 2b evidence shows that physiotherapy and educational therapy may be useful for end-stage osteoarthritis.[42] A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.[43]A pre-operative assessment and treatment session is very helpful in the planning of the post-operative management of patients following a total hip replacement. Benefits include decreased length of stay[44],decreased anxiety levels[45], improved self-confidence[46] and establishing a relationship of trust between the physiotherapist and patient early on. Further benefits include improved quality of life and psychological health.[45] It also helps to develop a patient-specific rehabilitation programme to follow post-operative, taking assessment findings into consideration. The main factors defining the therapy management are the surgical approach and the general state of the patient. Whether the patient desires to gain physical fitness or wishes to recover for recreational activity should also be taken into account when establishing the rehabilitation programme.Research has shown that a combination of verbal explanation and written pamphlets is the best method for health education.[45] It is very important to incorporate this into the pre-operative physiotherapy management of patients prior to total hip replacements. Pre-operative education on precautions are liked to better post-operative adherence.[45]AssessmentSubjective historyRange of motionMuscle powerCirculationMobility and function[46]TreatmentEducation and advice:Patient information bookletPrecautions and contraindicationsRehabilitation processGoals & expectationsFunctional/ADL adaptionsSafety principlesEncourage to stop smoking if applicableDischarge planningTeach:Bed exercisesTransfers in and out of bed (within precautions)Gait re-education with mobility assestive device (crutches vs walking frame vs rollator)Stair climbingPost-operativeThe aim of post-operative rehabilitation is to address the functional needs of the patient (e.g. start mobilising) and to improve strength and range of motion. This starts off as an assisted process, but the aim is to get the patient as functional as possible prior to discharge. As a result of the underlying pre-operative pathology, patients may present with muscle atrophy and loss of strength, particularly in the gluteus medius and quadriceps muscles. The result of the loss of strength is that the elderly are less independent.[8] Although the surgery will correct the joint problems, any associated muscle weakness that was present before the surgery, will remain and require post-operative rehabilitation. Research has shown hip abductor weakness after surgery is a major risk associated with joint instability and prosthetic loosening.[9] Early postoperative rehabilitation after a total hip replacement focuses on resorting mobility, strength, flexibility and reducing pain.[10] It is found that patients can achieve significant improvements through a targeted strengthening programme following total hip replacement.[47]No specific general hip replacement protocol is currently in use, as small elements of the rehabilitation process is surgeon specific. For example, in some enhanced recovery after surgery protocols, patients are mobilised out of bed within the first 6 hours post surgery. Other settings may only start mobilising patients out of bed on day 1 or 2 post surgery. Accelerated rehabilitation programmes and early mobilisation have shown to give patients more confidence in their post-operative mobilization and activities of daily living, as well as being more comfortable with earlier discharge.[48]EvidencePhysiotherapy can improve strength and gait speed after total hip replacement and help prevent complications such as subluxation and thromboembolic disease. In addition, physiotherapy increases the patient’s mobility and offers education about the exercises and precautions that are necessary during hospitalization and after discharge.[49] (level of evidence 1a)Physiotherapy maximizes the patient’s function which is associated with a greater probability of earlier discharge, which is in turn associated with a lower total cost of care[50](level of evidence 2c).Physiotherapy provides pain relief, promotes rehabilitation and the reintegration of patients into ADLs. It also provides a better quality of life through the patients’ reintegration into social life [51] (level of evidence 1b).Level 1b evidence suggests that bed exercise following a total hip replacement does not seem to have an effect on the quality of life[52], but stays important for the effects on oedema, cardiac function and improving range of motion and muscle strength (level 4 evidence).[53]. It also allows an assessment of the physical and psychological condition of the patient right after surgery.Early weight bearing and physical activity has benefits for the quality of bone tissue[32] as it improves the fixation of the prosthesis and decreases the incidence of early loosening. The amount of activity is patient specific, and clinical reasoning should be used to make adaptions where needed. Certain specific sport movements have a higher risk of injury for unskilled individuals, and should be incorporated later in the rehabilitation process under supervision of a physiotherapist or biokinetisist.The following is a suggested protocol in the absence of complications. Surgeon preference should be taken into account, as well as any other factors that might hinder the following of the protocol. Adaptions should be made to make it more patient specific.[46][54]Day 1 Post-SurgeryEducation and adviceEducation of muscular relaxationRevision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).Bed exercises:Circulation drillsUpper limb exercises to stimulate the cardiac functionMaintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilisation on the operated hipIsometric quadriceps (progressing to consentric VMO) and gluteal contractionsActive-assisted (progressing to active) heel slides, hip abduction/adductionBed mobilisation using unilateral bridging on the unaffected legTransfer to sit over edge of bedSit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)Sitting out in chair for maximum 1 hourPostioning when transferred back to bedDay 2 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceIncorporate balance exercises if neededSitting in chairDay 3 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceStair climbing (at least 3, or as per home requirements)Sitting in chairRevision of precautions, contraindications and functional adaptionsGive 6 week progressive resistive strengthening home exercise to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)Discharge from hospitalAccelerated ProtocolCombination of day 2 & 3 to discharge patient day 2 post surgery.Only selected patients6 Weeks Post SurgeryPatients are normally followed up by orthopaedic surgeonSurgeon determine if the patient are allowed the following:Full range of motion at the hipFull weight bearing without mobility assistive deviceDrivingAfter 6 WeeksGain of initial ROM, stabilization, and proprioceptionEnduranceFlexibilityBalanceSpeed, precision, neurological coordinationFunctional exercisesOutcome MeasuresHarris Hip ScoreOxford Hip Score (OHS)6 Minute Walking TestTimed Get Up & Go TestWestern Ontario and McMaster universities osteoarthritis index (WOMAC)SF-36Fear Avoidance Belief ScoreHip Disability & Osteoarthritis Outcome Score (HOOS)International Hip Outcome ToolIbadan Knee/Hip Osteoarthritis Outcome MeasureTake Home MessageProper preoperative examination and early postoperative rehabilitation is crucial for successful outcome.ResourcesPre-operative patient workbook on "living with osteoarthritis"Related articlesTotal Knee Arthroplasty - PhysiopediaDefinition/Description Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee joint ( the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.[1] In 50% of the cases the patella is also replaced. Reasons for a patella replacement include: osteolysis, maltracking of the patella, failure of the implant. The aim of the patella reconstruction is to restore the extensor mechanism. The level of bone loss will dictate which kind of patella prosthesis is placed. [2] The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function..[3] Clinically Relevant Anatomy The Knee is a modified hinge joint, allowing motion through flexion and extension, but also a slight amount of internal and external rotation. There are three bones that form the knee joint: the upper part of the Tibia , the lower part of the Femur and the Patella. The bones are covered with a thin layer of cartilage, which ensures that friction is limited. On both the lateral and medial sides of the tibial plateau, there is a meniscus, which adheres the tibia and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule. Epidemiology /Etiology When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is Osteoarthritis [4]. Osteoarthritis causes the cartilage of the joint to become damaged and no longer able to absorb shock. There are a lot of external risk factors that can cause knee osteoarthritis. For example: being overweight; previous knee injuries; partial removal of a meniscus; [5] rheumatoid arthritis; fractures; congenital factors. There might also be some genetic factors the contribute to the development of osteoarthritis, but more research is necessary. Total knee arthroplasty is more commonly performed on women and incidence increases with age.[5] IN the US in 2008 63% of TKR operations were on women. Also a dramatic increase in TKR surgery is projected to occur with a 673% increase by 2030 in America..[6] Another trend for TKR surgery is the increasing rate of of recipients under 60, whilst initially designed as an operation for the >70 age bracket.[7] Characteristics/Clinical Presentation Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods ( this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls. Complications Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.[8] *0 5 of patients have some degree of movement limitation.[6]In addition to stiffness, the following complications can impact on function following this surgery: Loosening or fracture of the prosthesis components Joint instability and dislocation Infection Component misalignment and breakdown Nerve damage Bone fracture (intra or post operatively) Swelling and joint pain Complications as above may require joint revision surgery to be performed. Diagnostic Procedures In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered[9] Obesity is an important factor that needs to be considered prior to surgery as evidence suggests a correlation between higher body mass index (BMI) and poorer post-operative functional outcomes [10] These are the different stages of osteoarthritis that you can see at a MRI. Outcome Measures Knee disability and Osteoarthritis Outcome score (KOOS) The Timed Get Up and Go Test (TUG) Visual Analogue Scale (VAS) Range of motion (ROM) [11] Examination Subjective Assessment First the examiner should ask the patient about the history of complaints and also about expectations from surgery. The examiner should then perform a full objective examination. After this different tests could be carried out to determine whether the patient needs total knee arthroplasty: Active ROM Passive ROM Muscle power Functional tasks Post-operative Tests Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor. Palpation: post-operative swelling, hypertonia (adductors), pain and warmth. [12] Medical Management The purpose of the surgical procedure is to achieve pain free movement again, with full functionality of the joint, and to recreate a stable joint with a full range of motion. Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis. During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.[13] Physical Therapy Management Pre-operative The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.[14] Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.[15] Post-operative Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.[16] Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.[17] The optimal physical therapy protocol should also include strengthening and intensive functional exercises given through land-based or aquatic programs, that are progressed as the patient meets clinical and strength milestones. Due to the highly individualized characteristics of these exercises the therapy should be under supervision of of a trained physical therapist for best results. [18] [19] There is evidence that cryotherapy improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of cryotherapy.” [20] Common Bed and Chair Exercises [21] Ankle plantarflexion/dorsiflexion Isometric knee extension in outer range Inner Range Quadriceps strengthening using a pillow or rolled towel behind the knee Knee and hip flexion/extension Isometric buttock contraction Hip abduction/adduction Straight leg raises BridgingPartial Knee Replacement - PhysiopediaDescription A partial knee replacement (PKR) is a surgical procedure to replace only one part of a damaged knee. It can replace either the inside (medial) part, the outside (lateral) part, or the kneecap (Patellofemoral) part of the knee. With PKR, only the damaged area of the knee joint is replaced, which may help to minimize trauma to healthy bone and tissue, and also helps relieve arthritis in on or two of the three compartments of the knee. Surgery to replace the whole knee joint is called total knee replacement. Indication Partial Knee Replacement is intended for use in individuals with joint disease resulting from Degenerative, Rheumatoid and post-traumatic arthritis, and for moderate deformity of the Knee. Clinical Presentation People with advanced osteoarthritis and conservative treatments have been exhausted.[1] Mild valgus or varus deformity. Pain is often noted when performing physical activities requiring a wide range of motion in the knee joint.[2] Diagnostic Tests X-ray and MRI of the joint will reveal the joint disease resulting from Degenerative, Rheumatoid or any Post traumatic arthritis, and also moderate deformity of the Knee. The x-ray indication for a knee replacement would be weightbearing x-rays of both knees- AP, Lateral, and 30 degrees of flexion. AP and lateral views may not show joint space narrowing, but the 30 degree flexion view is most sensitive for narrowing. If this view, however, does not show narrowing of the knee, then a knee replacement is not indicated. Surgical Procedure & Types of Partial Knee Replacement Types MEDIAL PATELLOFEMORAL LATERAL BICOMAPRMENTAL Unicondylar Knee Replacement is a procedure that replaces only the single affected compartment of the knee, either the medial or lateral compartment. Patellofemoral Knee Replacement is a procedure that replaces the worn patella (the kneecap) and the trochlea (the groove at the end of the thighbone). Bicompartmental Knee Replacement is a procedure that replaces two compartments of the knee, the medial and patellofemoral compartments. Pre-operative Preparation Pre-operative preparation begins immediately following surgical consultation and lasts approximately one month. The patient is to perform range of motion exercises and hip, knee and ankle strengthening (Isometrics) as directed by Therapist. Before the surgery is performed, pre-operative tests are done: usually a complete blood count, electrolytes, APTT and PT to measure blood clotting, chest X-rays, Electrocardiogram, and blood cross-matching for possible transfusion. About a month before the surgery, the patient may be prescribed supplemental iron to boost the hemoglobin in their blood system. Accurate X-rays of the affected knee are needed to measure the size of components which will be needed. Medications such as warfarin and aspirin will be stopped some days before surgery to reduce the amount of bleeding. Patients may be admitted on the day of surgery if the pre-op work-up is done in the pre-anesthetic clinic or may come into hospital one or more days before surgery. Some hospitals offer a pre-operative seminar[3] for this surgery. Currently there is insufficient quality evidence to support the use of pre-operative physiotherapy in older adults undergoing total knee arthroplasty[4] Preoperative education is currently an important part of patient care. There is some evidence that it may slightly reduce anxiety before knee replacement surgery, with low risk of detrimental effects.[5] Weight loss surgery before a knee replacement does not appear to change outcomes.[6] Post-operative Rehabilitation The length of post-operative hospitalization is 5 days on average depending on the health status of the patient and the amount of support available outside the hospital setting.[7] Protected weight bearing on crutches or a walker is required until specified by the surgeon [8] because of weakness in the quadriceps muscle[9] To increase the likelihood of a good outcome after surgery, multiple weeks of physical therapy is necessary. In these weeks, the therapist will help the patient return to normal activities, as well as prevent blood clots,improve circulation,increase range of motion,and eventually strengthen the surrounding muscles through specific exercises. Week 1 Goals Decrease pain/swelling. Passive range of motion <90 degrees (secondary to stitches) x 2 weeks. Full weight bearing. Week 2 - 4 Goals Decrease pain/swelling. Tolerate bilateral stationary cycling. Active range of motion 0-90 degrees. Week 4 - 6 Goals Normal gait pattern. Week 6 - 8 Goals Active range of motion 0 to 110 degrees. Passive range of motion 120 degrees. Week 8 - 12 Goals Road cycling. Walk downstairs with reciprocal gait. Full range of motion.[10] Treatment includes encouraging patients to move early after the surgery. [11] Often range of motion (to the limits of the prosthesis) is recovered over the first two weeks (the earlier the better). Over time, patients are able to increase the amount of weight bearing on the operated leg, and eventually are able to tolerate full weight bearing with the guidance of the physical therapist. After about ten months, the patient should be able to return to normal daily activities, although the operated leg may be significantly weaker than the non-operated leg.[12] For knee replacement without complications, continuous passive motion (CPM) can improve recovery. [13]Additionally, CPM is inexpensive, convenient, and assists patients in therapeutic compliance. However, CPM should be used in conjunction with traditional physical therapy. In unusual cases where the person has a problem which prevents standard mobilization treatment, then CPM may be useful. Contra-indications & Common Side-Effects Key Evidence Some physicians and patients may consider having lower limbs venous ultrasonography to screen for deep vein thrombosis after knee replacement.However, this kind of screening should be done only when indicated. If a medical condition exists that could cause deep vein thrombosis, a physician can choose to treat patients with cryotherapy and intermittent pneumatic compression as a preventive measure.[14] Partial Knee EReplacement surgery is not appropriate for patienst with certain types of Infections, any mental or Nueromuscular disorder which would create an unacceptable risk of prosthesis instability, prosthesis fixation failure or complication in postoperative care, skeletal immaturity, severe instability of the knee or Excessive body weight. Comom side effects:as with any surgery, PKR has its risks which may be Implant related risks which may lead to a revision include dislocation, loosening, fracture, nerve damage, heterotropic ossification, wear of the implant, metal sensitivity, soft tissue imbalance, osteolysis(localized progressive bone loss) and reaction to particle debris. Knee implants may not provide the same feel or performance characteristics experienced with a normal healthy joint.Partial Hip Replacement - PhysiopediaDescription Partial Hip Replacement is a surgical procedure used to replace half of the hip joint. The operation involves replacing the ball of the femur that has worn from arthritis, degeneration, or a serious fracture involving the ball of the hip joint. Normal motion becomes restricted and painful with advanced wear of the hip joint.[1] Indication A fractured neck femur, where the fracture occurs just below the ball-and-socket hip joint causing the ball to get disconnected from the rest of the thigh bone or femur. Blood supply to the fractured portion of bone is often disrupted at the time of injury and is at high risk of not healing when the fracture is badly displaced. Osteoarthritis: the degeneration of cartilages located at the end of the hip bones. Rheumatoid arthritis: the inflammation of the synovial membrane in the hip joints causing abnormal production of synovial fluid. Traumatic arthritis, from hip fracture or severe hip injury. Avascular necrosis where the head of the femoral bone dies due to lack of blood supply, and many other degenerative diseases are also factors that lead to broken the head of femur.[2] Note: [Partial hip replacement is only recommended on occasion and generally when the patient is elderly and in poor health, because metal prosthesis bearing against bone is not the optimal solution. It can result in wear on the bone and possibly even to the point of wearing away the base of the socket. For this reason, certain patients (young and very able and active older patients) may have a total hip replacement.][3] Clinical Presentation add text here relating to the clinical presentation of the condition Diagnostic Tests add text here relating to diagnostic tests for the condition Pre-Op add text here relating to the pre-operative advice Post-Op add text here relating to post-operative rehabilitation Key Evidence add text here relating to key evidence with regards to any of the above headings Resources add appropriate resources here Case Studies add links to case studies here (case studies should be added on new pages using the case study template)Total Ankle Arthroplasty - PhysiopediaWhat is an Ankle Arthroplasty? Ankle arthroplasty is when the ankle joint (Talocrural Joint) is replace with prosthetic components comprised of polyethylene and metal and is preferred to ankle arthrodesis (fusion) as range of movement and function an not compromised. Main objectives of the arthroplasty are to Replicate ROM of the talocrural joint Function well under weight bearing Be wear resistent Maintain alignment and stability History of Total Ankle Arthroplasty Ankle replacement surgery has been available for over two decades however it is a far less common procedure than hip or knee arthroplasty owing to the less frequent incidence of osteoarthritis ankle pathology. The majority of ankle osteoarthritis is secondary to trauma.[1] Until relatively recently, ankle joint arthrodesis (fusion) was the gold standard of treatment, but this was not without its complications, e.g. non-union, osteoarthritis in the other mid/hind foot joints and stiffness and loss of proprioception[2] Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthesis loosened or malfunctioned and frequently needed to be removed[3]. In the late 70's Dr. Frank G. Alvine an orthopedic surgeon from Sioux Falls, SD developed the Agility Ankle which was the first FDA approved total ankle implant in use in the United States[4]. Since its introduction the Agility Ankle System has gone through several modifications. Currently the Agility Ankle System is the most widely used ankle prosthesis. With more than 20 years of experience it has the longest followup of any fixed bearing device[5]. On May 29, 2009 the medical news today announced the FDA approved the first mobile bearing device called the Scandinavian Total Ankle Replacement System (STAR). As a condition of FDA approval the company (Small Bone Innovations Inc.) must evaluate the safety and effectiveness of the device during the next eight years[6]. In a systematic review of the literature published in the Journal of Bone and Joint Surgery in 2007, the intermediate outcome of total ankle arthroplasty appears to be similiar to that of ankle arthrodesis however data was sparse[7]. In a study comparing reoperation rates following ankle arthrodesis and total ankle arthroplasty SooHoo, Zingmond and Ko confirmed that ankle replacement is associated with a higher risk of complications as compared with ankle fusion, but also has potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion[8]. In a seven to sixteen year follow up on the Agility Total Ankle Arthroplasty, Knecht, Estin, Callagham et al concluded that the relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging[9]. Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent pratitioners. In addition no level I or II studies have been published[10]. Poor patient satisfaction, high rates of revision due to loosening, and high wound complications rates were all very problematic when total ankle arthroplasty (TAA) surgeries were first introduced in the 1970’s.[11] In 1990, noncemented prostheses were shown to allow for bony ingrowth and less bone removal as compared to cemented.[11] Beyond the transition to cementless, further advances in technology over the years has led to new surgical arthroplasty techniques, primarily moving from a two-component design to a 3-component model. An observational study analyzed advantages of arthroplasty over arthrodesis stating individuals with monoarticular or polyarticular disease who undergo arthroplasty have less gait abnormalities and fewer adverse effects to other joints in the lower extremity.[12] A systematic review provided that in 852 individuals undergoing TAA's, there was a 78% implant survival 5 years post-op and 77% at 10 years post-op and overall only had a 7% revision rate. This provides evidence that the procedure yields satisfactory results and should be considered for potential candidates that are appropriate for surgical corrections.[13] The Arthroplasty Indication for Procedure There is no well-defined indication for a Total Ankle Arthroplasty. Surgery is considered only when conservative treatment has been attempted with no improvement. The operation is mainly being executed in patients who suffer from different types of arthrides. This cause advanced arthritic changes of disabling pain and loss of ankle motion. The ankle is most frequently affected by post-traumatic arthritis.[14] Total ankle joint replacement is also indicated following unsuccessful ankle arthrodesis [15] the ‘ideal’ patient for ankle joint replacement is an elderly person with the low physical demands who has good bone stock, normal vascular status, no immune-suppression, and excellent hind foot-ankle alignment.[16] Generally here are common indications for arthroplasty: Primary or post-traumatic osteoarthritis Severe rheumatoid arthritis Rejected arthrodesis Indications: According to Saltzman, there are no exact indications for receiving a total ankle arthroplasty.[17] The “ideal” patient who would typically undergo this intervention is one who is elderly with a healthy immunity, normal vascular status, good bone density, and a proper hindfoot-ankle alignment who has not had success with conservative treatment measures. Individuals with debilitating ankle arthritis, unresponsive to nonoperative approaches, or have failures with the outcome of their ankle arthroplasty are typically treated with an arthrodesis procedure to fuse the joint. Contraindications: Arthroplasty is contraindicated for those with neuroarthropathic degenerative joint disease, infection, avascular necrosis of the talus, osteochondritis dessicans, malalignment of the hindfoot-ankle, severe benign joint hypermobility syndromes or soft tissue problems, or decreased sensation or motion in the lower extremities.[11] In individuals with rheumatoid arthritis (RA), inflammatory processes may occur before signs of swelling, tissue reaction, and joint destruction are seen. In the first and second year of this disease process, structural damage (ie. joint erosion) can be seen with X-ray imaging.[18] Diabetic patients may develop gouty arthritis in their ankle joint. This is caused by uric acid changing into urate crystals, which is deposited into the joint.[18] Thus, RA and diabetic individuals may or may not be candidates for ankle arthroplasty depending on the severity of joint degeneration found with radiographic imaging. Common contraindications are: Severe talus subluxation, severe valgus or varus deformity Substantial osteoporosis Neurological disorders or recurrent infection Pre-operative Procedure and Definitive Diagnosis Weight bearing A-P and lateral mortise views of bilateral ankles is required to make effective preparation and anticipation of that will be required in the surgery. The rearfoot alignment (Cobey/Saltzman) view is essential to evaluate the ankle joint and identify any calcaneal-totibial deformities. This is performed by getting the patient to stand, elevated with a cassette positioned at 15 degres anteriorly inclined with the x-ray bemed perpendicular to the film. This position is altered if deformities are present, after this has been taken anterior distal tibial angle (ADTA) is measured. The ADTA is formed by the mechanical axis of the tibia and the joint orientation line of the ankle in the sagittal plane and measures 80° ± 3° in the normal lower extremity. In the coronal plane, the lateral distal tibial angle (LDTA), the tibial-talar angle and the calcaneal tibial alignment should be measured. The LDTA is formed by the distal tibial articular surface and the anatomical axis of the tibia and measures 89° ± 3°.29, if this is decreased this represents a varus deformity. The tibial-talar angle (Figure 3C) is defined by the tibial and talar articular surfaces in the ankle joint. When the tibialtalar angle is >10° the joint is defined as incongruent (unstable)[19]. "If an abnormal ADTA or LDTA is present (sagittal or coronal deformity), the center of rotation of angulation (CORA) is measured. The CORA is the intersection of the mid-diaphyseal line and the line starting from the middle of the joint and perpendicular to the abnormal ADTA or LDTA (Figure 4). The CORA can be located at the joint line level (usually due to anatomical joint line malalignment or to ankle degeneration) or proximally (usually due to tibial deformities/fractures)"[19]. So as you can see there are many consideration to be taken, and multiple angles to be analysed and this is important and any instability and malalignment of the new prosthesis can be excessively worn or may even fail[19]. Medical Management First generation: Early ankle prosthesis attempts involved cementing a stemmed metal ball into the tibia and a polyethylene cup cemented into the talus. Throughout the 1970’s, prosthesis evolved into using a vitallium component cemented into the talus. All designs used methylmethacrylate cement, which became the defining element of first generation prosthesis.[11] Types: Constrained - Increased stability due to only allowing dorsiflexion and plantarflexion. Loosening of the prosthesis was common from increased torque at the joint.[11] Nonconstrained - Allows full ROM, resulting in decreased stability that commonly caused impingement against the medial and/or lateral malleoli. Semiconstrained - A combination of contrained and nonconstrained models, allowing greater ROM and medial-lateral stability. The Imperial College, London Hospital prosthesis uses a concave polyethylene in the tibia and a stainless steel component on the talus.[11] Unfortunately, by the early 1980’s, first generation ankle arthroplasties were not recommended by the majority of orthaepedic surgeons. Numerous studies showed loosening of the cement fixation, wound issues, and low patient satisfaction [17][11]. As a result of the poor outcomes and high complication rate, surgeons began to recommended ankle arthrodesis. Second generation: Second generation arthroplasties are cementless, using bony ingrowth to stabilize the implant. Compared to cement, bony ingrowth prosthesis have less bone resection, damage to soft tissue and complications of the cement such as cement displacement[17]. Surgical Factors: Fixation: Ingrowth implants tend to have either a beaded surface along the bony interface, hydroxyapatite layer or a combination of both. Current surgical designs tend to use the combination fixation technique.[11][17] Between types of prosthesis the number of articulating surfaces and components both need to be considered.[17][11][20]. Components: Articulating surfaces: Current designs vary on the articulations that need to be resurfaced. Resurfacing may occur at the superior tibiotalar joint, superior and medial articulations, or medial, lateral, and superior joints.[11] Determining which patients would benefit the most from each type of surgery is ongoing.[17] Design components: 2 component implants include a tibial and talar articulating component. Implants may also incorporate syndesmosis fusion to resurface the medial and lateral recesses of ankle and converting the ankle from a 3-bone joint to a 2-bone joint. Known designs: Agility, Salto Talaris, Eclipse, INBONE Advantages: decreased shear and torsion on prosthesis[21], syndesmosis decreases shear force and increase the bony support for the tibial component[17] Disadvantages: increased bony resection, likelihood of soft tissue compromise, accelerated polyethylene wear, and possibility of syndesmosis fusion failure.[17] 2 Component Ankle Replacement Examples Salto Talaris Agility 3 component implants include a “mobile bearing” of polyethylene between the tibial plate and talar component. Known designs: Buechel-Pappas, Scandinavian Total Ankle Replacement (STAR), Mobility, HINTEGRA Advantages: low polyethylene wear rates, allow multiplanar motion[11], increased congruency, minimal bony resection[17][21] Disadvantages: mobile bearing segment may dislocate, more involved surgery, abnormal ligamentous stress due to malalignment of axis of rotation[17][11] 3 Component Ankle Replacement Examples STAR Buechel Pappas Both component designs permit semiconstrained motion, specifically allowing some inversion and eversion during sagittal plane ankle movement. The four 2 component designs have been approved by the U.S. Food and Drug Administration (FDA). The STAR was recommended for approval by the FDA in 2008.[22][21] There is insufficient evidence determining the life expectancy of current prosthesis designs.[21] Surgical Procedure To perfrom the procedure the patient is positioned supine with the hip slightly elevated and a tourniquet on the proximal thigh to restrict blood flow during the procedure. Next a 10 cm incision is made over the centre of the joint line to expose the relevent anatomical structures. Once the structures have been exposed the crucial nerves and tendons are identified as to protect and ensure their integrity to minimise operative complications, these include; peroneal nerves, tibialis anterior and extensor hallucis longus. This is also to achieve correct talocrural alignment and soft tissue balance to ensure the prosthesis can achieve plantar grade in standing. It is also important to debride and correct any osteophytes or any other structures that can contribute to malalignment. Depending on the natural angle of the talocrural joint (varus or valgus) more bone medially or laterally may have ot be removed, this also may occur if the joint is deep or shallow as it may need to be reduced or elevated[19]. Once the joints have been corrected and bones properly aligned the new components are trialed making sure rull ROM and stability is achieved. If dorsiflexion is limited and not due to malalignment then achilles tendon lengthening is required, the same goes for if there is instability in inversion or eversion the ligaments are reconstructed. Persistent malalignment can occure and may need separate procedures to correct such as subtalar fusion depending on severity and correctability[19]. Alternate Option: Ankle Arthrodesis Ankle arthrodesis or fusion was the recommended surgical option after the failure of the first generation ankle arthroplasty. The procedure includes resecting the articular surfaces of the joint, realignment the talus and tibia and fusing the bones together. As a result, the ankle joint doesn’t allow any motion. The goal of ankle arthrodesis is pain relief.[23][20] Unfortunately, the lack of ankle motion can cause elevated stress on the knee and hindfoot and in addition, increases motion at the hindfoot that may become arthritic.[11] Other complications of fusion include accelerated degeneration of adjacent joint and limitations in activity.[21] [24] Outcome Measures Foot and Ankle Disability Index Foot Function Index (FFI) Foot and Ankle Ability Measure (FAAM) Physical Therapy Management As it will be explained in the pre-operation and post-operation phase the multi-disciplinary team involved with the patient have a big role in making the arrangements before and after the surgery, this may involve physiotherapists, occupational therapists, discharge nurses, staff nurses, healthcare assistants as well as doctors. Both pre and post operative phases are integral to the progress of the patient and the pre-op should not be overlooked as important as it can be easy to focus on post-op. Pre-Operative Phase Before the surgery one of the main job for the team is to educate the patient about what will happen before, during and after the surgery as this will give the patient the opportunity to prepare, mentally rehearse, ensure smooth transition through short-term to long-term goals but also help control and reduce post-operative pain[25] (level of evidence 3B) ROM, muscle strength, gait and deviations will all be recorded as to compared before and after arthroplasty and ensure the patient is as optimal strength prior to operation if possible. For safety and ease of transition is can be important that the patient learns how to walk with crutches so they can perform ADL’s as soon as possible post arthroplasty but also understand that they will be non-weight bearing after the arthroplasty[26].(Level of evidence 4) As will all procedures under general anesthetic there are common pulmonary postoperative complications (PPC's) which need to be controlled and risk reduced and this can be explained at this stage as well. Post-Operative Phase It is important to ensure the risk of PPC's are reduced and respiratory physiotherapy may be used at this early stage, cough, deep breathing exercises and early mobility are essential here to reduce atelectasis and reinstate the muscoscilliary elevator as soon as possible. Atelecatsis occurs in 90% of anesthetized patients which leads to a 16-20% reduction in functional residual capacity which is why the alveoli tend collapse resulting in increased work of breathing, hypoxia, reduced compliance, V/Q mismatch and risk of pneumonia[27][28].(Level of evidence 5)T(Level of evidence 5)here is a 9% chance of developing pneumonia and this is where physiotherapy intervention is crucial at reducing the rate of all of these complications[29].(Level of evidence 5) IT IS IMPORTANT TO KNOW YOUR OWN HOSPITALS/SURGEONS GUIDELINES FOLLOWING ARTHROPLASTY OR ANY OPERATION AND THE FOLLOWING SHOULD ONLY BE USED TO EDUCATE AND CONSIDER SOME BASIC/COMMON PROTOCOLS THIS SHOULD NOT BE USED IN REPLACEMENT OF THE SURGEONS PROTOCOL THIS IS A PROTOCOL BY THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST[30], utilising the best available evidence[31][32][33][34][35][36] As can be expected after any type of surgery, pain and inflammation must be controlled. This is the case especially after ankle replacement because pain and inflammation can last up to 12 months after surgery.[37] Surrounding muscles can be damaged during surgery and can result in decreased range of motion and strength.[38][39][40] Damage to joint proprioceptors during excision of the capsule may cause deficits in both static and dynamic balance.[41][42] These components can lead to gait disability and decreased efficiency of locomotion.[43] Correction of gait posture and ambulation deficiencies will be a target of therapy once the patient is ambulating independently. Physical Therapy Goals: Decrease pain Decrease inflammation Increase strength Increase range of motion Improve dynamic and static balance Improve proprioception Proper independent ambulation Assessment Mechanism of injury or etiology of illness Date of surgery and type of implant Use of assistive device with weight bearing status Use of controlled ankle motion (CAM) walker/walking boot Functional deficits/assistance with ADLs/adaptive equipment Pain/ Symptom history: Location, duration, type, intensity (VAS), aggravating and relieving factors, 24 hour symptom behavior Relevant Current/Past Medical history: Other lower extremity arthritis or injuries,upper extremity issues that may limit ability to ambulate with an AD and comorbid diagnoses Medications for current/previous diagnoses Diagnostic tests Sleep disturbance Barriers to learning Social/occupational history Patient’s goals Vocation/avocation and associated repetitive behaviors Living environment Relevant Tests & Measures: Observation/inspection/palpation: Skin and incision assessment, edema, muscle atrophy Circulation: Dorsal pedal pulse Sensory and proprioception testing Range of motion and Muscle length: Average postoperative arc of motion (dorsifexion and plantarfexion) is 23°[44][45] Muscle strength Posture: Increased pronation/supination in standing, ability to maintain wait bearing status Assess assistive and adaptive devices for need and proper fit Balance: Static and dynamic standing balance, unilateral balance of the unaffected extremity (especially if patient is still non-weight bearing).[44] Patient may demonstrate dynamic postural imbalance, less reliance on ankle strategy and deficit of motor control ability[41] Functional mobility American Orthopaedic Foot and Ankle Society ankle-hindfoot score[46], Outcome measures Self-selected normal walking speed[47] Assess safety in mobility Gait Assessment[44] Initial Rehab 0-4 Weeks Restrictions: Non-weight bearing 2/52 with a back slab Below knee POP at 2/52 and begin full weight bearing in this POP POP removed at 4/52 and aircast boot is considered Elevation If sedentary employment, return to work at 4/52 as long as elevated and protected Goals: Safe and independent mobility with walking aid Independent with exercise programme Know monitoring and protection Treatment: POP Pain-relief POLICE Basic circulatory exercises Mobility Progress when: Out of POP, fully weight bearing, no complications and then refer to physiotherapy out patients Recovery Rehab 4 weeks - 3 months Restrictions: No strengthening against resistance until 3 months if any tendon transfers No stretching tendons if transferred Goals: Independent from aircast boot Achieve full ROM Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Full ROM, independently mobile, neutral foot position in standing Intermediate Rehab 12 weeks - 6 months Restrictions: None Goals: Independent with no aids Normal footwear Grade 5 strength Grade 4 strength in tendons transferred Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Normal footwear, independent with no aids, pain controlled, strength 5/5 (4/5 if tendon transferred) Final Rehab 6 months - 1 year Goals: Return to gentle no-impact/low impact sports Grade 5 strength in transferred tendons Treatment: Maximise function End stage exercises, balance and proprioception and sport specific Manual therapy Muscles to Consider Here is a unfinished list of some of the major muscles of the lower leg and foot, consider these in your rehabilitation and mechanism of pathology. Some may have had tendons moved or stretched and now need to be specifically rehabilitated as the proprioceptive function may now have changed. Posterior Compartment - Superficial Gastrocnemius Plantaris Soleus Posterior Compartment - Deep Popliteus Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Posterior Lateral Compartment Peroneus Longus Peroneus Brevis Anterior Compartment Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Tertius Sample Exercises Balance c perturbation Ball toss Standing reach Standing reach Seated rocker board DF theraband Ankle eversion DF stretch Ankle PF Additional Information After the surgery it is important that the patient keeps moving and performing his daily activities. However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically. However it’s the job of the physician to try to improve: the patient’s ROM of the ankle, maintain the ROM in the hip and knee, increase the muscle strength with exercise for the Gluteus Maximus, Quadriceps femoris muscles and the muscles that are responsible for dorsal flexion and the plantar flexion of the ankle[48]. Postoperative mobilization begins early, with rapid progression to resumption of normal activities.[49] The goal is to obtain 10° of dorsal flexion and 30° of plantar flexion. For patients who have almost no motion in their ankle is any motion an improvement.[50] In early postoperative period it is important that the incision heals and the implant becomes solidly fixed to the bony bed to do this they will use a below knee non-weight bearing immobilization. This is maintained until there is satisfactory bony in growth. [51]. Another goal is to increase the ROM of the ankle and maintain the hip and the knee ROM. After a few months the patient needs to make an appointment with the doctor. Here they will take X-ray scans to see if there are no complications like: joint debridement for osseous impingement; the next most common procedures were extra-articular procedures for axial misalignments and component replacements.[52] Prognosis & Outcome Outcome of ankle arthroplasty includes pain, function implant survival and complications. There are numerous studies looking at survival rate of implants and rates are reported around 67-94% at 5 years[53][54][55] and 75% at ten years[53] which is reasonably reliable. A systematic review of intermediate and long term outcomes of arthrolplasty and arthrodesis performed by Haddal et al[56] had interesting results. It reviewed 49 primary studies of 1262 patients and utilised the AOFAS score (Americal Orthopaedic Foot and Ankle Society). This score is out of 100 (0=worst outcome, 100=best outcome) broken into 8 sections of pain, function walking distance, walking surface, gait abnormality, sagittal mobility, hindfoot mobility, ankle hindfoot mobility and alignment. The score has mixed reviews and the objective aspect of the score is hard to make reliable between therapists[57]. The mean AOFAS score was 78.2 points for the patients treated with total ankle arthroplasty and 75.6 points for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% and the ten-year survival rate was 77%. The revision rate following total ankle arthroplasty was 7% with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% , with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group. Their conclusion was that on the basis of these findings, "the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion"[56]. Resources [58] [59] [60] [61]Physical Activity Pre and Post Surgery - PhysiopediaBenefits of Exercise Pre and Post Surgery The effect of exercise on outcomes after surgery has been extensively studied in a number of populations. The most common populations studied are Those post- hip replacement Those post- knee replacement Those post- cardiac surgery Those post- abdominal surgery Other surgical groups such as colorectal, thoracic, post- cancer resection, vascular and urological Whilst the evidence is good in general terms, unfortunately, as yet there is no clear consensus on the specifics of exercise prescription pre-surgery[1]. Studies can be divided into those that look at the effect of interventions pre-operatively on post- surgical outcomes and those that look at the effect of different exercise interventions post- surgery. What Are the General Benefits of Preoperative Exercise? The evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of complications in the postoperative period is compelling, with several studies demonstrating this across different types of surgeries[2][3][4][5][6][7] The measure of CRF also offers significant advantage when compared to age alone in predicting mortality after major surgery[5]. CRF is a significant independent predictor of length of stay in hospital with patients older than 75 A low CRF is associated with an average of 11 days longer in hospital and 2 days longer in critical care Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. It also exerts beneficial effects on physical fitness and postoperative outcomes measures across various surgical fields.including cardiac surgery, orthopedic surgery, abdominal surgery, thoracic surgery, vascular surgery and urologic surgery[9]. In their scoping study, Pouwels et al (2016) conclude that more research is needed to focus on heterogeneous outcome measures, patient populations and guidelines for exercise regimes[9]. What Are the Benefits of Preoperative Exercise in Specific Populations? Hip Replacement In patients undergoing this surgery, significant improvements (small to moderate effect sizes) have been observed in pain, function, and length of stay with exercise interventions preoperatively. [10] Knee Replacement A 2014 systematic review (Chesham and Shanmugham) concluded that there is minimal evidence so far supporting education and exercise interventions pre-operatively, compared with no physiotherapy or usual care. Interventions reviewed in the 10 RCTs were preoperative exercise; combined exercise and education; combined exercise and acupuncture; neuromuscular electrical stimulation; and acupuncture versus exercise. Outcomes assessed were knee strength, ambulation, and pain. Good quality research into this is ongoing[11]. However Moyer et al (2017) in their systematic review and meta analysis found small to moderate effect sizes for pre-rehabilitation in this population. Significant improvements were made in function, quadriceps strength and length of stay.[10] Cardiac Surgery A Cochrane review in 2012 found that evidence from small trials suggests that preoperative physical therapy, with an exercise component, for elective cardiac surgery patients reduces postoperative pulmonary complications and length of hospital stay. They concluded that there is a lack of evidence to effect changes to postoperative pneumothorax, or prolonged mechanical ventilation[12]. It has been known for some years that inspiratory muscle training provided pre-operatively reduces the risk of anaesthetic complications as well as reducing post-operative complications[13] as well as length of postoperative hospital stay and pulmonary function[14]. Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. Abdominal Surgery O'Doherty et al (2013) in their systematic review conclude that pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but 'prehabilitation' consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease postoperative complications after intra-abdominal operations.[15] Other Mixed Populations A systematic review in 2010 found that preoperative exercise therapy is effective for reducing both postoperative complication rates and length of hospital stay after cardiac or abdominal surgery[16]. A Cochrane review in 2015 concluded that preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications (such as actelectasis and pneumonia) and length of hospital stay compared with usual care in adults undergoing cardiac and major abdominal surgery[17]. Colorectal Surgery A study on patients undergoing colorectal surgery found benefits from exercise programmes pre-operatively: improved physical function, peak exercise capacity, mental health and self-perceived health[18] Cancer-resection surgery A Cochrane review in 2017 found low quality evidence that preoperative exercise training may reduce some risks in those having lung resection surgery for early stage non-small cell lung cancer (NSCLC).[19]. These were- developing postoperative pulmonary complications, duration of intercostal catheter use, a reduced postoperative length of stay and improved exercise capacity and FVC post-operatively. [19] What Are the Benefits of Post-Operative Exercise? There is clear evidence for the following surgeries: Spinal surgery - improved spinal mobility[20] Total Hip and Knee Replacement surgery - earlier discharge[21] Colorectal surgery - increased cardiovascular fitness[22] Breast surgery - fewer side-effects[23] In many surgeries: reduced risk of blood clots[24] Cardiac surgery - inspiratory muscle training on length of postoperative hospital stay and pulmonary function [14] Contraindications to Exercise Pre/Post Surgery In addition to the absolute contraindications (see the Exercise Physiology page), specific precautions will apply depending on the surgery. The treating team ( Doctors, Nurses, Physiotherapists) will give the patient specific advice on this. Resources The Motivate2Move website, created by Wales Deanery, has a comprehensive section on surgery and exercise.ReferencesLevine BR, Klein GR, Cesare PE. Surgical approaches in total hip arthroplasty: A review of the mini-incision and MIS literature. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):5-18.Learnmouth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007; 370: 1508–19.University of Stellenbosch, Advanced orthopaedic training center. Orthopaedic referral guidelines, Tygerberg Hospital 2013 - Arthroplasty unit. http://www0.sun.ac.za/aotc/referrals/guidelines/Arthroplasty.pdf (accessed 26/06/2018).Iglesias SL, Gentile L, Mangupli MM, Pioli I, Nomides RE, Allende BL. Femoral neck fractures in the elderly: from risk factors to pronostic features for survival. Journal of Trauma and Critical Care. 2017;1(1).Meyers HM. Fractures of the hip, Chicago: Year of the book medical publishers Inc.,1985Trudelle-Jackson E, Smith SS. Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial. Archives of physical medicine and rehabilitation 2004;85(7):1056-62.Meyers HM. Fractures of the hip. Chicago: Year of the book medical publishers Inc., 1985Gremeaux V, Renault J, Pardon L, Deley G, Lepers R, Casillas JM. Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial. Archives of physical medicine and rehabilitation 2008;89(12):2265-73.Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. Effects of a home program on strength, walking speed, and function after total hip replacement. Archives of physical medicine and rehabilitation 2004 ;85(12):1943-51.Stockton KA, Mengersen KA. Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(10):1652-7.Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(5):745-55.Crawford AJ, Hamblen DL. Outline of Orthopaedics , thirteenth edition, London: Churchill Livingstone, 2001Batra S, Batra M, McMurtrie A, Sinha AK. Rapidly destructive osteoarthritis of the hip joint: a case series. Journal of orthopaedic surgery and research 2008;3(1):3.Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.Brunner LC, Eshilian-Oates L, Kuo TY. Hip fractures in adults. American family physician 2003;67(3):537-42.Kingma MJ, Koekenberg LJL, Van Linge B, Van Rens THJG, Sijbrandij S. 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Philidelphia, PA: Lippincott Williams and Wilkins, 2009.Oldenrijk JV, Hoogland PV, Tuijthof GJ, Corveleijn R, Noordenbos TW, Schafroth MU. Soft tissue damage after minimally invasive THA. Acta Orthopaedica 2010; 81 (6): 696-702Zhang XL, Shen H, Qin XL, Wang Q. Anterolateral muscle sparing approach total hip arthroplasty: an anatomic and clinical study. Chinese medical journal. 2008 Aug;121(15):1358-63.Röttinger H. Minimally invasive anterolateral surgical approach for total hip arthroplasty: early clinical results. Hip International 2006;16(4):42-7.Sköldenberg O, Ekman A, Salemyr M, Bodén H. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach: a prospective study of 372 hips. Acta orthopaedica 2010;81(5):583-7.Alecci V, Valente M, Crucil M, Minerva M, Pellegrino C, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthopaed Traumatol 2011;12:123-129.Verywell Health. Orthopedics - hip and knee - replacement http://implants.http://orthopedics.about.com/od/hipkneereplacement/a/implants.htm (accessed 23/07/2018).Bader R, Steinhauser E, Zimmermann S, Mittelmeier W, Scholz R, Busch R. Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability against dislocation of total hip replacement. Journal of materials science: materials in medicine 2004;15(6):711-8.Garcia-Rey E, Cruz-Pardos A, Garcia-Cimbrelo E. Alumina-on-alumina total hip arthroplasty in young patients: diagnosis is more important than age. Clinical Orthopaedics and Related Research 2009;467(9):2281-9.Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties: relation to implant failure and pseudotumor formation. Acta orthopaedica 2009;80(6):653-9.Zimmer Biomet. The E1™ Antioxidant Infused Technology Process. E1- Vitamin E infused polyethylene for hip and knee replacement bearings (accessed 2506/2018).Lindalen L, Nordsletten L, Høvik Ø, Röhrl SM. E-Vitamin Infused Highly Cross-Linked Polyethylene: RSA Results from a Randomised Controlled Trial Using 32 mm and 36 mm Ceramic Heads. Hip International 2015;25(1):50 - 55Dargel J, Oppermann J, Brüggemann G, Eysel P. Dislocation Following Total Hip Replacement. Dtsch Arztebl Int 2014;111:51-52.Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg 2015;58(2):128–139.Oliveira CA, Candelária IS, Oliveira PB, Figueiredo A, Caseiro-Alves F. Metallosis: A diagnosis not only in patients with metal-on-metal prostheses. European journal of radiology open. 2015 Jan 1;2:3-6. Available from: Metallosis: A diagnosis not only in patients with metal-on-metal prostheses (last accessed 24.2.2019)American Association of Orthopaedic Surgeons. Total hip replacement. Total Hip Replacement - OrthoInfo - AAOS (accessed 25/06/2018).Partridge T, Jameson S, Baker P, MBBS, Deehan D, Mason M, Reed MR. Ten-Year Trends in Medical Complications Following 540,623 Primary Total Hip Replacements from a National Database. J Bone Joint Surg Am 2018;100(5):360–367.Mirza S, Dunlop D G, Panesar S, Syed G N, Shafat G, Saif S. Basic Science Considerations in Primary Total Hip Replacement Arthroplasty. The Open Orthopaedics Journal. 2010;4,169-180Gill SD, McBurney H. Does Exercise Reduce Pain and Improve Physical Function Before Hip or Knee Replacement Surgery? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. 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News, sport and opinion from the Guardian's US edition | The GuardianMary Beard: why ancient Rome matters to the modern worldFailure in Iraq, debates about freedom, expenses scandals, sex advice … the Romans seem versions of ourselves. But then there’s the slavery and the babies on rubbish heaps. We need to understand ancient Rome, but should we take lessons from it?Illustration by Richard Wilkinson.Mary BeardFri 2 Oct 2015 11.00 BSTBy the late fourth century CE the river Danube had become Rome’s Calais. What we often call the “invasions” into the Roman empire of barbarian hordes (or “swarms”, perhaps) could equally well be described as mass movements of economic migrants or political refugees from northern Europe. The Roman authorities had no better idea of how to deal with this crisis than our own authorities do, and, predictably, they were less humane. On one notorious occasion, uncomfortable even for some Roman observers, they sold dog-meat as food to the asylum-seekers who had managed to get across the river (dog was off limits for human consumption then as now). It was just one stage in a series of standoffs, compromises and military conflicts that eventually destroyed central Roman power in the western part of their empire. And it was exacerbated by the calculating policy of the Romans in the east, who by this era effectively formed a separate state. Their solution to the crisis of migration was to point the migrants firmly westwards, and try to make them someone else’s problem.It’s tempting to imagine the ancient Romans as some version of ourselves. They launched disastrous military expeditions to those parts of the world where we too have failed. Iraq was as much a graveyard for the Romans as it has been for us. And one of their worst defeats, in 53BCE at the hands of a rival empire in the east, took place near the modern border between Syria and Turkey. In a particularly ghoulish twist, uncomfortably reminiscent of the sadistic showmanship of Islamic State, the head of the Roman commander was cut off and used by the enemy as a makeshift prop in a performance of Euripides’ play The Bacchae – in which the head of King Pentheus, horribly decapitated by his mother, takes a macabre starring roleBack in Italy too, Roman life had a familiar side. Urban living in a capital city with a million inhabitants, the biggest conurbation in the west before the 19th century, raised all the usual questions: from traffic congestion (one law tried to keep heavy vehicles out of the city during the day, with the knock-on effect of appalling noise at night) to rudimentary planning problems (exactly how high were high-rise blocks allowed to be, and in what materials to make them safe from fire?). Meanwhile the political classes worried about everything from expenses scandals to benefits scroungers. There was endless, and largely unsuccessful, legislation aimed at preventing officials lining their own pockets out of the public purse. Even the famously upright Marcus Tullius Cicero – politician, poet, philosopher and jokester – left one overseas posting with a small fortune in his suitcase; he had apparently been “economical” with his expenses allowance.AdvertisementThere was also endless debate over the distribution of free or subsidised grain to citizens living in the capital, one half of the infamous pair of “bread and circuses”, which, according to a hard-nosed Roman satirist, had sapped the political energy and independence of the people. Was this a proper use of the state’s resources and a precedent to be proud of – the first time any state in the west had decided to guarantee the basic subsistence of many of its citizens? Or was it an encouragement to idleness, and an extravagance that the exchequer could not afford? One rich Roman conservative was once caught standing in line to collect this allowance of which he vehemently disapproved and certainly did not need. When asked why, he replied: “If you’re sharing out the state’s property, I’ll come and take my cut, thank you.” This is not far from the logic of the elderly modern millionaire who claims his free TV licence or bus pass.Their sluggish image has a humorous form in the tales of plucky Astérix and his struggles with the Roman legionAstérix is misleading when it masquerades as the answer to questions about ancient Rome. Photograph: AllstarBut it is not so simple. To study ancient Rome from the 21st century is rather like walking on a tightrope – a careful balancing act, which demands a very particular sort of imagination. If you look down on one side, everything does look reassuringly familiar, or can be made to seem so. It is not just the military escapades or the problems of urban life and migrants. There are conversations going on that we almost join, about the nature of freedom or the problems of sex. There are jokes we still “get”, buildings and monuments we recognise and family life lived out in ways we understand, with all their quarrels, divorces and troublesome adolescents. Cicero’s disappointment in the first century BCE with his son Marcus, who, at university in Athens, preferred clubbing and drinking to attending lectures on philosophy, is one that many of us can share. So too is the dilemma revealed by a surviving Roman do-it-yourself fortune-telling kit. Among the many questions it lists for anxious consulters is: “Will I get caught in adultery?” And among the many possible responses you could receive (depending on how the dice fell) was the wise and realistic: “Yes, but not yet.”On the other side of the tightrope, however, is completely alien territory. Some of that strangeness is well recognised. The institution of slavery disrupted any clear idea of what it was to be a human being (neither Greeks nor Romans ever worked out whether slaves were things or people). The filth of the place was, in our terms, shocking. There was hardly any reliable system of refuse collection in ancient Rome, or in any ancient city, and there were revealing stories about stray dogs walking into posh dinner parties clutching in their mouths human body parts they had picked up in the street. And that’s not to mention the slaughter in the gladiatorial arena or the death from illnesses whose cure we now take for granted. More than half of the Romans ever born would have died before they were 10 years old. Childbirth was as deadly to women as battle was to men.Cicero's dismay at his son Marcus, who preferred clubbing to going to lectures, is a feeling many of us can shareLess well known are the thousands of unwanted new‑born babies who were thrown on to rubbish heaps (or “exposed” to use the modern scholarly euphemism); the boundary between contraception and infanticide was a blurred one, and disposing of children after birth was safer than getting rid of them before. Likewise overlooked are the young Roman girls, who were not uncommonly married by the age of 13 or 14, and sometimes even earlier, into what we would have little hesitation in calling child abuse. How soon these marriages were consummated is anyone’s guess, but Cicero’s response, on the eve of his second marriage, to questions about why, in his 60s, he was taking as a bride a young virgin, a child in her mid-teens, is instructive. “Don’t worry,” he said, “she’ll be a grown-up woman tomorrow” (that is, a virgin no longer). The ancient critic who quoted this answer thought that it was a brilliantly witty way of deflecting criticism, and held it up for admiration. We are likely to put it somewhere on the spectrum between uncomfortably coarse and painfully bleak – one powerful marker of the distance between the Roman world and our own.The truth is that Roman history offers very few direct lessons for us, and no simple list of dos and don’ts. We hardly need to read of the difficulties of the Roman legions on the Syrian borders to understand that modern military interventions in western Asia might be ill‑advised, or that feeding inedible food to refugees is likely to rebound. I am not even certain that those modern generals who boast of following the tactics of Julius Caesar or Hannibal really do so, in anything more than their own imaginations; most military victories in the ancient world were achieved by massive superiority in numbers or by some variety of “going round the back” of the enemy and capturing them in a pincer movement (“tactics”, in any more sophisticated sense, just weren’t in it). Besides, “the Romans” were no less divided about how they thought the world worked, or should work, than we are. There is no simple Roman model to follow, or reject. If only things were that easy.Ancient Rome still matters for very different reasons – mainly because Roman debates have given us a template and a language that continue to define the way we understand our own world and think about ourselves, from high theory to low comedy, while prompting laughter, awe, horror and admiration in more or less equal measure. Of course, western culture is not the heir of the classical past alone, nor would anyone wish it to be. There are, happily, many different influences woven into our cultural fabric: Judaism, Christianity and Islam only three of the most obvious. But since the Renaissance at least, many of our most fundamental assumptions about power, citizenship, responsibility, political violence, empire, luxury, beauty, and even humour, have been formed, and tested, in dialogue with the Romans and their writing.Detail from a fresco depicting the arrival of the Trojan Horse, from Pompeii. Photograph: RexWe see that in the vocabulary of modern politics, from “senators” to “dictators”, and in our own catchphrases and cliches. “Fiddling while Rome burns” is a reference to the emperor Nero playing his lyre while the city went up in flames in the great fire of 64CE (not, as is now often assumed, “fiddling” in the modern sense of fussing aimlessly). “Fearing Greeks even when bearing gifts” is how Virgil in his Aeneid scripted the warning of one of the Trojan elders at the appearance of the great “Trojan horse”, a treacherous present from their Greek enemies. And the single Latin word “plebs” is still an insult, whether actually uttered or not, that can force a government minister to resign. We see it too in the political geography of modern Europe. The main reason that London is the capital of the United Kingdom, so inconveniently located in many respects, is that the Romans made it the capital of their province Britannia – a dangerous place lying, as they saw it, beyond the great ocean that encircled the civilised world. Britain is in many ways a Roman creation.But even more importantly, we have inherited from Rome many of the fundamental principles and symbols with which we define and debate politics and political action. The assassination of Julius Caesar on the “Ides of March” in 44BCE was in reality a bungled and slightly seedy operation. Despite Shakespeare’s glamorising recreation of the conspiracy, it was headed by the decidedly unattractive Marcus Junius Brutus, whose previous claim to fame had been to extract an almost 50% rate of interest for loans to the unfortunate people of Cyprus (when they could not come up with the repayments he had the main council chamber on the island besieged, starving five councillors to death in the process). It caught several innocent people in what we would call “friendly fire”. And in the medium term it did more to bring about one-man rule in Rome than to eradicate it as the assassins had hoped. Yet, helped no doubt by the Shakespearean version, it has provided the model and the justification for destroying “tyrants” in the name of “liberty” ever since. It is no coincidence that John Wilkes Boothused “Ides” as the code word for the day on which he planned to kill Abraham Lincoln. Almost every assassination in western politics has been seen against the background of the Ides of March.Twenty years before Caesar’s murder there was another event that has had an equally long afterlife in western history and thought. While he held the chief office of the Roman state, the consulship, in 63BCE, Cicero uncovered what he claimed (and probably believed) to be a terrorist plot to overthrow the government and to eliminate several of its senior politicians, himself included. The mastermind was supposedly a bankrupt aristocrat by the name of Catiline, who had turned to revolution when he had failed to reach power by legitimate means. Cicero had been tipped off by his undercover agents, intelligence reports and intercept evidence, and so – displaying a breastplate under his toga (more or less the equivalent of turning up at the House of Commons with a bulletproof vest and pistol) – he denounced Catiline who quickly fled, and he rounded up the other conspirators. These he executed without trial, in the interests of homeland security. “Vixere,” he announced, in a chilling understatement, as he emerged from the prison where he had overseen their punishment: “They have lived.” That is: “They are dead.”Detail from Ara Pacis Augustae, an altar in Rome dedicated to Pax, the Roman goddess of peace. Photograph: Tristan Lafranchis/akg-imagesWe know about this incident almost wholly from Cicero’s side; in fact, four speeches that he delivered accusing Catiline of treason and revealing what he knew of the plot went on to the Roman school curriculum almost immediately, as models of persuasive oratory, and have been read and studied ever since. The speeches still have their foothold in the modern western school curriculum, albeit a considerably more tenuous one. But we also know that there was another side to the debate. Whatever Catiline was really up to (and there is still disagreement about how far the “reds under the bed” were a figment of Cicero’s conservative imagination or paranoia), every Roman citizen had the fundamental right to due process and fair trial; summary execution contravened the most basic of civil liberties, then as now. Cicero did not escape scot-free. He was shortly sent into exile, his house in Rome was demolished, and a shrine to the goddess Liberty was pointedly constructed on its site.The exile was unpleasant for Cicero, and copies of his unattractively self-pitying letters, sent back to his family and friends, still survive. Roman men did not often have the stiff upper lips of popular imagination, and Cicero wallowed in his tears. But the crying did not last long, for in a year he was recalled – in his account again – to a hero’s welcome and to the rebuilding of his house. His career, however, never fully recovered and the basic clash between, on the one hand, the obligation on the elected officials of the state to ensure its security and, on the other, the civil liberties of every citizen, no matter how criminal, continued to be debated – as it still is, whether in relation to detention without trial, Guantánamo Bay or British drone strikes against British citizens in Syria.Over the centuries Cicero and Catiline have hovered in the background of these and other political debates, and have sometimes provided an explicit template for them. Writing a play on the subject in the aftermath of the Gunpowder Plot, Ben Jonson turned Catiline into a sadistic anti-hero (though his Cicero was an almost equally unattractive droning bore), while from the other side of the political spectrum Henrik Ibsen, in the fallout of the European revolutions of the 1840s, imagined a highly principled Catiline pitted against the corruption of the world in which he lived. Even now, the very words that Cicero used in his speeches against Catiline – and especially the first line of the first speech “Quousque tandem abutere, Catilina, patientia nostra?” (“How long, Catiline, will you go on abusing our patience”) – get replayed as a signal of fundamental and principled political opposition. That goes from the hard-line Republican senator for Texas, Ted Cruz, who just last year started his attack on Barack Obama’s immigration plans with the words, “When, President Obama, do you mean to cease abusing our patience?”, to protesters against the government in Hungary a couple of years before who emblazoned banners with just the words Quousque tandem. No more needed to be said.‘How long yet?’ … a banner bears a phrase from Cicero’s speech at a protest denouncing Hungary’s new constitution, 2012. Photograph: Getty ImagesWhat is important here is the debate, not the resolution. Ancient Rome is not a simple lesson for us, nor is it a civilisation that we should gratefully admire. There is much in the classical world – both Roman and Greek – to engage our interest and demand our attention. But admiration is a different thing. After 50 years of working on, and with, the Romans, I bridle when I hear people talking, as they so often do, of “great” Roman conquerors, or even of Rome’s “great” empire. That certainly wasn’t what it looked liked from the other end of Roman swords. But admiration apart, Roman debates are embedded in our own, and they are embedded in those of our predecessors who have in turn bequeathed their own problems, solutions and interpretations to us. I am not only referring to debates on Catiline and civil liberties, but also to the lurid, largely fictional, anecdotes of Roman emperors that have framed our own views of political corruption and excess (where does autocratic excess end and a reign of terror begin?), or the justifications, bad and good, for imperial expansion and military intervention.Why did a very ordinary little town by the Tiber come to dominate most of the known world?Our own world would be immeasurably the poorer, and immeasurably less comprehensible to us, if we did not continue to interact with the Roman past. If we want, for example, to understand why John F Kennedy, like Lord Palmerston before him, chose to adopt the slogan Civis Romanus sum (“I am a Roman citizen”) – in Kennedy’s case as a defence of the freedom of West Berlin, in Palmerston’s in defence of some gunboat diplomacy – we need to keep engaged with the history of ancient Rome itself, with Roman approaches to citizenship and nationhood, and why they might underpin our own. Cynically, we should probably also wonder whether Kennedy (or Palmerston) actually knew that their cherished slogan had first become a Roman commonplace after being uttered as a desperate plea from a tragic Sicilian as he was pinned to a cross and illegally crucified by a rogue Roman provincial governor in the first century BCE – a plea that had no effect whatsoever.Inevitably, the Rome with which we engage is a moving target. Roman history has changed dramatically over the last 50 years, and even more so over the last 250 years since Edward Gibbon wrote The Decline and Fall of the Roman Empire, his idiosyncratic historical experiment that began the modern study of Roman history in the English-speaking world (and which certainly would have been on Palmerston’s desk). That is partly because of the new ways of looking at the old evidence, and the different questions we choose to put it. It is a dangerous myth that we are better historians than our predecessors. We are not. But we come to Roman history with different priorities – from gender identity to food supply – that makes the ancient past speak to us in a new, as well as an old, idiom. Whereas once the empress Livia, wife of the first emperor Augustus, was presented as a scheming manipulator and poisoner, we are now much more sensitive to the way male traditions tend to project villainy and self-interest on to women who have the fortune, or misfortune, to be married to the man in charge (think Cherie Blair). Livia may not have been a shy retiring lady innocent of all machinations, but we now realise that we would be the dupes of a tendentiously patriarchal vision to think of her simply as the wicked witch behind the throne.There have also been an extraordinary array of new discoveries – in the ground, under water, even lost in libraries – presenting novelties from antiquity that tell us more about ancient Rome than any modern historian before us could ever have known. We now have a manuscript of a touching essay by Galen, a Roman doctor whose prize possessions, kept in a lock-up store in the centre of Rome, had just gone up in flames; this resurfaced in the library of a Greek monastery only in 2005. We have discovered wrecks of Mediterranean cargo ships that never made it to Rome, with their foreign sculpture, furniture and glass destined for the houses of the rich, and the wine and olive oil that were the staples of everyone. Soundings off the coast of Sicily have even located on the sea bed the detritus of the last great naval battle in the first Punic war between Rome and Carthage in the mid-third-century BCE – including the metal rams from the prows of the ships inscribed with appropriate messages (one Carthaginian specimen has words to the effect of “Up yours, Rome”), helmets of the fighters and their day-to‑day supplies. Surprising as it may seem, the best-preserved ancient battlefield turns out be under the sea.And, as I write, archaeological scientists are carefully examining samples drilled from the ice cap of Greenland to find the traces, even there, of the pollution produced by Roman industry – the mines in Roman Spain, for example, where thousands of people, children included, worked in appalling industrial conditions to produce the silver that ended up as Roman small change. Others are putting under the microscope the human excrement found in a cess-pit in Herculaneum, in south Italy, to itemise the diet of ordinary Romans, and to ask what went into – and out of – their digestive tracts, 2,000 years ago. A lot of eggs and sea urchins are part of the answer.Roman history is always being rewritten, and always has been. It is a work in progress, and the myths and half-truths of our predecessors always demand correction – as our own myths will no doubt be corrected by our successors in due course. For me, it is the one-sided thuggish image of the Romans that we especially need to re-examine. It has a harmless and humorous form, perhaps, in the tales of plucky Astérix and his struggles with the Roman legions (and that is where most of us come across it first). But it is much more misleading when it masquerades as the answer to some of the biggest questions about ancient Rome. Why did a small and very ordinary little town by the Tiber, with no obvious advantages, come to dominate first the peninsula of Italy and then most of the known world? Were they simply, as is often claimed, a community committed to aggression and conquest, built on the values of military success and little else?The Roman empire in 117CE.The fact is that Romans did not start out with a grand plan of world conquest. They did eventually parade their empire in terms of some manifest destiny, and Virgil in his national epic, the Aeneid, could in retrospect make the god Jupiter prophesy for Rome “an empire without limit”. But the motivations that originally lay behind their conquests through the Mediterranean world are far harder to pin down. One thing is certain: in acquiring their empire, the Romans did not viciously trample over innocent peoples who were minding their own business in peaceable harmony until the legions appeared on the horizon.Roman conquest undoubtedly was vicious. Caesar’s conquest of Gaul has not unfairly been compared to genocide, and was criticised by some Romans at the time in those terms. One of Caesar’s political rivals even suggested that he should be put on trial for war crimes, with the jury made up of the tribesmen he had conquered. But Rome expanded into a world not of communities living at peace with one another, but one of endemic violence, rival power bases backed up by military force (there was not really any alternative backing) and mini empires. Most of Rome’s enemies were as militaristic as the Romans, and, in our terms, as sadistic. This is where the “Astérix image” is part of the problem, with its suggestion that Caesar’s adversaries in Gaul relied on little more than wit, ingenuity and magic potion. One Greek visitor to Gaul a few decades before Caesar’s invasion reported seeing enemy heads regularly strung up as trophies outside Gallic huts – an alarming sight, he confessed, though in time one did get used to it.What cries out for explanation is not the Romans’ militaristic character or psychic aggression, but why in a world that was universally violent the Romans were so consistently more successful than their enemies and rivals. The basic answer to that has little to do with superior tactics or even with better military hardware; it has much more to do with boots on the ground. In its early centuries at least, standard Roman practice, unique in the ancient world and most of the modern, was to turn those it had defeated into Roman citizens and to convert erstwhile enemies into allies and future manpower. It was an empire built – as those desperate refugees on the Danube must have hoped, long after the policy had ceased to be feasible – on the extension of citizenship and the incorporation of outsiders.It was also an empire of which some Romans themselves were the most powerful critics. Rome was not simply the unsophisticated and badly behaved younger sibling of classical Greece, committed to engineering, military efficiency and absolutism, whereas the Greeks preferred intellectual inquiry, theatre and democracy. It suited some Romans to pretend that was the case, and it has suited many modern historians to present the classical world in terms of a simple dichotomy between two very different cultures. That is misleading, on both sides. The Greek city states were as keen on winning battles as the Romans were, and most had very little to do with the brief Athenian democratic experiment. And far from being the unthinking advocates of imperial might, several Roman writers sharply analysed the origins and effects of their interventions in the world. “They create desolation and call it peace,” is a slogan that has often summed up the consequences of military conquest. It was written in the second century CE by the Roman historian Tacitus, referring to the Roman conquest of Britain.The history of Rome lasted for well over 1,000 years (and well over 2,000 if we count the centuries of the Byzantine Romans in the east). For better or worse, Rome is ingrained in our political, cultural and literary traditions, and ways of thinking. It is a fair bet that there has not been a single day since 19BCE when someone somewhere has not been reading Virgil’s Aeneid, and it is hard to think of many other books, apart from the Hebrew Bible, of which one could say that. I am making no plea for a fan club for ancient Rome. We do the Romans a disservice if we heroise them, as much as if we demonise them. But we do ourselves a disservice if we fail to take them seriously – and if we close our long and complicated conversation with them.• Mary Beard’s SPQR: A History of Ancient Rome is published by Profile on 20 October.the Guardian Industries Home