The Role Of Body Mass Index Bmi On Total Knee: Fill & Download for Free

Weight loss is a complex issue and you have to do so many things for that. Unless you understand it in proper perspective, short term things will not do.Why weight loss?There is a thing called standard or ideal or normal body weight which we all should strive to maintain. Anything above that is excess weight. It needs to be reduced. This excess weight is also called excess fat in body. Any excess fat not digested by body shows up in terms of excess weight. This excess weight causes harm to the body. “It presents a health risk” says Harvard school of Public Health. What are the associated risks with excess weight.• Excess weight is normally associated with lifestyle diseases- hypertension ( BP), type -2 diabetes, high level of bad cholesterol and cancer.• Your heart has to work harder to pump blood and thus weakening and hardening of hearts muscles. Hardening of blood vessels lead to heart attack.• Your joints have to bear increased body weight so wear and tear of joints become faster causing knee and joints pain and arthritis.• Persons having excess weight are more disposed to depression, tension, anxiety, low self esteem. It sometimes causes breathing problems and sleep apnea.What is the ideal weight?Men and women have separate charts for their anatomical and physiological differences. The height weight chart for male and female is given below for your reference.Height inchesHeight CMWeight in KgMaleWeight in KgFemale4’6”13728.5/34.928.5/34.94’7”14030.8/38.130.8/37.64’8”14233.5/40.832.6/39.94’9”14535.8/43.934.9/42.64’10”14738.5/46.736.4/44.94’11”15040.8/49.939.0/47.65’0”15243.1/53.040.8/49.95’1”15545.8/55.843.1/52.65’2”15748.1/58.944.9/54.95’3”16050.8/60.147.2/57.65’4”16353.0/64.849.0/59.95’5”16555.3/68.051.2/62.65’6”16858.0/70.753.0/64.85’7”17060.3/73.955.3/67.65’8”17363.0/70.657.1/69.85’9”17565.3/79.859.4/72.65’10”17867.6/83.061.2/74.85’11”18070.3/85.763.5/77.56’0”18372.6/88.965.3/79.8Is there any other method of measuring obesity/ excess weightYes you can use BMI ( body mass index) for measuring yourBMI uses your height and weight to calculate BMI index.calculate your BMI:Type your height and weight into the online BMI calculator from NIH.World Health Organization (WHO) states that for adults, the healthy range for BMI is between 18.5 and 24.9.Overweight is defined as a body mass index of 25 to 29.9, andobesity is defined as a body mass index of 30 or higher. These BMI cut points in adults are the same for men and women, regardless of their age.Worldwide, an estimated 1.5 billion adults over the age of 20-about 34 percent of the world’s adult population-are overweight or obese.By 2030, this is expected to rise to more than 3 billion people.Apart from standard weight table and BMI, there is yet another method. Waist to hip measurement.Is there any yardstick to measure weight- waist to hipBodies come in all shapes and sizes, so you won't find a chart that lists standard waist and hip size to go with each height and weight. You will, however, find a healthy weight range for each height, a healthy waist size range for a given hip size, and a healthy waist size range for a specific height. These ratios are all used to determine whether you are at a healthy weight and body fat percentage -- or you're overweight.Waist CircumferenceYour waist size also plays a role in your health; a waist circumference that's larger than 35 inches for women and larger than 40 inches for men indicates a higher disease risk. While these are outer limits our endeavour should be lower than this- if we could bring it to 35 for men and 32 for women nothing like this. Anything higher than 40 and 35 for men and women respectively means higher risk of life style diseases ( BP, heart disease and type 2 diabetes). A large waist is a sign that you have a lot of abdominal fat, the type of fat that's around your organs. This kind of fat has been linked to an increased risk for breast cancer, gallbladder surgery, type 2 diabetes and heart disease.Waist-to-Hip RatioPeople who carry pounds around their waist are usually more likely to suffer from certain health conditions than those who carry their weight mostly in the hip area. To determine your waist-to-hip ratio, divide your waist circumference in inches by your hip circumference in inches. This ratio can help you determine your body shape and whether you should take extra steps to limit your risk for obesity-related health issues. If the number is above 0.80, you have what is often referred to as an "apple" shape, and if it is below this number, you have more of a "pear" shape, which is healthier.Theory of weightWe need calories ( energy) to repair/ maintain and sustain our body lack of which should not hinder our daily activities. If we are taking/ ingesting same amount of calories that body needs for smooth functioning, our body weight will be constant.If on the other hand, we are taking more calories than required, we will gain weight.Similarly if we are taking/ ingesting less calories than required we will lose weight.This brings us to a question how do I know how much I am expending and how much ingesting.First expenditure part, we are listing major activities in which body spends calories.Before we look at the table let us also understand that each kg of weight loss requires burning of some 9000 calories. Let us now look at the table and then we will analyse it further.Expenditure sideThe table given below lists various activities ( if done for 30 minutes) and resultant calorie loss. It is linked to our body weight, if someone has higher weight, he will burn higher amount of calories. If you have weight in between the value given in the table, you can extrapolate using these values.Name of activity done for 30 minutesCalorie loss56 kg body weightCalorie loss70 kg body weightCalorie loss83 kg body weightHatha yoga, Pilates120149178Aerobics low impact165205244Weight lifting180223266Dancing90112133Walking 5.6 km per hour or 11 minutes per KM120149178Walking 6.5 km per hour or 9.5 minutes per km135167200Swimming180223266Jogging 10 minutes180223266Bicycling240298355Running240298355Gardening/ moving135167200Household activitiesSleeping192328Watching TV232833Reading344250Cooking and cleaning utensils7593111Food shopping105130155Occupational activitiesOn computers415161Light office work455667Desk work536578Now understand the weight loss principle-As mentioned earlier if you want to reduce 1 kg of weight and if you are walking ( one km of walk will burn roughly 60 calories) 5 km of daily walk will burn 300 calories. Similar expenditure will happen if you attend a yoga and Pilates class. But if you are jogging, running, swimming, doing aerobics, burning rate will be higher- may be 400 to 500 calories per hour. So walking and yoga for an hour will burn 300 calories per day and if we do all 30 days in a month we will end up burning 9000 calories that is equivalent to one kg of weight loss in a month provided of course our ingestion of calories remain the same as required by the body. If we are ingesting more than required our efforts will be neutralised to that extent.We can now understand how difficult it becomes to reduce weight.Now ingestion sideFollowing table gives us an idea how much calories a food item containsName of the food itemCaloriesSmall phulka/ chapati of 20 grflour70A bowl of cooked rice 40 gr136A plate of rice 80 gr272Parantha 30 gr floor121Parantha stuffed with potato210One bowl of cooked daal 30 gr104Dry veg sabji – bhindi, potato, cauliflower150Dahi curd 100 gr100Chicken curry – depends on how you cook120-240Fish fry190-220Besan burfi 2 pcs220Fruit cake 1 piece70Tea30-40More about calorie ingestionIt is not home made food- whether North Indian, South Indian or any part of India that creates problem. All home made freshly cooked food is healthy. Problem comes from snacking. This is the time we want to taste varieties, some thing tasty and spicy, outside foods- biscuits, cakes, pastries, donuts ,pizzas, burgers, vadas, samosa, kachori, farsan etc. All these are used as snacks and these are all high calorie foods. All sweets and farsanas ( packaged namkeen) 100 gram quantitywill generally have calories in excess of 600. One samosa has more than 200 calories. If you eat one bowl say 100 grams of carrot pudding ( gajar halwa) you have ingested 600 calories which will need you to walk 10 km to neutralise it’s effect. That is how we add weight. In wedding parties we take something like 3000/3500 calories whereas out total requirement is 2500/3000 calories per day.Weight loss strategyThe immediate first thing we need to do is to put a stop to any further weight gain possibility by taking only that much calories that body needs.Now we can have a two pronged strategy1) Expend more- Burning calories by way of exercises, sports or other physical activities.2) Ingest less- Reducing intake of calories by way of avoiding fats and sugar, reducing portion size, intermittent fasting.Or3) A combination of both like- to burn 500 extra calories ( 250 by diet adjustment and 250 by way of exercise . This is feasible and would not put any undue strain on body.Exercise1) Set tangible goals- small, achievable and measurable. Goals should be specific- time wise – this much duration- weight wise – this much loss week/ month wise. Note down your measurements on the day you start – your body weight, BMI, waist to hip ratio etc. Affirm yourself that with changes in lifestyle I’ll lose this much weight.2) Any exercise is good provided you maintain consistency and regularity. Walking , yoga and aerobics are good . Gymming is also good but certain precautions are required which I have explained in a separate blog. Surya namaskar is wonderful- highly effective- start small from 20/25 rounds to 101 rounds or even more. At our classes we make students do 101 Surya Namaskar.3) Start slow and than gradually build on. Have patience. Respect your body and listen to the signals it is sending, enjoy your workout- make it a fun, put your emotions and never make it mechanical , dull and boring.Celebrate small successes in the beginning as that will give you confidence.4) Apart from regular exercise , use other methods also. Like park your car at a little distance and walk down , don't use escalators wherever you can, go for a stroll after dinner and try to be on your legs whenever and wherever you can .5) It is important to be healthy and energetic even if you have some extra weight rather than a body which is dull, lethargic and aching.6) The weight in your body gets accumulated over a period of time but we take notice of it either when it results in some life style disease ( BP/ diabetes/ stress) or when our body loses its shape. So if it has taken years to pile up why then rush to reduce it in a month or two. I have seen students coming to my classes andwanting to reduce weight as quickly as possible . A thing which got accumulated say in 5/10 years cannot be got rid of in say some months or a year. It may rather cause other serious problems in the body. In Ashtanghridayama vagbhattamentionsतृष्णा क्षय: प्रतमको रक्तपित्तं श्रम: क्लम:।अतिव्यायामात: कासो ज्वरश्दिश्च जायते ।।व्यायामजागराह वस्त्रीहास्यभाष्य दिसाहसम्गजं सिंह इवाकर्षन भजन्नति विनश्यति॥Excessive of workout results in increased thirst, weakening of muscles, disturbed breathing, impure blood, early fatigue, mental weakness, fever and vomiting. Over exertion, remaining awake till late in night, excessive walking, over indulgence in sex, talkativeness, over laughing all are bad. A person who indulges in excess of all these things gets perished like a lion who drags an elephant .DietWe mentioned above that it is the snacks that is primarily responsible for weight gain in most of the Indians.Following dietary restrictions should be followed.1) As far as possible avoid all processed, packaged, refrigerated, refined and outside food.2) It is not possible that we can completely give up socialising . Being social animals we need to attend birth day/ marriage parties and other functions. But take care that you exercise healthy options. Your one day merry making can bring your entire month workout to a naught .3) Whenever you buy any food item see the labels on the packing. As per govt regulations all packaged food manufactures are required to declare the energy and other nutrients in the food. Energy and calories are synonymous . See how much calories or energy per 100 gram is there in that particular item. Also look for other nutrients and particularly Trans fats.4) Have more plant based food particularly fruits and vegetables.5) Manage your portion size. It’s easy to overeat when you’re served too much food. Smaller portions can help prevent eating too much.6) Avoid sugar and fats – ghee and edible oils if not completely, reduce their intake drastically particularly sweets and namkeen. Mind it sugar increases belly fat.7) Eat more Protein. Studies have shown that It reducescravings by 60%, boost metabolism by 80-100 calories per day and help you eat up to 441 fewer calories per day.Good luck

Some say weight and health are perfectly correlated, but others don't. There's a veritable cornucopia of opinions on what good digestive health looks like, and only a handful of those assessments line up in agreement. And let's not even get started on the issue of what constitutes a healthy diet!In an effort to lock down some solid information, here's what physicians, researchers, and other folks in the know have to say when it comes to indicators of good health.Full, lustrous hairWhile brittle, dry, or thinning hair can be signs that something might be going awry (such as hypothyroidism, stress, or nutrient malabsorption), the reverse is also true: healthy hair is an indication of a healthy body. "Hair is a barometer of your overall health," says British Science Corporation in New York City's hair and scalp expert, David H. Kingsley, Ph.D."Good hair depends on the body's ability to construct a proper hair shaft, as well as the health of the skin and follicles," writes Today show health expert Joy Bauer, MS, RDN. "Good nutrition assures the best possible environment for building strong, lustrous hair." Nourished by key components of your diet like protein, vitamins, and healthy fats, healthy hair reflects that you're eating well and absorbing all the good stuff from your food.Strong nailsAnother window into your health is, one might say, right at your very fingertips: it's your nails! (Forgive the pun. As I gradually turn into my parents, my attempts to resist the allure of dad jokes is increasingly futile.) "Your nails are a very good reflection of your health. Many things can occur in the nails that can signify systemic or skin problems," says dermatologist Christine Poblete-Lopez, MD, of the Cleveland Clinic. According to Dr. Poblete-Lopez, just like stress can affect your hair, your nails can also reveal signs of strain on your body.A pink nail bed without lines or discolorations, as well as strong nails without pitting, lines, or weakness, are all signs of good health. However, if your nails undergo changes like discoloration (whiteness or brown marks in the nail bed) or start to look pitted, it could be a sign that something is amiss. "Changes in the nails can be a sign of a local disease like a fungus infection or a sign of a systemic disease like lupus or anemia," according to Joshua Fox, MD, director of Advanced Dermatology and spokesman for the American Academy of Dermatology.Healthy teeth and gumsOral health is also a key barometer of health and wellness, according to the Mayo Clinic. Strong teeth and healthy, pink gums that aren't inflamed play a key role in staying healthy, as does proper oral hygiene.Just like other areas of your body, such as your skin and intestines, your mouth is full of bacteria. While most of them are totally harmless or even beneficial, according to the Mayo Clinic, "Normally the body's natural defenses and good oral health care, such as daily brushing and flossing, can keep these bacteria under control. However, without proper oral hygiene, bacteria can reach levels that might lead to oral infections, such as tooth decay and gum disease."It's also possible that those run-amok oral bacteria (bacteria gone wild?), along with the inflammation that accompanies a severe form of gum disease called periodontitis, may have a role in the development of other problems such as cardiovascular disease and, among women who are pregnant, issues like premature birth and low birth weight. Moral of the story: floss often (even though it's quite possibly *the* most onerous of hygiene tasks), and visit your dentist regularly.Waist circumferenceHappily, Body Mass Index (BMI) is falling out of favor as a means of measuring health. BMI, which measures weight relative to height and is often used to evaluate the amount of excess fat on a person's body, has long had its detractors, and those objections have picked up steam in recent years.For example, a UCLA study published in the International Journal of Obesity noted that after examining how peoples' cardiac health correlated with their BMI, "Nearly half of overweight individuals, 29 percent of obese individuals and even 16 percent of obesity type 2/3 individuals were metabolically healthy. Moreover, over 30 percent of normal weight individuals were cardio-metabolically unhealthy.You get enough sleepWe all know how not getting enough sleep is ─ to put it mildly ─ absolutely wretched. According to the UK's National Health Service (NHS), lack of sleep puts people at higher risk of all sorts of less-than-fun conditions such as diabetes, weight gain, and heart disease, and can even decrease a person's life expectancy. As the NHS states, "It's now clear that a solid night's sleep is essential for a long and healthy life."Even though researchers haven't yet fully grasped why we sleep, Harvard Medical School's Division of Sleep Medicine notes that "scientists have gone to great lengths to fully understand sleep's benefits. In studies of humans and other animals, they have discovered that sleep plays a critical role in immune function, metabolism, memory, learning, and other vital functions."One theory that has gained a great deal of traction and support recently is that sleep is a restorative process which allows the body to repair and rejuvenate itself. "The most striking of these is that animals deprived entirely of sleep lose all immune function and die in just a matter of weeks," writes Harvard's sleep medicine program. "This is further supported by findings that many of the major restorative functions in the body like muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly, or in some cases only, during sleep." So, needless to say, getting enough sleep ─ and feeling well-rested, rejuvenated, and energized when you wake up ─ is a sign of good health.Let's talk about pooOk, so this one is super awkward — but it's also super important. As Dr. Vasudha Dhar, a gastroenterologist writing for Everyday Health, so accurately notes, "There really is no easier way to discover what's happening inside your body than seeing what comes out of it." So, bear with me on this one!According to Dhar, there's a wide range of "normal" bowel movements. Despite what various blogs or famous TV doctors say, you don't need to go once a day (or have a perfectly-shaped poo, or have stool that doesn't stink) in order for it to be within the range of normalcy. "Everyone's GI tract operates differently based on a combination of constant and changing factors ─ genetics, hydration, dietary habits, medication use, and ongoing health issues," Dhar writes. Instead of worrying about whether or not your poo meets these purportedly ideal criteria, focus on "how your GI tract normally functions and what typical bowel activity is for you. If you notice a prolonged change, that's when you need to closely monitor what's happening. In addition, if you are feeling pain or other pronounced symptoms, it's time to call your doctor." Some symptoms to look out for include visible blood, continual constipation, or prolonged diarrhea.Social supportSome of the most interesting research to come out recently has shown that having friends, a strong social support network, and opportunities for interaction are all profoundly good for you. It seems obvious that this would impact mental health, but research is showing that it affects physical health, too.According to a study published in the Journal of Health and Social Behavior, people with more social connections are "healthier, and live longer, than their more isolated peers." Among other key findings, the study found that not only do social relationships have a significant impact on health, but that those connections and relationships affect behavioral, mental, and physical health. Basically, no aspect of a person's health goes untouched by their degree of isolation and loneliness — or, conversely, their social connections, friendships, and healthy relationships.This begs the question: why do social connections have such a profound impact on overall health? According to the Harvard Women's Health Watch newsletter, social connectivity "helps relieve harmful levels of stress, which can adversely affect coronary arteries, gut function, insulin regulation, and the immune system. Another line of research suggests that caring behaviors trigger the release of stress-reducing hormones...research has also identified a range of activities that qualify as social support, from offers of help or advice to expressions of affection. In addition, evidence suggests that the life-enhancing effects of social support extend to giver as well as to receiver." So, having friends is good for you.An often-overlooked sign: your tongueMelanie St. Ours, a Baltimore-based clinical herbalist, wrote a piece for MindBodyGreen detailing how the Chinese Medicine-inspired practice of tongue reading can be a great barometer of health and wellness. I also had the chance to speak to her directly, and she told me: "It's not a substitute for medical diagnosis, but if you want to get a sense of how well you're digesting last night's dinner, or how your body is handling stress, your tongue can tell you a lot."She elaborated in her article that if the tip of your tongue is red, for example, it's a sign that your heart, mind, and emotions are revved up. She wrote: a red tip often "accompanies symptoms like insomnia, palpitations, nervousness, and an unquiet mind." Other tongue signs include a thick coating ─ particularly towards the back ─ which signals that your digestion isn't performing optimally, and teeth marks on the sides of the tongue, which "point to low energy, sluggish digestion, loose stools, and mental rumination."St. Ours encourages people to let their tongue readings guide them toward positive changes. "Let your tongue reading inspire you to make the necessary shifts so that you can thrive," she wrote. "Then, enjoy watching your tongue change in response to your new healthy habits!"Your diet includes lots of fruits, veggies, and healthy fatsWhile there tends to be all sorts of angst and competition surrounding how to eat healthily (e.g., the vegan vs. paleo sectarian tension, orthorexia, "clean" eating, etc.), one thing everyone can agree on is the importance of fruits, veggies, and healthy fats.According to the Harvard School of Public Health (HSPH), regularly eating your fruits and veggies "can lower blood pressure, reduce risk of heart disease and stroke, prevent some types of cancer, lower risk of eye and digestive problems, and have a positive effect upon blood sugar." Variety and quantity are equally important, HSPH notes, because each piece of produce is different; "no single fruit or vegetable provides all the nutrients you need to be healthy." So, it's important to eat a wide variety of produce, with as many different colors as possible, each day. (Think "taste the rainbow," but with things like apples, carrots, and purple cabbage, instead of Skittles.)If totally overhauling your diet seems way too overwhelming, there's some good news: according to TIME, a recent study has shown that just adding more healthy foods to your diet — even over the course of years, as opposed to the radical overhaul of your diet in days or weeks — can have a positive impact on health and longevity. So, no need to clean out and replace all the food in your house — just adding some fruits and veggies to your day can make a big difference.You have normal vital signs and fitness levelsWhile I've spent many an hour going down the rabbit hole of fitness tips on Instagram ─ there's a tipping point where I go from feeling inspired ("Ok, I can do this!") to feeling discouraged ("Noooope, my knees ache just thinking about those exercises") ─ it turns out you don't have to be an Insta-worthy fitness expert in order to be considered healthy.According to the BBC, basic fitness guidelines include "30 minutes of moderate exercise at least five times a week." Doctors also look at whether a person has a "reasonable level of fitness," which includes things like being able to "walk a mile in 15 minutes," carry two shopping bags from the store to the car, and climb a flight of stairs without getting winded.Furthermore, having normal vital signs is, well, vital. By looking at a person's blood pressure, heart rate, and respiratory rate, health care providers can get a good sense of how well your insides are working. As published in the BBC report, normal, healthy vital signs include "blood pressure below 140/90 mmHg each time it is taken, a resting pulse of about 70 beats per minute, and a respiratory rate of about 16 to 20 breaths per minute."You pay attention to your mental and emotional healthProactively managing your mental and emotional health is another key sign of being healthy, especially since, according to the U.S. government's Office of Disease Prevention and Health Promotion (ODPHP), "Mental health and physical health are inextricably linked. Evidence has shown that mental health disorders ─ most often depression ─ are strongly associated with the risk, occurrence, management, progression, and outcome of serious chronic diseases and health conditions, including diabetes, hypertension, stroke, heart disease, and cancer."Furthermore, explains David Goldberg, a professor at the Institute of Psychiatry in London, "Depression and chronic physical illness are in reciprocal relationship with one another: not only do many chronic illnesses cause higher rates of depression, but depression has been shown to antedate some chronic physical illnesses."While the reciprocal relationship is mostly talked about in the context of illness, it also holds true when it comes to health. By nurturing your mental and emotional well-being, you're also improving your physical health. Supporting your mental health ─ especially if you incorporate exercise, stress management (such as meditation, deep breathing, or yoga), and working with a qualified therapist into your mental health routine ─ helps keep the rest of you healthy, too.To your health!One thing that people often find when trying to make healthy changes is that it can all feel totally overwhelming. (Overhaul your diet! Exercise every day! Eliminate sugar! Go to bed early! Hustle! Grind! No excuses! Oh, and be sure to relax!)But, if you find that you want, or need, to make some changes, it's okay to take things slowly. Adding in a few things that you feel good about, whether it's a piece of fruit with lunch, an afternoon walk, or calling a friend for support, can actually go a long way. Doing the best you can with the circumstances and resources that you have is, in fact, a huge victory! (Gold star stickers are optional, but I fully support grown-ups using them just as much as kids do.[1]Footnotes[1] Signs that your body is really healthy

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. Letsels van het steun en bewegingsapparaat, Utrecht/Antwerpen: Scheltema; Holkema BV,1983Chan G, Bezuidenhout L, Walker L, Rowan R. The Impact on Life questionnaire: validation for elective surgery prioritisation in New Zealand prioritisation criteria in orthopaedic surgery. The New Zealand Medical Journal 2016;129:1432Affatato S. Perspectives in total hip arthroplasty: Advances in biomaterials and their tribological interactions. London: Woodhead Publishing, 2014.Brotzman B. Clinical Orthopedic Rehabilitation (2003)-S. Brotzman, KE Wilk.Kelmanovich D, Parks ML, Sinha R, MD, Macaulay W. Surgical Approaches to total hip arthroplasty. Journal of the Southern Orthopaedic Association 2003;12:90-94.Chechik O, Khashan M, Lador R, Salai M, Amar E. Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg. 2013;133(11):1595-600.Hoppenfeld S, DeBoer P, Buckley R. Surgical exposures in orthopaedics: the anatomic approach. 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. Archives of physical medicine and rehabilitation. 2013;94(1):164-76.Ferrara PE, Rabini AL, Maggi LO, Piazzini DB, Logroscino G, Magliocchetti G, Amabile E, Tancredi G, Aulisa AG, Padua L, Gnocchi DC. Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty. Clinical rehabilitation 2008;22(10-11):977-86.Saw MM. The effects of a six-week physiotherapist-led exercise and education intervention in patients with osteoarthritis, awaiting an arthroplasty in the South Africa [dissertation]. Cape Town: University of Cape Town. 2015.Crowe J,Henderson J. Pre-arthroplasty rehabilitation is effective in reducing length of hospital stay. Canadian Journal of Occupational Therapy 2003;70:88-96.Barnes RY, Bodenstein, K, Human N. Raubenheimer J, Dawkins J, Seesink C, Jacobs J, van der Linde J, Venter R. Preoperative education in hip and knee arthroplasty patients in Bloemfontein. South African Journal of Physiotherapy 2018;74(1).Raymond Sohier, Kinesitherapie de la hanche ; La Hestre : Sohier, 1974Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. A targeted home-and center-based exercise program for people after total hip replacement: a randomized clinical trial. Archives of physical medicine and rehabilitation 2008;89(8):1442-7.Robertson NB, Warganich T, Ghazarossian J, Khatod M. Implementation of an accelerated rehabilitation protocol for total joint arthroplasty in the managed care setting: the experience of one institution. Advances in Orthopedic Surgery. 2015;387197.Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. Journal of physiotherapy. 2013;59(4):219-26.Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Physical therapy 2000;80(5):448-458.Umpierres CS, Ribeiro TA, Marchisio ÂE, Galvão L, Borges ÍN, Macedo CA, Galia CR. Rehabilitation following total hip arthroplasty evaluation over short follow-up time: Randomized clinical trial. Journal of rehabilitation research and development. 2014;51(10):1567-78.Smith TO, Mann CJ, Clark A, Donell ST. Bed exercises following total hip replacement: a randomised controlled trial. Physiotherapy 2008;94(4):286-91.Perhonen MA, Franco F, Lane LD, Buckey JC, Blomqvist CG, Zerwekh JE, Peshock RM, Weatherall PT, Levine BD. Cardiac atrophy after bed rest and spaceflight. Journal of applied physiology 2001;91(2):645-53.Suetta C, Aagaard P, Rosted A, Jakobsen AK, Duus B, Kjaer M, Magnusson SP. Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse. Journal of Applied Physiology 2004;97(5):1954-61.