ambulation in order to establish that Mrs. F.G. will be safe to transfer with nursing staff once the catheter is removed. 4. A concern with a patient who has had reduced mobility is the risk of a deep vein thrombosis. This is particularly the case if the patient has had any history of DVT or pulmonary embolus Case study two Mr. P.S. is a 55-year-old male who underwent a right total hip arthroplasty 4 weeks ago. During his most recent visit to his surgeon, he requested a referral to attend outpatient PT. He presents to his first PT appointment walking with a single tip cane in his right upper extremity. During his history he describes his general good health apart from hypertension which is controlled by medication. He owns several retail stores but does not spend much time on the floor but rather takes care of the business end of the stores from his home office. He spends 2 to 3 hours a day seated at his desk with paperwork for the stores and then finds that he is very stiff and struggles to stand upright for several minutes until he “limbers up.” He explains that his real passion is refereeing college football games, and this is something that he plans to get back to doing in 3 to 4 months’ time. During the physical examination, the physical therapist notices a reverse Trendelenburg gait pattern and reduced stance time on the right lower limb when ambulating. There is noted restriction of the right hip flexors with a positive Thomas test and weakness of the hip abductors and extensors. Questions 1. What should the first consideration be as the physical therapist formulates a problem list and potential interventions for this patient? 2. How would the physical therapist approach the issue of the tight hip flexors if the physical therapist knew that the patient had had an anterior surgical approach for his THA? 3. The patient notices that he limps and rocks his upper body. How would the physical therapist describe to him what is happening with his gait mechanics so that he can better understand the rationale for his exercises? 4. Considering the activity level of this patient, which would be the optimal self-reported outcomes measure to use to track his progress during rehabilitation? 5. He returns to the surgeon at 8 weeks and is released from any remaining restrictions. How would the physical therapist tailor his physical therapy program to meet his expectations of returning to refereeing college football games? Answers 1. The first consideration should be what surgical approach was used for the THA. The patient may be able to answer this for the physical therapist if it is not indicated on the script or it may be evident during the physical examination as you assess the healing of the surgical scar. Otherwise contacting the surgeon’s office will provide the physical therapist with Abdulkarim, A., Ellanti, P., Motterlini, N., Fahey, T., & O’Byrne, J. M. (2013). Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials. Orthop Rev (Pavia), 5 (1), e8. doi:10.4081/or.2013.e8 Adam, S. S., McDuffie, J. R., Lachiewicz, P. F., Ortel, T. L., & Williams, J. W., Jr. (2013). Comparative effectiveness of new oral anticoagulants and standard thromboprophylaxis in patients having total hip or knee replacement: a systematic review. Ann Intern Med, 159 (4), 275-284. doi:10.7326/0003-4819-159-4-201308200-00008 References Agostini, V., Ganio, D., Facchin, K., Cane, L., Moreira Carneiro, S., & Knaflitz, M. (2014). Gait parameters and muscle activation patterns at 3, 6 and 12 months after total hip arthroplasty. J Arthroplasty, 29 (6), 1265-1272. doi:10.1016/j.arth.2013.12.018 American Academy of Orthopaedic Surgeons [AAOS]. (2015). Retrieved from http:// orthoinfo.aaos.org/topic.cfm?topic=a00377 Anakwe, R. E., Jenkins, P. J., & Moran, M. (2011). Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients. J Arthroplasty, 26 (2), 209-213. doi:10.1016/j. arth.2010.03.013 Archibeck, M. J., Carothers, J. T., Tripuraneni, K. R., & White, R. E., Jr. (2013). Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthroplasty, 28 (1), 168-171. doi:10.1016/j.arth.2012.04.003 Artz, N., Dixon, S., Wylde, V., Beswick, A., Blom, A., & Gooberman-Hill, R. (2013). Physiotherapy provision following discharge after total hip and total knee replacement: a survey of current practice at high-volume NHS hospitals in England and Wales. Musculoskeletal Care, 11 (1), 31-38. doi:10.1002/msc.1027 Aynardi, M., Post, Z., Ong, A., Orozco, F., & Sukin, D. C. (2014). Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study. HSS J, 10 (3), 252-255. doi:10.1007/s11420-014-9401-0 Barnsley, L., Barnsley, L., & Page, R. (2015). Are Hip Precautions Necessary Post Total Hip Arthroplasty? A Systematic Review. Geriatr Orthop Surg Rehabil, 6 (3), 230-235. doi:10.1177/2151458515584640 Belmont, P. J., Jr., Goodman, G. P., Hamilton, W., Waterman, B. R., Bader, J. O., & Schoenfeld, A. J. (2014). Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence. J Arthroplasty, 29 (10), 2025-2030. doi:10.1016/j. arth.2014.05.015
in the past. Consulting with nursing staff and the surgeon would be appropriate in this case ahead of proceeding with the normal PT session of exercising and functional mobility, including ambulation.
this information. In the case of this patient he had an anterior surgical approach. 2. Based on the basic premise that the anterior soft-tissue structures have been compromised during the surgical procedure, caution should be exhibited with stretching the right femur into extension. Since it had been 4 weeks since surgery in this otherwise healthy male, it is possible that sufficient healing has occurred to allow pain-free stretching under the approval of the surgeon. In the case of this patient, the surgeon was approached and consulted about starting hip flexor stretches and he was in agreement with this. 3. There are several ways to explain to the patient the role of the hip abductors in the closed chain position that when working optimally stabilize the pelvis. At this early stage the patient frequently will struggle to complete right hip abduction in left side lying due to muscle weakness. Explaining to the patient that currently his hip abductors are not sufficient to lift the weight of his limb then can be translated to the fact that if those muscles cannot lift the weight of the limb then they will not be able to stabilize the torso, which is appreciatively greater than the lower limb. The second part to the explanation is that with the hip abductors being so weak, the torso reduces the effort required of the muscles by moving the center of gravity of the torso back over the limb that underwent THA. 4. The Hip Disability and Osteoarthritis Outcome Score (HOOS) would be optimal because it has components of this measure that relate to more active patients. 5. After the 8-week visit with the surgeon, the first element in changing the focus of the rehabilitation to getting this patient ready to return to his officiating would be to have a clear understanding of the demands of this role as a referee. There are demands that he runs short distances (up to 200 feet), that he changes direction quickly, and that he is on his feet for several hours. Knowing this, it would be pertinent to have a conversation with the surgeon about any concerns that he or she has with the patient returning to these activities. In order to reduce excessive loading of the joint, the patient was initially advised to aqua jog to work on running mechanics and to build his aerobic base. In conjunction with this, the patient was instructed in lateral shuffles between cones and resisted sideways skipping against a resistance band. The exercises were performed to fatigue or to when form deteriorated. Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport, 14 (1), 4-9. doi:10.1016/j. jsams.2010.08.002 Berliner, J. L., Brodke, D. J., Chan, V., SooHoo, N. F., & Bozic, K. J. (2016). John Charnley Award: Preoperative Patient-reported Outcome Measures Predict Clinically Meaningful Improvement in Function After THA. Clin Orthop Relat Res, 474 (2), 321-329. doi:10.1007/ s11999-015-4350-6 Birrell, F., Croft, P., Cooper, C., Hosie, G., Macfarlane, G., Silman, A., & Group, P. C. R. Hip Study. (2001). Predicting radiographic hip osteoarthritis from range of movement. Rheumatology (Oxford), 40 (5), 506-512. Brown, J. M., Mistry, J. B., Cherian, J. J., Elmallah, R. K., Chughtai, M., Harwin, S. F., & Mont, M. A. (2016). Femoral Component Revision of Total Hip Arthroplasty. Orthopedics , 1-11. doi:10.3928/01477447-20160819-06 Brown, T. D., Elkins, J. M., Pedersen, D. R., & Callaghan, J. J. (2014). Impingement and dislocation in total hip arthroplasty: mechanisms and consequences. Iowa Orthop J, 34 , 1-15. Cadossi, M., Mazzotti, A., Baldini, N., Giannini, S., & Savarino, L. (2016). New couplings, old problems: Is there a role for ceramic-on-metal hip arthroplasty? J Biomed Mater Res B Appl Biomater, 104 (1), 204-209. doi:10.1002/jbm.b.33383 Carroll, K. L., Schiffern, A. N., Murray, K. A., Stevenson, D. A., Viskochil, D. H., Toydemir, R., … Roach, J. W. (2016). The Occurrence of Occult Acetabular Dysplasia in Relatives of Individuals With Developmental Dysplasia of the Hip. J Pediatr Orthop, 36 (1), 96-100. doi:10.1097/BPO.0000000000000403 Chang, C. Y., & Huang, A. J. (2013). MR imaging of normal hip anatomy. Magn Reson Imaging Clin N Am, 21 (1), 1-19. doi:10.1016/j.mric.2012.08.006 Chen, A. F., Pigott, M., & Klatt, B. A. (2013). Surgical total hip arthroplasty options for geriatric patients. Top Geriatr Rehabil, 29 (4), 253-259. Choi, J. K., Geller, J. A., Yoon, R. S., Wang, W., & Macaulay, W. (2012). Comparison of total hip and knee arthroplasty cohorts and short-term outcomes from a single-center joint registry. J Arthroplasty, 27 (6), 837-841. doi:10.1016/j.arth.2012.01.016 Cibulka, M. T., White, D. M., Woehrle, J., Harris-Hayes, M., Enseki, K., Fagerson, T. L., … Godges, J. J. (2009). Hip pain and mobility deficits – hip osteoarthritis: clinical practice
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