Total Knee Replacement

Cemented knee replacements are the most commonly performed because of the excellent
results achieved in long-term clinical studies.
Several current studies show survivorship of total knee replacements to be approximately 93%
at 10 years.
Postoperative range of motion closely relates to preoperative range of motion.
Although commonly used, continuous passive motion machines and postoperative
manipulation and physical therapy of the knee do not affect long-term range of motion.
Functionally, 90 degrees of motion is required to arise from a chair without the use of the
upper extremities. Postoperative recovery after total knee replacement must therefore not only
achieve pain relief and ambulatory capacity, but also good range of motion in order to obtain a
satisfactory result.
Local complications specific to total knee arthroplasty include:
1. fractures of the patella and femur
2. patellofemoral pain and dislocation
3. peroneal nerve palsy
4. skin breakdown
5. postoperative stiffness
In resurfacing the patella, the lateral geniculate artery may be sacrificed resulting in an
avascular patella.
Minimally displaced fractures may be treated with immobilization.
Displaced fractures may require component removal with subsequent patellectomy or open
reduction with internal fixation.
Osteopenia and intraoperative notching of the femur can predispose to fracture of the femur
above the femoral implant. This injury usually requires either complete knee revision or open
treatment of the fracture.
Improper positioning of the patellar or femoral components may lead to postoperative pain and
dislocation of the patella.
Peroneal nerve injury may occur during surgery as a consequence of excessive force from
retractors or with correction of significant valgus deformities of the knee.
Patients who have had prior operative procedures through different skin incisions may have
breakdown of the skin in areas that bridge these different sites. To minimize the risk of this
complication, skin bridges should be at least 4 cm.
To maintain good motion, a structured postoperative rehabilitation program is essential.
Early in the postoperative phase of total knee replacement, poor motion is treated with a
return to the operating room for manipulation of the knee under anesthesia.
Special attention is directed to pain control during this period to allow the patient maximum
benefit from physical therapy.
Younger patients

As in other types of joint replacement, infection and deep venous thrombosis are significant
systemic complications.

Osteotomy of the tibia or femur is often used to transfer weight-bearing load to an uninvolved
tibiofemoral joint surface when there is unicompartmental disease. This procedure is most
commonly done at the proximal tibia for medial compartmental disease but may also be
performed at the distal femur in lateral compartment disease.

The best results are achieved in young patients who are not overweight and who have good
bone stock. This procedure is used primarily as a temporizing measure to gain 5 to 10 years
before total joint arthroplasty is performed.

Arthrodesis provides another surgical alternative for the management of young patients with
unstable degenerative knees, the management of septic arthritis with extensive destruction of
the joint, and in neuropathic joints.

Rotator Cuff and Biceps Tendon

The rotator cuff consists of four muscles:

1. the supraspinatus,
2. infraspinatus,
3. teres minor, and
4. subscapularis.
All insert onto the tuberosities of the humeral head. The primary function of the rotator
cuff is to provide dynamic stabilization of the glenohumeral joint by depressing the
humeral head into the glenoid cavity. The rotator cuff separates the subacromial bursa
from the glenohumeral joint.
Patients with rotator cuff pathology present with pain (especially at night), weakness,
and difficulties with the activities of daily living, particularly overhead motions.
On physical examination, they have limited shoulder abduction because of pain. It is
important to rule out referred pain from cervical spine pathology.
Plain radiographs are indicated, but MRI is the most useful means of evaluating the
rotator cuff.

Rupture of the long head of the biceps can lead to the characteristic "Popeye"
deformity of the arm.

This is caused by the muscle bunching in the upper arm. This is treated in young,
active patients, but not in older patients.

Frozen Shoulder

Patients with adhesive capsulitis or "frozen section" present with shoulder pain and limited
motion.
Diabetics have a higher incidence of adhesive capsulitis than do nondiabetics.
Physical therapy is the mainstay of treatment and it often takes up to 1 year to regain full
motion.

Glenohumeral Instability

Glenohumeral instability is a spectrum of disorders, which can vary in severity (subluxation to

complete dislocation), direction (anterior, posterior, or multidirectional), and duration (acute,
recurrent, or chronic).
An acute, traumatic, anterior dislocation is the most common instability situation.
The risk of developing recurrent subluxation or dislocations is inversely proportional to age,
with those patients who have their first acute dislocation before they are 20 years of age
having more than an 80% incidence of recurrence.
Recurrent instability is most often caused by a tear of the anterior labrum off the anterior
glenoid, the so-called Bankart lesion.
Posterior dislocations more often are caused by a seizure or a fall in an elderly patient.

Glenohumeral Arthritis

Arthritis of the shoulder joint occurs less often than arthritis of the hip or knee.
Idiopathic osteoarthritis is the most common cause of shoulder degeneration.
Pain, weakness, limited motion in all planes of motion, and crepitus are common complaints.
If conservative measures such as heat, activity modifications, and nonsteroidal antiinflammatory medications (NSAIDs) do not produce relief, total shoulder arthroplasty may be
indicated.
The acromioclavicular joint often is subject to osteoarthritis and commonly is a result of prior
trauma. The patient complains of shoulder pain with abduction and movements of the arm
across the body. The joint is tender to palpation. Resection of the distal clavicle often is
performed for this disorder.

Elbow Disorders

The elbow is a complex joint allowing flexion and extension as well as pronation and supination
of the forearm.
A normal elbow has 180 degrees of extension or a few degrees of hyperextension and flexion
to 15 degrees.
Epicondylitis most often affects the lateral epicondyle; however, the incidence of medial
epicondylitis has increased with the popularity of golf.
Lateral epicondylitis has been considered a tendinopathy of the extensor carpi radialis longus
(ECRB) origin.
Another common, nontraumatic elbow condition is ulnar nerve compression (cubital tunnel
syndrome), which is caused by compression of the ulnar nerve in the cubital tunnel or proximal
flexor carpi ulnaris muscle, and causes pain and dysesthesias in the little and ulnar border of
the ring fingers.
If severe, weakness and atrophy of the ulnar-innervated intrinsic muscles of the hand may
occur causing Froment's, Wartenberg's, or Jeanneau's signs.(tignan sa rehab note)
Rupture of the distal biceps tendon attachment to the bicipital tuberosity of the proximal radius
may occur as a consequence of a chronic, degenerative tendinopathy.
Treatment may be conservative or surgical repair may be performed. If treated conservatively,
the patient can expect good flexion strength, but notable weakness of supination and aching
with heavy use.
In younger patients, osteoarthritis, or posttraumatic arthritis, is a difficult problem as such
patients are not candidates for total elbow arthroplasty because high demands are associated
with implant loosening and/or failure as a consequence of prosthetic wear.
Aggressive arthroscopic dbridement, osteophyte removal, and contracture release have
proven valuable, although long-term studies are lacking.

Low Back Pain

Pain in the lumbar area and buttock is one of the most common complaints heard in medicine.
The
Most instances of low back pain will not have a specific diagnosis and the cause is generally
muscular strain and spasm.
Degenerative arthritis is a more common cause of low back pain, but a delay in making this
diagnosis is not significant.
Herniated disc with nerve compression is a relatively common cause of back pain associated
with leg pain and should be recognized from the patient's history and physical examination.
The initial evaluation includes the taking of a history to determine how the pain started, how
long it has persisted, how severe it is, what makes it worse, and what makes it better.

The abdomen should be examined. The patient's back is examined for tenderness, masses,
muscular spasm, alignment, and motion. A neurologic examination should be done and a rectal
examination is recommended.
If no abnormalities are noted, except decreased motion and muscular spasm, the patient can
be treated with a few days of rest and mild pain medication. If pain persists, a more complete
evaluation is indicated.
Patients with a herniated disc without compression of a nerve root do not need specific
treatment. They present with low back pain and virtually all will improve with nonoperative
care.
Those with compression of a nerve root will have pain that is distributed in the dermatome of
the compressed nerve root. The patient usually has a positive straight-leg-raise test. Initially,
nonoperative treatment is recommended, and most patients will have relief.
Those with persistent pain or recurrent pain should undergo disc removal.
Discitis is an infection of the disc.
This is not uncommon in children but is unusual in adults unless they are immunosuppressed
or IV drug users.
These patients will have unremitting back pain.
On a radiograph there will be a loss of disc height; however, this may not be apparent until
sometime after the patient has sought medical treatment.
Degenerative arthritis occurs in the elderly, and typically can be managed with physical
therapy and anti-inflammatory medication.
Some patients will develop spinal stenosis as a result of compromise of the spinal canal. These
patients may require decompression.
Another common cause of back pain, although usually seen more in the mid-back than in the
lower back, is a compression fracture. Most compression fractures occur in osteoporotic bone
and are caused by minimal trauma .
Compression fractures can occur in patients with normal bone and are usually caused by
significant trauma. However, the most common scenario is an elderly female who complains of
acute onset back pain after a minor fall or automobile accident.
There will be anterior wedging of a mid-thoracic vertebra. These patients are treated
nonoperatively, usually with an extension brace.