458 Clinical Orthopaedic Rehabilitation
Risk Factors for Osteoarthritis of the Knee
.'
• . jl
' knee but is surprisingly seldom a source of symptoms.
.., I
'I"'
The Arthritic Knee
Clinical Background
Arthritis of the knee can be due to many causes, includ-
ing congenital deformities (such as axial and rotatory de-
formity), trauma, and rheumatoid arthritis (Table 6-4).
Eighty percent of patients develop medial compartment
OA, and as the bone wears away, they develop a varus or
"bow-legged" deformity. Five to ten percent develop a lat-
eral compartment OA of the knee resulting in a valgus
or "knock-kneed" deformity. A small percentage of pa-
tients have rotatory deformities of the tibia that cause
significant patellar maltracking or subluxation.
Classification
Arthritic deformity of the knee is classified as varus or
valgus (with or without symptomatic patellar involve-
Established Controversial
Obesity Physical activity
Age Genetics
Osteoarthritis at other sites Smoking
Previous knee trauma or injury Estrogen deficiency
Previous knee surgery
Sex (female)
ment). Patellofemoral arthritis is common in an arthritic
Articular surface damage has been variously classified,
but the most useful categories are minimal, in which
there is no radiologic narrowing; mild, in which there is
loss of one third of the joint space; moderate, in which
two thirds of the joint space has been lost; and severe, in
which there is bone-an-bone contact.
Diagnosis
To examine for arthritis of the knee, move the joint un-
der load (e.g., to examine the medial compartment, a
varus strain is applied to the knee and the knee is
moved). Crepitus will be felt under the hand applying
the varus strain and pain will be produced. Similarly, a
valgus strain and load are applied to the lateral joint. The
knee should be examined for laxity of the collateral liga-
ments and, to some extent, the cruciate ligaments, al-
though this is less important. The presence of any fixed
flexion deformity (e.g., lack of passive extension of the
knee) should be noted. The patellar position (central or
subluxed) is important, as is the presence of a rotatory
deformity of the tibia. When the patient stands, note any
genu varum (bow-legged) or genu valgum (knock-kneed).
By the end of our history and exam of the arthritic
knee we have obtained the following information:
1. Symptom location
• Isolated (medial, lateral, or patellofemoral)
• Diffuse
 Chapter 6: The Arthritic Lower Extremity 459

2. Type of symptoms obtained with the knee in 30 degrees of flexion. The

• Swelling reason for this is that the articular cartilage loss in the
• Giving way, instability (ligament tear or weak medial compartment is in the distal femur and central
quadriceps) tibia, but articular cartilage loss in the lateral compart­
• Diminished ROM ment is in the posterior femur and posterior tibia.
• Mechanical (crepitance, locking, catching,
pseudolocking)
3. Timing of onset
Treatment of Knee Arthritis
(see Rehabilitation Protocol)
• Acute
• Insidious Nonoperative
4. Duration Treatment of early OA of the knee may be very ef­
5. Exacerbating factors fective if conscientiously carried out. Weight loss should
6. Prior intervention (e.g., NSAIDs, surgery) and the be strongly encouraged but not expected immediately.
patient's response Quadriceps strengthening makes a surprising difference.
Very strong quadriceps can considerably delay the neces­
Radiographic Evaluation of the Arthritic sity for surgery. If the patella is painful, extension exer­
Knee (Table 6-5) cises should be carried out only over the last 20 degrees
of extension. Activities such as deep squatting, kneeling,
Evaluation should always include a standing (weight­ and stair climbing that increase the patellofemoral joint
bearing) AP view of the knee. If surgery is contem­ reaction forces (PFJRFs) increase pain. Those activities
plated, there should be a full-limb (three-foot) view to should be avoided. If the patient starts with extremely
detect any deformities or problems above and below the weak muscles, electric stimulation may be used to begin
standard radiographic views (e.g., a valgus deformity of the process. Modalities other than heat or cold have not
the ankle). A lateral radiograph is required, as is a skyline been shown to be of value. Hyaluronic acid injections
view of the patella. If the problem is on the lateral side into the knee are of limited value. They appear to work
of the joint, a standing posteroanterior view must be best before there is bone-on-bone crepitus. Studies by in­
dependent researchers have found hyaluronic acid injec­
tions to be of "equal benefit" to nonsteroidal anti-inflam­
matory drugs (NSAIDs) (naproxyn [Naprosyn]). Patrella
Findings Indicating the Presence (2002) purports that hyaluronic acid intra-articular injec­
of Knee Osteoarthritis tion was of benefit. Careful review of the study actually
Symptoms Signs Radiography reveals that injection of hyaluronate sodium (Synvisc,
Pain with Joint line or Subchondral sclerosis
Provise, and Suplasyn) to be no better than placebo.
activity condylar tenderness Intra-articular osseous Similarly, intra-articular steroid injections have a very
debris (loose bodies or temporary and limited role.
joint mice) Keating (1993) found that of 85 patients with medial
Stiffness Effusion Joint narrowing compartment arthritis of the knee, more than 75% had sta­
(unicompartmental) tistical improvement on their Hospital for Special Surgery
Crepitation Joint irregularity pain scores at 12 months with the use of a lateral wedged
Decreased ROM Subchondral cysts insole in their shoe. For example, a 0.25 inch soft wedge or
Angular deformity Osteophytosis (" central or a 5 degree wedged insole placed laterally will reduce medial
marginal")
joint reactive forces from the medial joint line.

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee)
Brotzman

Tier 1: Nonoperative Options
• Weight loss! -successful weight loss (difficult) dramati­
cally improves pain in lower extremity arthritics and
prolongs total joint arthroplasty longevity after arthro­
plasty has been performed. Physician must be proactive
and implement low-impact aerobic exercise (water aero­
bics, cycling, swimming) and direct the patient to a rep­
utable weight-loss center (e.g., Weight Watchers).
continued

- -
460 Clinical Orthopaedic Rehabilitation

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee) (Continued)
Brotzman

Suggested Exercise Plan for Patients with Osteoarthritis of the Knee

Mild Symptoms" Moderate to Severe Symptoms

Active ROM exercises for the hip, knee, and ankle. Active-assisted ROM exercises for hip, knee, and ankle.

Physical therapy modalities as needed. Physical therapy modalities as needed.

Knee sleeve if comfortable. Stretching for quadriceps, hamstrings, adductors (Fig. 6-24),

Quadriceps sets for vastus medialis obliques, especially if

gastrocnemius; may use ultrasound for hamstrings if there is contraction.
there is a prominent patellofemoral component to Quadriceps sets for vastus medialis obliques; start supine if there

symptoms. is a hamstring contracture and gradually work up to a sitting position.

Advance to isometric progressive resistive exercises for Unloaded aerobic conditioning (pool, walker, grocery cart, cane);

quadriceps, hamstrings, and hip adductors and advance as described for hip.

abductors.
Advance strengthening to isometric closed-kinetic chain exercises,
Low-impact conditioning exerCISes. Avoid high
patellofemoral compressive forces.
Authors are strong proponents of aquatic (unloading)
exercise for mild, moderate, and severe arthritis
(see Chapter 7).
such as wall-sitting (not "slide," because this word implies repetitions,
which usually are not well tolerated).
Hip adductor and abductor strengthening.
Later, add straight leg raising progressive resistance exercise (2 pounds
on the thigh).
Later still, try lunges; however, lunges require great strength and excellent
balance and coordination, and few patients are strong enough or can
understand the importance of positioning; lunges can therefore
aggravate symptoms.

"The program for mild symptoms is given in one or two physical therapy visits.
OA, osteoarthritis; ROM, range of motion.
From Baum AL, Baum J: Coming to grips with depression in rheumatoid arthritis. J Musculoskel Med 15:36, 1998

B
Figure 6-24. Stretching exercises help preserve or increase joint range of motion (ROM). A, In
this example of a hip adductor stretch, the patient lies supine on a firm surface, with the hips
and knees bent and the feet flat. The patient then lets the knees fall apart, keeping the soles of
the feet together, until an inner thigh stretch is felt. B, To stretch the hamstrings, the patient
lies on the floor near a doorway, with one leg extending into the doorway. The patient slides
forward while gently raising the other leg with the foot flat against the wall until a gentle
stretch is felt behind the knee. (A and B, From Hicks JE: Rehabilitation strategies for patients
with rheumatoid arthritis. J Musculoskel Med 17:191, 2000.)

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee) (Continued)
Brotzman
• Activity modification (Table 6-6)
• Discontinue high-impact sports (e.g., running, tennis,
basketball), change to low-impact water-based sports
or cycling.
• Avoid stair-climbing, kneeling, squatting, low chairs
if patellofemoral arthritis exists.
• Change hard surface at work to soft if possible, sit
more than previously, and so on.
• Water aerobics in a warm pool (not a hot tub) for
aerobic exercise or strengthening.
• NSAIDs
• We typically employ cyclooxygenase-2 (COX-2) in­
hibitors (Vioxx, Celebrex) for their improved safety
profile (no difference in efficacy).
• Employ the minimal effective dose, intermittent use if
possible.
• Significant potential long-term complication rate makes
these less attractive
• Peptic ulcer disease.
• Renal effects.
• Gastrointestinal bleed.
• Cane in the opposite hand (see Fig. 6-1)
• Greatly decreases stress on arthritic joint, but for
cosmesis considerations, many "young" or female
arthritics will not use a cane.
• Viscosupplementation of the knee (e.g., hylan G-F 20
[Synvisc], hylauronate sodium [HyalganJ)
• Although some patients do respond well to serial in­
jections, studies have shown efficacy only comparable
with taking Naprosyn.
• "Unloading" graphite braces for knee arthritis (not
hip)
• If the patient has unicompartmental knee involve­
ment (e.g., medial), she or he may derive some bene­
fit from a custom "unloader" brace
• Very expensive.
• Most patients quit wearing quickly secondary to
bulkiness, inconvenience.
• Knee sleeve for proprioception (knee arthritis)
• Some patients derive benefit from a light Neoprene
knee sleeve, which may improve proprioceptive feed­
back (indications are soft, but the braces are inex­
pensive with little if any possible complication).
• Chondroitin sulfatejglucosamine
• Moderately expensive ($40 a mol.
• No multi-center studies confirming or denying efficacy.
• No side effects or complications. If patients wish to
try and derive great benefit (? placebo), we have
them continue. Otherwise, patient instructed to dis­
continue at 3 mo if no benefit.
• Physical therapy
• A brief course of therapy to teach home program of
hamstring and quadricep strengthening, flexibility,
-
- -= -:- -"'~-=..:~_::.._'2:~ ~
Chapter 6: The Arthritic Lower Extremity 461
ROM exercises, and aquatic therapy is very useful if
good patient compliance. Have follow-up visits to
monitor compliance and progression.
• Intra-articular cortisone (knee not hip)
• Response to aspiration and injection is highly vari­
able (2 wk-6 mol.
• Injections should be limited to three per year
(potential articular cartilage softeningjAVN). Warn
patients of potential corticosteroid-related flare.
Application of ice that evening can help avoid
this.
• Topical therapy
• We have found topical therapy to be largely
ineffective.
The Arthritis Foundation offers the following exercise pro­
grams for arthritic patients:
• Aquatics-heated pool, 6-10 wk, minimal joint stress,
increased ROM.
• Joint efforts-6-8 wk, for patients with very limited
mobility or elderly.
• PACE (People with Arthritis Can Exercise)-6-8 wk,
two levels of classes.
• PEP (Pool Exercise Program) -45-min video that in­
creases flexibility, strength, and endurance.
Multiple brochures on arthritis information are available. Call
Arthritis Foundation 1-800-283-7800 or www.arthritis.org.
Tier 2: Operative Options for Patients with
Symptomatic Arthritic Knees
Arthroscopy
• With OA, degenerating articular cartilage and synovial
tissue release proinflammatory cytokines that induce
chondrocytes to release lytic enzymes leading to degrada­
tion of type 2 collagen and proteoglycans.
• The "lavaging" effect of arthroscopy may dilute or
"wash out" these inflammatory mediators, although the
effect is temporary.
• Patients often have unrealistic expectations of
arthroscopy for arthritis, so counseling on the palliative
or temporary effect is needed.
• Microfracture mayor may not offer some pain benefit.
Drilling and abrasion chondroplasty seem to offer little
benefit.
• Patients who benefit most from arthroscopy have me­
chanical symptoms (locking meniscus) of short duration
«6 mol with mild arthritis on radiographs.
• Patients with 3 - 6 mo of unsuccessful supervised non­
surgical management with normal mechanical align­
ment and mild to moderate arthritis on weight-bearing
films are considered candidates for arthroscopic
debridements.
continued
462 Clinical Orthopaedic Rehabilitation

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee) (Continued)
Brotzman

Table 6-7
Prognostic Factors for Arthroscopic Debridement of the Arthritic Knee
History Physical Examination Radiographic Findings Arthroscopic Findings
Good Prognosis
Short duration Medial tenderness Unicompartmental Outbridge I or II changes
Associated trauma Effusion Normal alignment Meniscal flap tear
First arthroscopy Normal alignment Minimal Fairbank's changes Chondral fracture or flap
Mechanical symptoms Ligaments stable Loose bodies Loose bodies
Relevant osteophytes Osteophytes at symptom
site

Poor Prognosis
Long duration Lateral tenderness Bi- or tri-compartmental Outbridge III or IV changes
Insidious onset No effusion Malalignment Degenerative meniscus
Multiple procedures Malalignment Significant Fairbank's changes Diffuse chondrosis
Varus> 10 degrees
Valgus> 15 degrees
Pain at rest Ligaments unstable Irrelevant osteophytes Osteophyte away from
symptom site
Litigation
Work-related

From Di Nubile N: Osteoarthritis of the knee-a special report. Physician Sports Med May: 2000.

• Patients with tibial spine pain, osteophyte formation,
and lack of extension (flexion deformity) may benefit
from arthroscopic notch plasty and osteophyte removal.
• Table 6-7 reviews the prognostic factors for arthro­
scopic debridement of an arthritic knee.
• Arthroscopic management of the arthritic knee should
be considered palliative, temporary, and most effective
in the patient with concomitant mechanical findings
(e.g., bucket-handle meniscal tear with a positive Mc­
Murray examination).
Surgery for Focal Cartilage Defects of the Femur (Cartilage
Transfer or Chondrocyte Implantation) (Table 6-8)

~ ~ ~~t~> "'~C'ci"F~ut"";;"'{~f' ~AW

.
: ~ ..". J,;&~~"jl
.. ".~,.,. $,; ·,,1t#'~~,';]"I~~$ •
, 191!.'Wl
'. .
Table 6 - 8 ? , ~< ·%!:!;t;{llJ~~Jt!/~~ .

Surgical Treatment Options for Symptomatic Focal Cartilage Defects of the Femur*
Lesion Treatment Rehabi Iitation t Comments

Primary
<2 cm 2 Debridement and lavage. Straightforward. Provides short-term symptomatic relief.

Marrow stimulation Significant. Ideal for smaller lesions located on femoral condyle;

techniques. provides intermediate short-term relief; low cost.

Osteochondral autograft. Moderate. Relatively new procedure; probably as good as, if

not better than, marrow stimulation techniques;

provides potentially long-term relief.

>2 cm 2 Debridement and lavage. Straightforwa rd. Provides short-term symptomatic relief.

Marrow stimulation Significant. Has lower success rate for larger lesions; good choice

techniques. for symptomatic relief in low-demand individuals;

intermediate-term relief is possible; low cost.

 Chapter 6: The Arthritic Lower Extremity 463

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee) (Continued)
Brotzman

Surgical Treatment Options for Symptomatic Focal Cartilage Defects of the Femur*
Lesion Treatment Rehabilitation t Comments

Cartilage biopsy for

Straightforward. Staged procedure.
future autologous

chondrocyte implantation.

Osteochondral autograft.
Significant. With larger lesions, potential for donor site morbidity
exists; results are variable.

Osteochondral allograft.
Significant. Useful for larger lesions with significant bone stock

loss; small concern for disease transmission and

allograft availability; provides potentially long-term relief.

Secondary

2
<2 cm Osteochondral autograft.'
Moderate. Relatively new procedure; probably as good as, if not

better than, marrow stimulation techniques; provides

potentially long-term relief.

Autologous chondrocyte
Significant. High success rate for return to activities; potentially

implantation.
long-term relief; relatively high cost.

>2 cm 2 Osteochondral autograft.

Significant. With larger lesions, potential for donor site morbidity

exists; results are variable.

Osteochondral allograft.
Significant. Useful for larger lesions with significant bone stock loss;

small concern for disease transmission and allograft

availability; provides potentially long-term relief.

Autologous chondrocyte
Significant. High success rate for return to activities; potentially

implantation.
long-term relief; relatively high cost.

* Procedure selection depends on patient's age, expedations, demand, activity level, coexisting pathology, and extent and location of disease. For rehabili­

tation after articular defect surgery, please see Chapter 4, Knee Injuries.

'Straightforward, early weight-bearing and return to activities within 4 wk; moderate, short-term protected weight-bearing and return to activities within

12 wk; significant. prolonged protected weight-bearing and significant delay until return to activities (6-8 mol.

'Follows failed primary treatment.

From Cole BJ: Arthritis of the knee-a special report, Physician Sports Med 28(5):1-15, 2000.

Osteotomy Unicompartmental Knee Replacement

• Varus malalignment of the knee (bow-legged) in a • More controversial, patient selection is critical.
younger, active patient with medial compartment • Ideal candidate is
arthritis is addressed with a valgus-producing, high tibial • Older than 60 yr.
osteotomy. • Low-demand (sedentary).
• Mild valgus malalignment « 10 degrees of valgus) may • Thin.
be treated with a medial, high tibial closing wedge os­ • Isolated unicompartmental arthritic involvement
teotomy. Patients with greater than 10 degrees of valgus (Table 6-9).
undergo femoral osteotomy.
• Supracondylar femoral osteotomies do not interfere with Tier 3: Options for the Symptomatic Arthritic Knee
subsequent total knee replacements. However, tibial os­ TOTAL Joint Replacement
teotomies compromise total knee replacement results. • Total joint replacements work best in thin sedentary pa­
For this reason, osteotomies are seldom performed in the tients older than 6S yr.
United States. New opening-wedge osteotomy tech­ • A proportion of replacements "wear out" with time (oste­
niques for the tibia purport not to alrer the joint line for olysis), requiring revision. This revision rate is increased
later total knee replacement. with obesity, high-impact activity, overuse, and so on.
continued

-
- - - -

~
464 Clinical Orthopaedic Rehabilitation

Rehabilitation Protocol
Nonoperative and Operative Treatment Algorithm for Patients with
Arthritis of the Lower Extremity (Hip or Knee) (Continued)
Brotzman

Table 6-9
Treatment Criteria for Unicompartmental Knee Athritis
Unicompartmental Knee Arthroplasty High Tibial Osteotomy Total Knee Arthroplasty

History
>60 yr old <60 yr old, ideally 50s >65 yr old
Sedentary Laborer Sedentary
Pain with weight-bearing Activity-related pain Degenerative traumatic or
inflammatory arthritis
Noninflammatory arthritis Noninflammatory arthritis
No patellofemoral symptoms No patellofemoral
symptoms

Exam
ROM 5-90 degrees or better Flexion > 90 degrees Joint line tenderness
< 15 degrees coronal deformity Flexion contracture < 15 Altered ROM
degrees
Intact ACL (controversial) Competent MCl Varus or valgus deformity
Intact collateral ligaments Heavier patients
<200 pounds (90 kg)

X-rays
Isolated unicompartmental disease Mild to moderate Multicompartmental disease
osteoa rth ritis
Asymptomatic patellofemoral disease Varus alignment Varus or valgus alignment
Acceptable
No tibial or femoral bowing

Intraoperative Findings
Contralateral compartment without Inspection of articular Multicompartmental articular
eburnated bone and has normal meniscus surface prior to osteot­ degeneration
omy of no prognostic value
No evidence of inflammatory process Bony defects

Contraindications
Inflammatory arthritis Inflammatory arthritis Acute infection
Limited ROM Limited ROM Extensor mechanism disruption
Advanced patellofemoral disease or contra­ Advanced patellofemoral Severe recurvatum deformity
lateral compartment disease disease
Chondrocalcinosis (controversial) Varus> 10 degrees Severe vascular disease
ACl deficiency (controversial)

ACl, anterior collateral ligament; MCl, medial collateral ligament; ROM, range of motion.

From Seigel JA. Marwin SE: The role of unicompartmental knee arthroplasty. Orthopaedics Special Ed 5(2):62, 1999.

Operative - Arthritic Knee cellent overview on arthroscopy in patients with knee

Arthroscopic debridement is of temporary value,
simply cleaning out the tags and meniscal tears and
flushing from the joint fluid that contains pain-producing
peptides. Cole and Hamers' (1999) article on the evalu­
ation and management of knee arthritis provides an ex­
arthritis.
Livesley et al (1991) compared the results in 37
painful arthritic knees treated with arthroscopic lavage by
one surgeon against those in 24 knees treated with physi­
cal therapy alone by a second surgeon. The results sug­

gested that there was better pain relief in the lavage
group at 1 year. Edelson et al (1995) reported that lavage
alone had good or excellent results in 86% of their pa­
tients at 1 year and in 81 % at 2 years using the Hospital
for Special Surgery scale.
Jackson and Rouse (1982) reported on the results of
arthroscopic lavage alone versus lavage combined with
debridement, with 3-year follow-up. Of the 65 patients
treated with lavage alone, 80% had initial improvement
but only 45% maintained improvement at follow-up. Of
the 13 7 patients treated with lavage plus debridement,
88% showed initial improvement, and 68% maintained
improvement at follow-up. Gibson et al (1992) demon­
strated no statistically significant improvement with ei­
ther method, even in the short term. Patients who pre­
sent with flexion deformities associated with pain or
discomfort and osteophyte formation around the tibial
spines may benefit from osteophyte removal and notch­
plasty, as demonstrated by Puddu et al (1994).
The efficacy of lavage with or without debridement is
controversial, and randomized prospective controlled tri­
als have not been performed. The literature suggests that
arthroscopic lavage and debridement, when performed for
appropriate indications, will provide improvement in pain
relief for 50% to 70% of patients, with relief lasting from
several months to several years. Drilling and abrasion
arthroplasty do not appear to offer additional benefit.
Arthroscopy is also a sensitive way to evaluate cartilage
when contemplating osteotomy or unicompartmental
knee arthroplasty, as plain radiography and magnetic reso­
nance imaging often underestimate the extent of os­
teoarthritis.
Several factors determine prognosis after lavage and
debridement. Those who benefit most present with a
history of mechanical symptoms, symptoms of short dura­
tion «6 months), normal alignment, and only mild to
moderate radiographic evidence of osteoarthritis. It is not
uncommon for patients to have unrealistic expectations
after arthroscopic debridement. Thus, it is important to
counsel patients about the limited indications and pallia­
tive results.
Osteotomy of the Knee
This is a mechanical load-shifting procedure. The
mechanical axis of the knee is "shifted" from the worn
compartment (usually medial) to the good compartment.
Closing wedge osteotomies have an inherent disadvan­
tage in that the tibiofibular joint must be disrupted with
some degree of shortening and joint-line alteration. Be­
cause the joint line must remain "horizontal," in OA
with a valgus deformity, the osteotomy is done through
the supracondylar region of the femur; and for varus
deformity, it is done through the proximal tibia. Con­
traindications to tibial osteotomy include panarthrosis
(tricompartmental involvement), severe patellofemoral
disease, severely restricted ROM (loss of more than 15 to
Chapter 6: The Arthritic Lower Extremity 465
20 degrees of extension, or flexion less than 90 degrees),
and inflammatory arthritis. There are very few con­
traindications to a varus osteotomy other than damage to
the medial compartment. There are many contraindica­
tions for a tibial osteotomy. Outcome after a valgus os­
teotomy depends on the varus thrust force. This force,
however, can be detected only by the use of a very so­
phisticated force plate analysis, of which there are very
few available worldwide, and other indications must be
used. Strength-to-weight ratio is extremely important,
meaning that the older the patient and the heavier they
are, the less the indication. A straight tibial diaphysis
will result in an oblique joint line. A pagoda-shaped or
sloping surface of the tibial plateaus usually produces a
bad result. Lateral subluxation of the tibia on the femur
and flexion contracture of more than 7 degrees also pro­
duce a bad result.
No osteotomy will last indefinitely. Supracondylar
femoral osteotomies do not interfere with subsequent
total knee replacement because the osteotomy is done
above the level of the collateral ligaments. Tibial os­
teotomy will produce an inferior result with a total
knee replacement because the osteotomy is done inside
the collateral ligaments and patellar tendons and may
produce a patella baja deformity. Eventually, a total knee
replacement will be required in these patients. For this
reason, osteotomies are seldom done in the United
States, although they remain moderately popular in many
places in the world. New "opening wedge" techniques
with Puddu plate type fixation are currently being evalu­
ated. Their purported value is that the open wedge does
not adversely affect the joint line in subsequent total
knee replacement.
Total Knee Arthroplasty
Many surgeons use identical routines after total knee
replacement, whether the implants are cemented or non­
cemented. Their rationale is that the initial fixation of
noncemented femoral and tibial components is in gen­
eral so good that loosening is very uncommon. The tibia
is largely loaded in compression. The stability achieved
with pegs, screws, and stems on modern implants is now
adequate to allow full weight-bearing. However, if the
bone is exquisitely soft, weight-bearing should be delayed.
The progression to weight-bearing, therefore, must be
based solely on the surgeon's discretion and intraoperative
observations.
The guidelines for rehabilitation given here are
general guidelines and should be tailored to individual
patients. Concomitant osteotomies and significant struc­
tural bone grafting are indications for limited weight­
bearing until healing has been achieved. Similarly, if the
bone is extremely osteoporotic, full weight-bearing is
delayed until the peri-implant bone plate develops. Expo­
466 Clinical Orthopaedic Rehabilitation
sure problems requmng a tibial tubercle osteotomy or a
quadriceps tendon division may require that SLR be
avoided until adequate healing has occurred, which typi­
cally takes 6 to 8 weeks.
Component design, fixation methods, bone quality,
and operative techniques all affect perioperative rehabili­
tation. The implant choice no longer determines rehabili­
tation methods. It does not or should not make much
difference whether the implant is unconstrained, semi­
constrained, or fully constrained.
Postoperative return of 90 degrees of knee flexion
is generally considered the minimal requirement for
activities of daily living with an involvement of one
knee. However, if both knees are replaced, it is essential
that one knee reach more than 105 degrees of knee
bend to allow the patient to rise from a normal low toi­
let seat.
Continuous passive motion (CPM) may be used af­
ter surgery, but there is a certain increase in wound prob­
lems with it. Furthermore, if the patient is left on it for
long periods of time, a fixed flexion contracture of the
knee tends to develop. If CPM is to be used, therefore,
the patient must come off the machine for part of the
day and work at achieving full extension. We limit ag­
gressive or prolonged CPM use in patients with the po­
tential for wound problems (such as those with diabetes
or obesity).
Immediately after surgery, patients frequently have a
flexion contracture because of hemarthrosis and irrita­
tion of the joint. These flexion contractures generally
resolve with time and appropriate rehabilitation. How­
ever, patients who have been left with a fixed flexion
contracture at the time of the surgery frequently are un­
able to achieve full extension. It is important, there­
fore, that full extension be achieved in the operating
room.
Manipulation under anesthesia may occasionally be
required. This is a very individual decision on the part
of the surgeon. The author's (HUC) preference is to
carry out a full manipulation under anesthesia using
muscle relaxant if the patient has not achieved greater
than 70 degrees of flexion by 1 week. The usual area at
which adhesions develop is the suprapatellar pouch.
Many surgeons rarely perform any manipulations under
anesthesia and believe that the patient will be able to
work through the motion loss. Late manipulation under
anesthesia (after 4 weeks) requires great force and risks
serious injury to the knee. Alternatively, arthroscopic ly­
sis of adhesions in the suprapatellar pouch can be done
with an arthroscopy obturator or a small periosteal
elevator.
Reflex sympathetic dystrophy (RSD) of the knee is
uncommon after total knee replacement and is usually di­
agnosed late. The hallmarks are chronic pain that is pres­
ent 24 hours a day and allodynia or skin tenderness. Such
patients usually fail to achieve a reasonable ROM and
usually also develop a flexion contracture. If this sus­
pected, a lumbar sympathetic block may be of not only
diagnostic but also therapeutic value and should be car­
ried out as soon as possible.
Total Knee Arthroplasty: Indications and
Contraindications
Indications for total knee arthroplasty include disabling knee
pain with functional impairment and radiographic evidence
of significant arthritic involvement, and failed conservative
measures; including ambulatory aids (cane), NSAIDs, and
lifestyle modification (see p. 461)
Contraindications for Total Knee Arthroplasty
Absolute
• Recent or current joint infection-unless carrying out an
infected revision.
• Sepsis or systemic infection.
• Neuropathic arthropathy.
• Painful solid knee fusion (painful healed knee fusions are
usually due to RSD. RSD is not helped by additional
surgery).
Relative Contraindications
• Severe osteoporosis.
• Debilitated poor health.
• Nonfunctioning extensor mechanism.
• Painless, well-functioning arthrodesis.
• Significant peripheral vascular disease.
Classification of Tricompartmental Total
Knee Implants
Constraint
Unconstrained (Fig. 6-25)
• Relies heavily on soft tissue integrity to provide joint
stability.
• Rarely used in total knee arthroplasty.
Semiconstrained
• Most knee prostheses fall into this group.
• With judicious soft tissue releases and proper implant se­
lection, flexion contractu res up to 45 degrees and angu­
lar deformities up to 25 degrees can be corrected.
Fully Constrained
• Fully constrained in one or more planes of motion.
• Because of restriction of motion in one or more planes of
motion, implant stresses are very high, with potentially
higher incidence of loosening, excessive wear, and
breakage.
• Reserved for severe instability and severe deformity too
large for semiconstrained implants.

Figure 6-25. Total knee arthroplasty. (From Howmedica In­
structional Handout. Salt Lake City, Howmedica Press, 1993,
p2.)
Goals of Rehabilitation after Total
Knee Arthroplasty
• Prevent hazards of bedrest (e.g., DVT, pulmonary em­
bolism, pressure ulcers).
• Assist with adequate and functional ROM
• Strengthen knee musculature.
• Assist patient in achieving functional independent
activities of daily living.
• Independent ambulation with an assistive device.
Perioperative Rehabilitation Considerations
Component design, fixation method, bone quality,
and operative technique (osteotomy, extensor mechanism
technique) will all affect perioperative rehabilitation. Im­
plants can be posterior cruciate ligament (PCL) -sacrific­
ing, PCL-sacrificing with substitution, or PCL-retaining.
See the box for advantages and disadvantages of these
component designs.
Chapter 6: The Arthritic Lower Extremity 467
Rehabilitation of Patients with "Hybrid"
Ingrowth Implants versus Those with
Cemented Total Knee Implants
Cemented Total Knee Arthroplasty
• Ability for weight-bearing as tolerated with walker from
1 day postoperative.
"Hybrid" or Ingrowth Total Knee Arthroplasty
• Touch-down weight-bearing (TDWB) only with walker for
first 6 wk.
• Next 6 wk, begin crutch walking with weight-bearing as
tolerated.
Note: Surgeon's preference may be different. Many believe
that because of compression with weight-bearing and good
stability of the tibial implant, weight-bearing as tolerated
with a walker is allowed immediately after surgery.
Posterior Cruciate Ligament- Sacrifice
or Retain
Advantages of Preserving the Posterior Cruciate
Ligament
• Potentially restores more normal knee kinematics, result­
ing in a more normal stair-climbing ability compared with
those with PCL-sacrificing knees.
Disadvantages of Preserving the Posterior Cruciate
Ligament
• Excessive rollback of the femur on the tibia if too tight.
• Preoperative joint line must be reproduced.
• More difficult collateral ligament balancing.
• More difficulty in correcting large flexion contractures.
Fixation Method for Total Knee Implants
Cemented
• Used for older, more sedentary patients.
Porous Ingrowth
• Theoretically, porous ingrowth fixation should not deterio­
rate with time (unlike cemented fixation) and is thus the
ideal choice for younger or more active candidates.
Hybrid Technique
• Noncemented "ingrowth" femoral and patellar compo­
nent with a cemented tibial component.
• Frequently used because of failure to achieve fixation
with some of the original porous-coated tibial compo­
nents reported in the literature.
468 Clinical Orthopaedic Rehabilitation

Continuous Passive Motion

There is conflicting data on the long-term effects Patient-related Risk Factors for Postoperative
of CPM on ROM, DVT, PE, and pain relief. Several Complications
studies have shown a shorter period of hospitalization • Chronic use of corticosteroids
with the use of CPM by shortening the length of • Smoker
time required to achieve 90 degrees of flexion. How­ • Obesity
ever, an increased incidence of wound complica­ • Malnutrition (albumin < 3.5 and lymphocyte count

tions has also been reported. Reports vary on whether < 1500)

there is any long-term (l year) improvement of postop­
erative flexion in patients using CPM versus those who
do not.
Transcutaneous oxygen tension of the skin near the inci­
sion for total knee replacement has been shown to decrease
significantly after the knee is flexed more than 40 degrees.
Therefore, a (PM rate of 1 cycle per minute and a maximal
flexion limited to 40 degrees for the first 3 days is recom­
mended.
If a CPM unit is used, the leg seldom comes out into
full extension. Such a device must be removed several
times a day so that the patient can work to prevent the
development of a fixed flexion deformity.
• Diabetes mellitus
• Immunosuppressive use (e.g., methotrexate)
• Hypovolemia
• Peripheral vascular disease
Deep Vein Thrombosis Prophylaxis
The incidence of DVT after total knee arthroplasty is
much higher than originally suspected. Based on clinical
detection, the DVT rate after total knee arthroplasty
ranges from 1 to 10%. However, more sensitive tech­
niques (radioactive fibrinogen scans) have revealed a
much higher incidence (50 to 70%). Prophylactic treat­
ment is indicated (p. 457).

Total Knee Arthroplasty Rehabilitation Outline

Preoperative Physical Therapy
• Review transfers with patient
• Bed-to-chair transfers.
• Bathroom transfers.
• Tub transfers with tub chair at home.
• Teach postoperative knee exercises and give patient handout.
• Teach ambulation with assistive device (walker): TDWB or WBAT for total knee arthroplasty at the discretion of the surgeon.
• Review precautions
• To prevent possible dislocation, avoid hamstring exercises in a sitting position when using a posterior stabilized prosthesis (cruci­
ate-sacrificing).

Inpatient Rehabilitation Goals

• 0-90 degrees ROM in the first 2 wk before discharge from an inpatient (hospital or rehabilitation unit) setting.
• Rapid return of quadriceps control and strength to enable patient to ambulate without knee immobilizer.
• Safety during ambulation with walker and transfers.
• Rapid mobilization to minimize risks of bedrest.

Because of tradeoffs between early restoration of knee ROM (especially flexion) and wound stability in the early postoperative period,
different protocols are used, according to surgeon preference.

Rehabilitation Protocol
Total Knee Arthroplasty-"Accelerated" Postoperative Rehabilitation
Protocol
Cameron and Brotzman

Day 1 NOTE: Use knee immobilizer during ambulation until patient is

• Initiate isometric exercises (p. 447) able to perform three SLR in succession out of the immobilizer.
• SLR. • Cemented prosthesis: Weight-bearing as tolerated
• Quad sets. (WBAT) with walker.
• Ambulate twice a day with knee immobilizer, assistance, • Noncemented prosthesis: TDWB with walker.

and walker.


Rehabilitation Protocol
Total Knee Arthroplasty-"Accelerated" Postoperative Rehabilitation
Protocol (Continued)
Cameron and Brotzman
• Transfer out of bed and into chair twice a day with leg
in full extension on stool or another chair.
• ePM machine ~ patient can independently execute transfers and
• Do not allow more than 40 degrees of flexion on set­
tings until after 3 days.
• Usually I cycle pe{min.
a
• Progress 5 - 10 degrees day as tolerated.
• Do not record passive ROM measurements from
CPM machine, but rather from patient because these
may differ 5-10 degrees.
• Initiate active ROM and active-assisted ROM exerises.
• During sleep, replace the knee immobilizer and place
• Prescribe prophylactic antibiotics for possible eventual
a pillow under the ankle to help passive knee
dental or urologic procedures.
extension.
• Do not permit driving for 4-6 wk. Patient must have
2 Days - 2 Weeks
• Continue isometric exercises throughout rehabilitation.
• Use vastus medialis oblique (VMO) biofeedback if pa­
tient is having difficult with quadriceps strengthening or
control.
• Begin gentle passive ROM exercises for knee
• Knee extension (Fig. 6-26).
• Knee flexion.
• Heel slides.
• Wall slides.
• Begin patellar mobilization techniques when incision
chair, and then lifts the leg over.
stable (postoperative days 3 - 5) to avoid contracture.
• Tub mats and nonslip stickers for tub floor traction
• Perform active hip abduction and adduction exercises.
• Continue active and active-assisted knee ROM
exercises.
6 Weeks
• Continue and progress these exercises until 6 wk after
surgery. Give home exercises with outpatient physical
therapist following patient two to three times per week.
Chapter 6: The Arthritic Lower Extremity 469
• Provide discharge instructions. Plan discharge when
ROM of involved knee is from 0-90 degrees and
ambulation.
10 Days-3 Weeks
• Continue previous exercises.
• Continue use of walker until otherwise instructed by
physician.
• Ensure that home physical therapy and/or home nursing
care has been arranged.
regained functional ROM, good quad control, and pass
physical therapy functional testing.
• Provide walker for home and equipment and supplies as
needed.
• Orient family to patient's needs, abilities, and limita­
tions.
• Review tub transfers
• Many patients lack sufficient strength, ROM, or
agility to step over tub for showering.
• Place tub chair as far back in tub as possible, facing
the faucets. Patient backs up to the tub, sits on the
also are recommended.
• Begin weight-bearing as tolerated with ambulatory aid, if
this has not already begun.
• Perform wall slides; progress to lunges.
Figure 6-26. Passive ROM exer­
cises for knee extension. The pa­
tient places a towel under the
foot. Use a slow, sustained push
with the hands downward on
the quadriceps.
continued
470 Clinical Orthopaedic Rehabilitation

Rehabilitation Protocol
Total Knee Arthroplasty-"Accelerated" Postoperative Rehabilitation
Protocol (Continued)
Cameron and Brotzman

L
Figure 6-27. Four-inch-high step-ups for quadriceps
strengthening.

• Perform quadriceps dips or step-ups (Fig. 6-27). ~

• Begin closed-chain knee exercises on total gym and

progress over 4-5 wk

• Bilateral lower extremities. Figure 6-28. Lap-stool exercises for hamstring strengthen­
• Single-leg exercises. ing.
• Incline.
• Progress stationary bicycling. • Use McConnell taping of patella to unload
• Perform lap-stool exercises (hamstring strengthening)
patellofemoral stress if patellofemoral symptoms occur
(Fig. 6-28).
with exercise.
• Cone-walking: progress from 4- to 6- to 8-inch cones. • Continue home physical therapy exercises.

Rehabilitation Protocol
After Total Knee Arthroplasty
Wilk

Phase 1: Immediate Postoperative Phase-Days • Knee flexion to 90 degrees or greater.

1-10 • Control of swelling, inflammation, and bleeding.
Goals Days 1-2
• Active quadriceps muscle contraction. Weight-bearing
• Safe (isometric control), independent ambulation. • Walker/two crutches WBAT.
• Passive knee extension to 0 degrees.
 Chapter 6: The Arthritic Lower Extremity 471

Rehabilitation Protocol

After Total Knee Arthroplasty (Continued)

Wilk

Continuous Passive Motion Exercises

• 0-40 degrees as tolerated if stable wound, and no con­ • Quad sets.
traindications. Take knee out of CPM several times a • Knee extension exercise 90-0 degrees.
day and place in a knee immobilizer with pillows under • Terminal knee extension 45-0 degrees.
the ankle (not the knee) to encourage passive knee ex­ • SLR (flexion-extension).
tension (see p. 469). • Hip abduction-adduction.
Cryotherapy • Hamstring curls.
• Commerical unit used. • Squats.
• Stretching
Deep Vein Thrombosis Prophylaxis
• Hamstrings, gastrocnemius, soleus, quads.
• Per physician.
• Bicycle ROM stimulus.
Exercises • Continue passive knee extension stretch.
• Ankle pumps with leg elevation. • Continue use of cryotherapy.
• Passive knee extension exercise. • Discontinue use of TED hose at 2- 3 wk (with physi­

• SLR if not contraindicated (see p. 447). cian's approval).

• Quad sets.
Weeks 4-6
• Knee extension exercise 90- 30 degrees.
Exercises
• Knee flexion exercises (gentle).
• Continue all exercises listed above.
Days 4-10 • Initiate
Weight-bearing • Front and lateral step-ups (minimal height).
• As tolerated. • Front lunge.
Continuous Passive Motion • Pool program.
• 0-90 degrees as tolerated. • Continue compression, ice, and elevation for
Exercises swelling.
• Ankle pumps with leg elevation. Phase 3: Intermediate Phase-Weeks 7-12
• Passive knee extension stretch.
Criteria for Progression to Phase 3
• Active-assisted ROM knee flexion.
• ROM 0-110 degrees.
• Quad sets.
• Voluntary quadriceps muscle control.
• SLR.
• Hip abduction-adduction. • Independent ambulation.
• Knee extension exercise 90-0 degrees. • Minimal pain and inflammation.
• Continue use of cryotherapy. Goals
Gait Training • Progression of ROM (0-115 degrees and greater).
• Continue safe ambulation. • Enhancement of strength and endurance.
• Instruct in transfers. • Eccentric-concentric control of the limb.
• Cardiovascular fitness.
Phase 2: Motion Phase-Weeks 2-6 • Functional activity performance.
Criteria for Progression to Phase 2 Weeks 7-10
• Leg control, able to perform SLRs. Exercises
• Active ROM 0-90 degrees. • Continue all exercises listed in phase 2.
• Minimal pain and swelling. • Initiate progressive walking program.
• Independent ambulation and transfers. • Initiate endurance pool program.
Goals • Return to functional activities.
• Lunges, squats, step-ups (small 2-inch step to start).
• Improve ROM.
• Enhance muscular strength and endurance. • Emphasize eccentric-concentric knee control.
• Dynamic joint stability. Phase 4: Advanced Activity Phase-Weeks 14-26
• Diminish swelling and inflammation.
Criteria for Progression to Phase 4
• Establish return to functional activities.
• Improve general health. • Full, nonpainful ROM (0-115 degrees).
• Strength of 4+/5 or 85% of contralateral limb.
Weeks 2-4
• Minimal or no pain and swelling.
Weight-bearing
• Satisfactory clinical examination.
• WBAT with assistive device.
continued

- -

---- = - =­
 472 Clinical Orthopaedic Rehabilitation

Rehabilitation Protocol
After Total Knee Arthroplasty (Continued)
Wilk

Goals • Squats.
• Allow selected patients to return to advanced level of • Lateral step-ups.

function (recreational sports).

• Knee extension exercise 90-0 degrees.
• Maintain and improve strength and endurance of lower • Bicycle for ROM stimulus and endurance.

extremity.
• Stretching
• Return to normal lifestyle. • Knee extension to 0 degrees.
Exercises • Knee flexion to 105 degrees.
• Quad sets. • Initiate gradual golf, tennis, swimming, bicycle, walking
• SLR (flexion-extension). program.
• Hip abduction-adduction

Recommended Long.term Activities after Total
Joint Replacement
DeAndrade (1993) developed an evaluation scale of
the activities for patients with total joint replacements.
Stress on the joint replacement should be minimized to
avoid excessive wear and tear that would reduce the
longevity of the implant. Intensity of the exercise should
be adjusted so that it is painless, but still promotes car­
diovascular fitness. Running and jumping should be
avoided, and shoes should be well cushioned in the heel
and insole. Joints should not be placed at the extremes of
I'
motion. Activity time should be built up gradually, with
frequent rest periods between activity periods. Correct use
of walking aids is encouraged to minimize stress on the
joint replacement. The first long-term activity undertaken
should be walking (Table 6-10).
Management of Rehabilitation Problems after
Total Knee Arthroplasty
Recalcitrant Flexion Contracture (Difficulty Obtaining
Full Knee Extension)
• Initiate backward walking.
• Perform passive extension with the patient lying
prone with the knee off the table, with and without
weight placed across the ankle (see Fig. 4-24 ). This
should be avoided if contraindicated by the PCl sta­
tus of the arthroplasty.

Table 6-10
Recommended Long-term Activities after Total Replacement of the Hip or Knee
Needs Some Skill.
Very Good. Highly Prior Significant With Care. Ask Your
Recommended Good. Recommended Expertise Doctor AVOID

Stationary bicycling Bowling Bicycling (street) Aerobic exercise Baseball

Ballroom dancing Fencing Canoeing Calisthenics Basketball
Square dancing Rowing Horseback riding Jazz dancing Football
Golf Speed walking Rock climbing Softball
Stationary (Nordic­ Table tennis Inline skating Handball
Track) skiing Cross-country skiing Nautilus exercises Jogging
Swimming Ice skating Racq uetba 11/
Walking Downhill skiing squash
Weight-lifting Tennis-doubles Lacrosse
Step machines (for Soccer
patients with hip re­ Tennis-singles
placements; not for
Volleyball
those with knee re­
placements)

From De Andrade RJ: Activities after replacement of the hip or knee. Orthop Special Ed 2(6):8, 1993.

• Eccentric extension. The therapist passively extends
the leg and then holds the leg as the patient at­
tempts to lower it slowly.
• With the patient standing, flex and extend the in­
volved knee. Sports cord or rubber bands can be used
for resistance.
• Use electric stimulation and VMO biofeedback for
muscle re-education if problem is active extension.
• Passive extension is also performed with a towel roll
placed under the ankle and the patient pushing
downward on the femur (or with weight on top of
the femur) (see Fig. 6-26).
Delayed Knee Flexion
• Passive stretching into flexion by therapist.
• Wall slides for gravity assistance.
• Stationary bicycle. If patient lacks enough motion to
bicycle with saddle high, then begin cycling back­
ward, then forward, until able to make a ryolution.
Typically, this can be done first in a backward
fashion.
Bibliography
Hip Arthritis
Brady LP: Hip pain: don't throwaway the cane. Postgrad
Med 83(8):89, 1988.
Cameron HU: The Cameron anterior osteotomy. In: Bono
JV et al (ed): Total Hip Arthroplasty. New York, Springer­
Verlag, 1999.
Centers for Disease Control and Prevention: Health-related
quality of life among adults with arthritis: behavioral risk
factor surveillance system. MMWR Morb Mortal Wkly Rep
49(17):366, 2000.
Chandler DR, Glousman R, Hull 0, McGuire PI, Kim IS,
Clarke IC, Sarmiento A: Prosthetic hip range of motion
and impingement: the effects of head and neck geometry.
Clin Orthop June (166):284, 1982.
Collis OK: Total joint arthroplasty. In Frymoyer JW (ed):
Orthopedic Knowledge Update, No.4. Rosemont, Ill,
American Academy of Orthopedic Surgeons, 1993.
DeAndrade RJ: Activities after replacement of the hip or
knee. Orthop Special Ed 2(6):8, 1993.
teoarthritis of the knee. Orthop Rev 22:921, 1993.
Horne G, Rutherford A, Schemitsch E: Evaluation of hip
Kozzin Sc, Scott R: Current concepts: unicondylar knee
pain following cemented total hip arthroplasty. Orthope­
arthroplasty. J Bone Joint Surg 71A:145, 1989.
dics 3(4):415, 1990.
Livesley PJ, Doherty M, Needoff M, Moulton A: Arthro­
Johnson R, Green JR, Charnley J: Pulmonary embolism
and its prophylaxis following Charnley total hip replace­
ment. J Arthroplasty Suppl 5:21, 1990.
Kakkar VV, Fok PI, Murray WJ: Heparin and dihydroergo­
tamine prophylaxis against thrombo-embolism of the hip
arthroplasty. J Bone Joint Surg Aug; 67(4):538, 1985.
Little JW: Managing dental patients with joint prostheses. J
Am Dent Assoc 125:1374, 1994.
Chapter 6: The Arthritic Lower Extremity 473
Pellicci PM: Total joint arthroplasty. In Daniel OW, Pellicci
PM, Winquist RA (eds): Orthopedic Knowledge Update,
No.3, Rosemont, Ill, American Academy of Orthopedic
Surgeons, 1990.
Steinberg ME, Lotke PA: Postoperative management of to­
tal joint replacements. Orthop Clin North Am 19(4):19,
1988.
Knee Arthritis
Bradley JD, Brandt KD, Katz BP, et al: Comparison of an
anti-inflammatory dose of ibuprofen, an analgesic dose of
ibuprofen, and acetaminophen in the treatment of patients
with osteoarthritis of the knee. N Engl J Med 325:87, 1991.
Chen PQ, Cheng CK, Shang HC, Wu JJ: Gait analysis after
total knee replacement for degenerative arthritis. J Formos
Med Assoc Feb; 90(2):160, 1991.
Cole BJ, Harner CD: Degenerative arthritis of the knee in
active patients: evaluation and management. J AAOS
7(6):389, 1999.
Colwell CW, Morris BA: The influence of continuous pas­
sive motion on the results of total knee arthroplasty. Clin
Orthop 276:225, 1992.
Corsbie WJ, Nichol AC: Aided gait in rheumatoid arthritis
following knee arthroplasty. Arch Phys Med Rehabil
71:191, 1990.
DeAndrade RJ: Activities after replacement of the hip or
knee. Orthop Spec Ed 2(6):8, 1993.
Edelson R, Burks RT, Bloebaum RD: Short-term effects of
knee washout for osteoarthritis. Am J Sports Med 23:345,
1995.
Fox JL, Poss P: The role of manipulation following total
knee replacement. J Bone Joint Surg 63A:357, 1981.
Ghosh P, Smith M, Wells C: Second-line agents in os­
teoarthritis. In Dixon JS, Furst DE (ed): Second-Line
Agents in the Treatment of Rheumatic Diseases. New York:
Marcel Dekker, 363, 1992.
Gibson IN, White MD, Chapman VM, Strachan RK:
Arthroscopic lavage and debridement for osteoarthritis of
the knee. J Bone Joint Surg 74:534, 1992.
Jackson RW, Rouse OW: The results of partial arthroscopic
meniscectomy in patients over 40 years of age. J Bone Joint
Surg Br 64:481, 1982.
Keating EM, Faris PM, Ritter MA, Kane J: Use of lateral
heel and sole wedges in the treatment of medial os­
scopic lavage of osteoarthritic knees. J Bone Joint Surg Br
73:922, 1991.
Maloney WI, Schurman OJ, Hangen 0: The influence of
continuous passive motion on outcome in total knee
arthroplasty. Clin Orthop Jul; 256:162, 1990.
McInnes J, Larson MG, Daltroy LH: A controlled evalua­
tion of continuous passive motion in patients undergoing
total knee arthroplasty. JAMA Sep 16; 268(11):1423, 1992.
 474 Clinical Orthopaedic Rehabilitation
Morrey BF: Primary osteoarthritis of the knee: a stepwise
management plan. J Musculoskel Med 79:(3), 1992.
Puddu G, Cipolla M, Cerullo C, Scala A: Arthroscopic
treatment of the flexed arthritic knee in active middle-aged
patients. Knee Surg Sports Traumatol Arthrosc 73, 1994.
Ritter MA, Campbell ED: Effect of range of motion on the
success of a total knee arthroplasty. J Arthroplasty 2:95,
1987.
Ritter MA, Stringer EA: Predictive range of motion after
total knee arthroplasty. Gin Orthop 143:115, 1979.
Shoji H, Solomoni WM, Yoshino S: Factors affecting post­
operative flexion in total knee arthroplasty. Orthopedics
June; 13:643, 1990.
Steinberg ME, Lotke PA: Postoperative management of to­
tal joint replacements. Orthop Gin North Am 19(4):19,
1988.
VanBaar ME, Assendelft WJ, Dekker J: Effectiveness of ex­
ercise therapy in patients with osteoarthritis of the hip or
knee: a systematic review of randomized clinical trials.
Arthritis Rheum 42(7):1361, 1999.