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Emerging Technologies in Rehabilitation Medicine

The impact of evolving surgical approaches on the postoperative treatment of joint restoration, scarring, pain, and swelling.
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Injury, disease, and aging may all lead to the necessity for surgery at some point in a person’s life. Musculoskeletal surgeries to the lower extremities, in particular, may lead to a variety of pain-related conditions, including: scarring/fibrosing, effusion (swelling), soft tissue atrophy, reduced stamina and mobility, decreased flexibility and active range of motion, gait/balance deficits, and an overall functional decline stemming primarily from pain and inflammation. Pain and inflammation may further lead to arthrogenic inhibition, which may short-circuit functional mobility.

A healthy musculoskeletal system is required for optimal mobility and function, including strength, power, endurance, flexibility, stability, and balance. In a finely tuned nervous and muscular system, these two systems coordinate (known as neuromuscular integration) to form the basis of general motor control, which is governed by both brain and spinal cord-mediated activities. Physical medicine and rehabilitation (PM&R) providers are faced with restoring this integration in the postsurgical setting.

Practical Pain Management previously featured technology trends in rehabilitation medicine, with a focus on electrotherapy devices. This report casts a broader net to look at how rehabilitation technology is evolving to reflect changes in surgical techniques that have emerged or are in the pipeline. Specifically, new-generation knee, hip, shoulder, and lower spine procedures are addressed, with postoperative approaches for related joint instability, scarring, pain, and swelling.

Innovative Surgical Approaches

Today’s orthopedic surgeons have responded to the growing need for longevity and quality of life with innovative surgical techniques that aim to minimize invasiveness to both spare tissue and to reduce rehabilitation time after a procedure. Below are examples of cutting-edge surgical procedures that demonstrate improved patient outcomes. The section that follows offers a discussion of how PM&R professionals may aid in recovery efforts.

Resurfacing Versus Replacement for the Knee and Hip

Over the past 20 years, knee and hip replacement surgeries increasingly have been followed by later-life ankle and shoulder replacement procedures. Full prosthetic replacements were previously the norm, providing, for the most part, enhanced quality of life with few postoperative complications.1 The most common complications were prosthesis failure in the hip2 and arthrofibrosis in the knees,3 a complication that is not necessarily the fault of the surgeon or therapist, and one which has been linked more closely to collagen metabolism.4 Nonetheless, arthroplasty, or full joint replacement, is invasive and may inevitably lead to significant pain and inflammation, necessitating some level of post-surgical physical therapy and pain management.

As we approach the year 2020, candidates for hip and knee replacement, as well as younger prospective patients between the ages of 40 and 55, now have an option for joint restoration through the use of minimally invasive techniques that not only offer similar benefits, but also provide potential advantages, including bone and tissue sparing.5 This newer generation of mobility enhancing orthopedic surgeries—known as resurfacing—are more similar to partial joint replacements, but devoid of bulky prosthetic ball and sockets. Resurfacing provides patients with a new liner (articulating surface) for a joint that has degenerated with time and wear. One example, approved by the FDA in 2011, is the ConforMIS system (Billerica, MA), which promises a fresh, custom-fit, articulating surface for the knee patient.6 The ConforMIS is essentially a patient-specific implant that acts to provide a new articulating surface for a severely worn-out joint. Its original unicompartmental design has evolved to provide bicompartmental capability, which makes it a viable option for total joint replacement.

Another resurfacing option known as the MAKOplasty procedure, approved in 2012, uses a minimally invasive robotic arm (MAKO Surgical Corp, Stryker, Kalamazoo, MI)7 (see Figure 1). The robotic-assisted technology includes 3D imaging, allowing the implant to be seated with precision and custom fit. As a result, problems related to prosthetic device overhang or under-hang are minimized and/or eliminated. A pre-operative set of CT scans may be loaded into the operating software, which then creates a patient-specific template for the surgery. This procedure may be used in painful hip and unicompartmental knee problems as in the case of severe osteoarthritis of the joint.

Hip resurfacing may appeal to younger patients who wish to remain active and only have a small area of exposed (bone-on-bone) joint destruction. A MAKOplasty procedure may enable a surgeon to remove a few millimeters of damaged hyaline cartilage, sparing bone as well as surrounding soft and boney tissue. This less-invasive procedure may result in lower costs and reduced postoperative disability.

Resurfacing procedures, in comparison to arthroplasty, do not require primary stabilizing structures, such as the anterior and posterior cruciate ligaments. As a result, this approach may be more appealing to the aging demographic that places a premium on functional mobility.

Reverse vs Traditional Arthroplasty for the Shoulder

Reverse shoulder arthroplasty (RSA) procedures, approved by FDA in 2003, are also being performed more often by orthopedic surgeons rather than traditional shoulder replacement. The newer procedure is preferred when cuff tear arthropathy (ie, large to massive rotator cuff rupture) is detected. If there is little chance of preserving the cuff musculature, an RSA method may be preferred in order to enable the deltoid muscle to take over as the dominant stabilizer of the shoulder. In RSA, the ball and socket components are switched so the metal ball is placed where the glenoid fossa is typically located, and a plastic socket is attached to the proximal upper part of the humerus (see Figure 2). While RSA does not replace traditional arthroplasty, it may provide an additional option for the patient afflicted by a severely damaged shoulder.

Artificial Discs for the Spine

Another procedure changing the surgical landscape and challenging rehabilitation professionals is synthetic or artificial disc replacement, which was developed to overcome the shortcomings of interbody fusion procedures.8 This type of surgery is still controversial as it is in its infancy in the United States, emerging in 2006, where as the procedure has been performed across Europe for the past 25 or more years, with respect to the treatment of degenerative disc disease in particular.9

Last updated on: April 10, 2018
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Managing Perioperative Pain
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