CHOITHRAM INSTITUTE CHOITHRAM INSTITUTE OF HEALTH SCIENCESOF HEALTH SCIENCES

ARTHROPLASTY AND ARTHRODESIS

& PHYSIOTHERAPY MANAGEMENT

PRESENTED TO- presented by- DR.KIRAN SIR Priyanka Das

BPT

CONTENTS-CONTENTS-1. ARTHROPLASTY INTRODUCTION INDICATION CONTRAINDICATION TYPES OF ARTHROPLASTY PROSTHESIS BONE CEMENT IN ARTHROPLASTY OPERATED APPROACHES COMPLICATION PHYSIOTHERAPY MANAGEMENT PREVENTION

INTRODUCTION INTRODUCTION Arthroplasty is a

operative treatment of orthropaedic disorder .

Arthroplasty is the operation for reconstruction of a new movable joint .

INDICATION INDICATION Severe osteoarthritis of the hip and

knee joint.Advance rheumatoid arthritis with

disabling pain. Quiescent destructive tuberculous

arthritis. Un united femoral neck fracture.Correction of certain type of

deformity, especially hallux valgus.Avascular necrosis.

Cont.-Cont.-Hip displasia. Bone tumors.Instability of hip joint.Joint stiffness.Acetabular dispasia.Frozen shoulder and loose shoulder.Failure of conservative

management or joint reconstruction procedure.

CONTRAINDICATIONCONTRAINDICATIONABSOLUTE contra indication 1.Active joint infection.2.Systemic infection or sepsis.3.Chronic osteomyelitis.4.Neuropathic of hip joint.5.Severe paralysis of the muscles

surrounding the joint.

RELATIVE contraindicationRELATIVE contraindication 1.Localized infection such as

bladder or skin.2.Insufficient function of the

gluteus medius muscles.3.Progressive neurological disorder.4.Insufficient femoral or acetabular

bone stock associated with progressive bone disease.

TYPES OF ARTHROPLASTYTYPES OF ARTHROPLASTYIt may two types- 1.Replament arthroplasty- it is

reconstruction of the joint by replacing the joint partially or totally.

It can be-HEMI REPLACEMENT-in this type, only

one of the articulating surfaces is remove and is replaced by a prosthesis of a similar type.

TOTAL JOINT REPLACEMENT-in this type, both of the opposed articulating surfaces are removed. and replaced by prosthetic compounds.

1. EXCISION ARTHROPLASTY-in this type, one or both of the articular ends are excised so that a gap is created between them.

This gap fills with fibrous tissue.

PROSTHESIS IN PROSTHESIS IN ARTHROPLASTYARTHROPLASTY

Joint replacement is a procedure where by one or both the component forming a joint are replaced with artificial component is called as prosthesis.

Prosthesis are made up of special metal alloy and special high density polyethylene.

Two types prosthesis are use- 1.Austin moore prosthesis.2.Thomson prosthesis.These are commonly use in hip joint.

BONE CEMENTBONE CEMENTBone cement is a methyl-

methacrylate compound.Cement can be used with or

without in hip joint.It can be two types-1.CEMENTED HIP-in the cemented

hip the acetabular as well as femoral component are fixed with the help of bone cement.

Cemented hip arthroplasty use in elderly patient with expected life of 10-15 years.

As the stability of the prosthesis is achieved within 15 minutes of surgery.

2.NON-CEMENTED HIP-is a recent development in which bone cement is not used to fixed the components of the hip joint.

Non-cement hip is use In younger people.

OPERATIVE APPROACHESOPERATIVE APPROACHESIt can be divided into two broad

categories-1.Standard surgical approaches.2.Minimally invasive approaches.1.STANDARD SURGICAL

APPROACHES- it can be three types-

a.postero-lateral approach.b.Direct-lateral approach.c.antero-lateral approach.

2.MINIMALLY INVASIVE 2.MINIMALLY INVASIVE APPROACHES-APPROACHES-it can be two types-a. Single-incision approach.b. Two-incision approach.In this approach the length of

incision is less than 10cm,depending on the location of the approach and the of the patient .

A. Postero -lateral approach -this is the most frequently used approach for total hip arthroplasty.

In this approach the gluteus maximus is split in line with the muscle fibers.

In this approach the gluteus medius and vastus lateralis muscles is not splited.

In this approach after total hip arthroplasty early postoperative motion of hip joint is hip FLEXION,ADDUCTION, and INTERNAL ROTATION of hip joint movement is AVOID.

2.DIRECT LATERAL APPROACH-in this approach requires longitudinal division of the tensor fasciae latae,one-half of the gluteus medius and longitudinal splitting of the vastus minimus.

In this approach disruption of the abductor mechanism is associated with post operative weakness and gait abnormalities.

In direct lateral approach the positive Trendelenburg sign is present.

3.ANTERO-LATERAL APPROACH-in addition to the gluteus medius, soft tissues disturbed include gluteus minimus, tensor fascie latae,iliopsoas,rectus femoris,and vastus lateralis muscles as well as the anterior capsul is disturbed.

COMPLICATON COMPLICATON 1. DEEP VEIN THROMBOSIS-this occurs

due to inadvertent manipulation of the thigh during surgery, venous stasis in the limb due to immobility.

2. INFECTION-this is the most serious of all complication.

3. NERVE PALSIES-the sciatic nerve is most commonly affected.

4. VASCULAR INJURY- this is uncommon, but can occur mainly due to technical reasons.

6.FRACTURE-these may occur during the process of implantation of the prosthesis.

7.DISLOCATION-it is primarily due to malpositioning of limb during early post operative period.

8.HETEROTROPIC BONE FORMATION-new bone formation around the components occurs in some cases such as ankylosing spondilitis,and results in decreased range of joint movements.

PHYSIOTHERAPY PHYSIOTHERAPY MANAGEMENTMANAGEMENTTOTAL HIP ARTHROPLASTY

MANAGEMENT-Goal`s-1.A pain free hip joint.2.A Stable joint for lower extremity

weight bearing and function ambulation.

3.Adequate range of motion for functional activities.

4.Strength of lower extremity for functional activity.

PHYSIOTHERAPY PHYSIOTHERAPY MANAGEMENTMANAGEMENT

1. PREOPERATIVE - a) Evaluation:- Pain Deformity ROM Ms power Ms atrophy Ambulation & Gait

2. Preoperative patient education:-

It should be taught on the sound limb for easy grasp.

PREOPERATIVE PREOPERATIVE PHYSIOTHERAPYPHYSIOTHERAPY1.Deep breathing & coughing.2.Strong & sustained isometric

contraction.3.Guidance of ROM & Strengthening

exercises.4.Resisted exercises .5.To teach proper limb positioning.6.To teach appropriate technique of

transfer.7.To mentally prepare the patient for the

painful active stage ahead.

Post operated management-Post operated management-Day ;-1 =1.Chest pt2.Vigorous toe and ankle movements3.Isometrics to quadriceps.

Day ;-2=1.Sitting up by gradually raising the back

rest.2.Bed transfer 3.Standing, walking with partial weight

bearing or toe down weight bearing with a walker.

Day;- 3-7 =1.Isomatric to gluteus maximus, medius

and minimus.2.Assisted hip flexion [heel drag] and

hip abduction.3.Initiate prone lying.4.Thomas stretch.5.Relaxed passive hip movement.

Week 2=1.Active hip flexion, knee extension

[bed side sitting or chair sitting with back rest].

Week 3 =1.Partial weight bearing walking on crutches

with free swinging of the operated leg.Week 4=1.Ped-o-cycle or static bicycle [possible free

ROM].2.Stair climbing going up with the GOOD LEG

first. Coming down with the OPERATED LEG first.

3.Initiate leg rotation in supine and progress to against gravity and against resistence.

Week 5-6=1.Gradually increase hip abduction and

rotation in supine and bed side sitting.

PRECAUTIONPRECAUTION

Avoid early initiation of hip abduction and rotation.

Transfer to the sound side from bed to chair or chair to bed.

Do not cross the legs.Keep the knees slightly lower than

hips when sitting.Avoid sitting in low, soft chairs.If the bed at the home is low, raise it

on blocks.

Use a raised toilet seat.Avoid bending the trunk over the

legs when rising from or sitting down in a chair or dressing or undressing.

Avoid standing activities that involve rotating the body toward the operated extremity.

Always use pillow between the legs in resting, sitting, while turning in bed or during transfers.

Avoid SLR or hip abduction against gravity.

TOTAL KNEE REPLACEMENT TOTAL KNEE REPLACEMENT ARTHROPLASTYARTHROPLASTY

Total knee arthroplasty , also called as total knee replacement

It is a widely performed procedure for advanced arthritis of the knee, primarily in older patients (more than 70 years of age) with osteoarthritis.

The primary goals of TKA are to relieve pain and improve a patient’s physical function and quality of life.

INDICATION OF TKAINDICATION OF TKASevere joint pain with weight bearing

or motion.Extensive destruction of articular

cartilage of the knee joint.Marked deformity of the knee such as

genu varum or genu valgum.Gross instability or limitation of

motion.Failure of non-operative management. Failure of a previous surgical

procedure.

NUMBER OF NUMBER OF COMPARTMENTS REPLACEDCOMPARTMENTS REPLACEDIt can be three compartment

replaced-1.UNI-COMPARTMENT:- only medial

or lateral joint surfaces replace.2.BI-COMPARTMENT:-entire femoral

and tibial surfaces replaced.3.TRI-COMPARTMENT:-

femoral,tibial,and patellar surfaces replaced.

SURGICAL APPROACH SURGICAL APPROACH

1. Standard/tradition or minimal invasive.

2. Quadriceps-splitting or quadriceps-sparing.

1. STANDARD APPROCH- antero-medial parapatellar vertical or curved incision from the distal aspect of the femoral shaft, running medial of the patella to just medial of the tibial tubercle, ranging from 8 to 12cm or 13 to 15 cm in length.

2. MINIMALLY INVASIVE APPROACH-reduced length of antero-medial skin incision 6-9cm in length.

Anterior capsule release.

IMPLANT FIXATIONIMPLANT FIXATION cemented. un-cemented. hybrid.

PHYSIOTHERAPY PHYSIOTHERAPY MANAGEMENT MANAGEMENT

IN TKRIN TKR

The principal aim of the physiotherapy is to offer maximum static as well as dynamic stability to the knee.

GOALS-1)Control post operative swelling. 2)Minimize pain.

PRE OPERATIVE PRE OPERATIVE ASSESSMENTASSESSMENTA thorough assessment is done prior

to the surgery, and the postoperative regime of physiotherapy is explained to the patient.

a)Pain.b)Deformity.c)Rom.d)Strength and endurance.e)Effusion and atrophy.f) Complete gait analysis.

PRE-OPERATIVE TRANINGPRE-OPERATIVE TRANINGIt includes the following-1)Explain to the patient the total post

operative regime and his responsibility.

2)Educate the patient on the measures taken in prevention of edema, deep venous thromosis,chest complication.

3)Training of isometrics to quagriceps,hamstings,and glutei.

4)Self-assisted passive mobilisation.5)Relaxed free movement. 6) techniques of self-assisted

mobilisation.

POST-OPERATIVE POST-OPERATIVE MANAGEMENTMANAGEMENTDAY-11.Chest physiotherapy.2.Vigorous toe and ankle movements.3.Maintain the limb with [with pop on

with heel or lower leg resting on a pillow].

4.Static glutei by pressing the pillow the heel.

5.Gentle isometrics to quadriceps.

DAY 2-3;-1.Transfer in bed.2.Gentle patellar mobilisation.3.Rapid isometrics to

quadriceps[speedy and with 10sec. Hold].

4.Assisted SLR.5.Stand and ambulate with pop on

and walker.

Day 4-5-6;-Day 4-5-6;-1.Transfer in chair.2. Self-assisted passive knee

flexion;- a) Heel drag in supine.b) Bed side, relaxed knee

movements with the help of sound leg[in unilateral TKA].

c) Sitting with feet plated on the ground, and push forward by raising trunk on arms.

3.- CPM 5-10 degree daily. Range of knee flexion must not exceed 40˚ because transcutaneous O2 tension of the skin near the incision decreases significantly after 40˚ of flexion.

4.-begin active or active assisted exercise, if the wound is clear and dry.

5.-bed side active knee flexion-extension[self-assisted, if necessary.

6.-ambulation without pop[can do three SLR without pop].

DAY 7-10;-DAY 7-10;-

1. Work up toward 90 degree flexion by 10-14 days.

2. Hamstring strengthening.3. Assisted step and stairs. DAY 11-3 WEEKS- progress all

exercise. WEEKS 4-6;-1. Work up toward knee flexion

110-115 degree.

2.-quadriceps dips and steps up.3.stastionary bicycle.4.total weight bearing with can.

RECOMMENDATION FOR RECOMMENDATION FOR PARTICIPATION IN TKAPARTICIPATION IN TKA

HIGHLY RECOMMENDED-1.Stationary cycling.2.Swimming, water aerobics.3.Walking4.golf [preferably with golf cart].5.Ballroom or square dancing.6.Table tennis.

RECOMMENDED IF RECOMMENDED IF EXPERIENCED BEFORE TKA-EXPERIENCED BEFORE TKA-

1.Road cycling.2.Speed/ power walking.3.Doubles tennis.4.Rowing.5.Bowling.6.Cross-country skiing [machine or

outdoor].

NOT RECOMMENDED;-NOT RECOMMENDED;-

1. Jogging, running.2. Basketball.3. Volleyball.4. Baseball.5. Football.6. Gymnastics.7. Squash.

ARTHRODESISARTHRODESISCONTENTS-1.Definition.2.Indication.3.Goals.4.types of arthrodesis.5.Position of arthrodesis.6.complication.7.Physiotherapy management.

DEFINITIONDEFINITIONArthrodesis also known as called

as fusion of joint.In this operation , fusion is

achieved between the bones forming a joint so as to eliminate any motion at the joint.

arthrodesis is mostly performed on ankle & wrist joint but it can be performed on other joint.

INDICATION OF INDICATION OF ARHTRODESISARHTRODESIS1. Advanced osteoarthritis and

rheumatoid arthritis with disabling pain.

2. Quiescent tubercular arthritis with destruction of the joint surfaces.

3. Instability from muscle paralysis, as after poliomyelitis.

4. For permanent correction of deformity as in hammer toe.

GOALSGOALS

1. To provide pain relief.2. To restore skeletal stability.3. Improve alignment in people

with advanced arthritis.

TYPES OF ARTHRODESISTYPES OF ARTHRODESISIn arthrodesis may be –1.Intra-articular type.2.Extra-articular type.3.Combined type.INTRA- ARTICULAR TYPE-in intra- articular

arthrodesis the articulating surfaces are raw and the joint immobilised in the position of optimum function until there is a bony between the bones.

EXTRA-ARTICULAR TYPE-in an extra articular arthrodesis ,an extra-capsular bridge of bone is created between the articulating bones.

COMBINED TYPE- in this type both intra and extra articular fused joint.

POSITION OF POSITION OF ARTHRODESISARTHRODESISThe best position of arthrodesis

of a joint the one which conforms to the requirements of the patients work.

POSITION OF ARTHRODESIS POSITION OF ARTHRODESIS OF DIFFERENT JOINTOF DIFFERENT JOINT1. SHOULDER JOINT= flexion-25 degree, = abduction-30

degree, = int.rota.- 45

degree.

2.ELBOW JOINT=A. Single joint- flexion=75 degreeB. Both- one in flex.70 degree, other in flex.130 degree.

3.WRIST JOINT= dorsi flexion-20 degree.

1. HIP JOINT = flexion-15 degree = no adduction = no abduction[neutral

position]

2. KNEE JOINT = flexion= 5 to 10 degree.

3. ANKLE JOINT = male= neutral position, female=planter-flexion for

high heels.

COMPLICATIONCOMPLICATION

1. Bleeding.2. Infection.3. Blood clots In the legs.4. Loosening of prosthetic part.

PHYSIOTHERAPY PHYSIOTHERAPY MANAGEMENT MANAGEMENT INARTHRODESISINARTHRODESISIn two phases-1.During immobilisation phase.2.During mobilisation phase.

DURING IMMOBILISATION DURING IMMOBILISATION PHASE;-PHASE;-

1.To prevent and manage the possible post operative complications.

2.Maintenance of the proper position of the operated joint.

3.Strengthening and ROM exercise for the joints free from immobilisation.

4.Initiating early non weight bearing ambulation in case of hip, knee, and ankle arthrodesis.

DURING MOBILISATION DURING MOBILISATION PHASE;-PHASE;-

1. In lower extremity gradual and correct weight bearing, weight transfer and balancing should be initiated with adequate aid.

2. Guidance and assistance with several sessions a day are needed to achieve functional proficiency.

MULTIPLE CHIOCE QUESTION MULTIPLE CHIOCE QUESTION OF arthroplasty and OF arthroplasty and arthrodesis arthrodesis Q.-1 which operation is called as

reconstruction of a new mobile joint-A.Arthrodesis.B.Arthroplasty.C.Arthroscopy.D.Osteotomy.Q.-2 which technique is known as fusion

of a joint-A.Arthroplasty.B.Arthrectomy.C.Arthroscopy.D.Arthrodesis.

Q.-3 which operation is called cutting of bone-

A.Osteotomy.B.Arthrodesis.C.Arthroplasty.D.Arthroscopy.Q.-4 which method is called as operative

method of treatment-A.Arthroplasty.B.Arthrodesis.C.Arthroscopy.D.All the above.

Q.-5 which compound form BONE CEMENT use in arthroplasty-

A.Methyl-ethacrylate.B.Ethyl-methacrylate.C.Ethyl-ethacrylate.D.Methyl-methacrylate.Q.6-in exicisional arthroplasty form a

gap which fills by-A.Adipose tissue.B.Aerolar tissue.C.Fibrous tissue.D.Elastic tissue.

Q.7- stability of prosthesis is achieve within minutes of surgery in total hip arthroplasty-

A.15 minutes.B.20 minutes.C.25 minutes.D.30 minutes.Q.8- in stair climbing going up and coming

down which leg first respectively in total hip replacement-

A.Good leg and operated leg.B.Operated leg and good leg.C.Alternate good and operated.D.All the above.

Q.-9 which are type of total hip implants use in arthroplasty-

A.Cemented hip.B.Non-cemented hip.C.Both a and b.D.None.Q.-10 why joint replacement occur in

human, why not occur in animals-A.Because human is bi-pedal locomotion.B.Because animal is Quadra-pod

locomotion.C.Both a and b.D.None.

Q.-11 in joint replacement surgery which types complication occur—

A.Deep venous thrombosis.B.Infection.C.Nerve palsy.D.All the above.Q.-12 in which range of motion knee

flexion must not exceed within the first three post operative day-

A.Must not exceed 40 degree.B.Must not exceed 50 degree.C.Must not exceed 30 degree.D.Must not exceed 20 degree.

Q.-13 in which types of arthrodesis only articulating surface is fused-

A.Extra-articular type.B.Intra-articular type.C.Combined type.D.All the above.Q.14 in joint replacement surgery which

type of artificial components is use-A.Orthosis.B.Prosthesis.C.Both a and b.D.None.

Q.-15 in the isometric quadriceps exercises how many second hold in total hip arthroplasty-

A.25 sec.B.2o sec.C.15 sec.D.10 sec.Q.-16 which day patient walk after

surgery of total hip replacement-A.2-3 day after surgery P.W.B. with walker.B.4-5 day after surgery F.W.B. with cane.C.7-9 day after surgery N.W.B. with crutch.D.11-12 day after surgery P.W.B. with

stick.

Q.-17 in which position of arthrodesis is done in shoulder joint joint-

A.Extension 25degree,adduction 30degree,external rotation 45 degree.

B.Flexion 30 degree, adduction 25degree,exernal rotation 50degree.

C.Extension 30 degree, abduction 25degree, internal rotation 50.

D.Flexion 25 degree, abduction 30 degree, internal rotation 45degree.

Q.-18 the prosthesis is made up of –A.Special metal alloy.B.Special high density poly ethylene.C.Both a and b.D.Special low density poly ethylene.Q.-19 In which operative approach the

positive Trendelenburg sign is present in total hip replacement-

A.Postero-lateral approach.B.Direct-lateral approach.C.Antero-lateral approach.D.All the above.

Q.-2O in Postero-lateral approach is use in total hip replacement which movement is initially AVOID after post operative period-

A.Hip extension,abduction,and external rotation.

B.Hip flexion,adduction,and internal rotation.C.Hip exension,adduction,and internal

rotation.D.Hip flexion,abduction,and exernal rotation.Q.-21 in which approach the HIP

EXTENSION,ABDUCTION,and EXTERNAL ROTATION is AVOID in after total hip replacement-

A.Direct-lateral approach.B.Antero-lateral approach.C.Postero-lateral approach.D.Both A.and B.

Q.-22 in direct-lateral approach of operative procedure in total hip replacement which type of sign is present-

A.Galleazzi sign.B.Gower`s sign.C.Tinel`s sign.D.Trendelenberg sign.Q.-22 chronic osteomyelitis,nearopathic

hip joint, active joint infection these are in arthroplasty is-

A.Indication.B.Contra-indication.C.Both A and B.D.None.

Q.-24 in which type of joint replacement surgery only one part of articulating surface is remove-

A.Excision arthroplasty.B.Hemi-replacement arthroplasty.C.Total replacement arthroplasty.D.Both A and B.Q.-25 after total hip arthroplasty which

activities are AVOID-A.Avoid cross the leg.B.Avoid Indian toilet seat.C.Avoid transfer to the affected side from

bed to chair or chair to bed.D.All the above.

Q.-26 in which type one both of the articular ends of the bone is excised-

A.Total replacement arthroplasty.B.Excision arthroplasty.C.Both A and B .D.Hemi-replacement arthroplasty.Q.27 which hip flexion range of motion to

be contra-indicated in total-replacement arthroplasty-

A.Beyond 30 degree.B.Beyond 45 degree.C.Beyond 60 degreeD.Beyond 90 degree.

Q.-28 in which condition arthrodesis is used most commonly-

A.Painless, and stiff joint.B.Painful, and stiff joint.C.Both A and B.D.None.

Q.29- which prosthesis used only without cemented in hip replacement arthroplasty is-

A.Thompson prosthesis.B.Charnley`s prosthesis.C.Muller`s prosthesis.D.Austin -moore prosthesis.Q.30- which physical activities following total

knee arthroplasty is highly recommended –A.Low impact aerobics.B.Middle impact aerobics.C.High impact aerobics.D. Water aerobics.

Q.31- which games after total knee arthroplasty is not recommended-

A. Table tennis.B. Doubles tennis.C. Single tennis.D.Golf.

Q.32- in standard or minimally invasive approach which incision is used in total knee arthroplasty-

A. Postero-medial-parapatellar incision.B. Antero-lateral –parapatellar incision.C. Postero-lateral- paratellar incision.D.Antero-medial-parapatellar incision.

Q.33- which type bone cement is used in total knee arthroplasty-

A. D-crylic cementB. B-crylic cement.C. A-crylic cement.D. C-crylic cement.

Q.33- in minimally invasive approach the incision is made in centimeter of length in THR-

A.Less than 25cm in length.B.More than 15cm in length.C.Less than 10cm in length.D.More than 20cm in length.Q.34- in postero -lateral approach which

muscle is split in line of muscle fibers-A.Gluteus medius. B.Gluteus minimus.C.Gluteus maximus.D.All the above.

Q.35- in cemented arthroplasty is generally used in-

A.Elderly people.B.Old people.C.Both a and b.D.None.Q.36- in nerve palsy complication of

joint replacement arthroplasty which nerve commonly affected-

A.Femoral nerve.B.Popliteal nerve.C.Gluteal nerve.D.Sciatic nerve.

Q.36- the implant of femoral component of total knee arthroplasty shape is –

A.`T`- shape.B.`C`- shape.C.`D`- shape.D.`U`-shape.Q.37- in which of the following is

relative contra-indication in THR-A.Active joint infection.B.Systemic infection.C.Neuropathic hip joint.D.Progressive neurological disorder.

Q.38- which surgical approach is most recent is use in knee arthroplasty-

A.Minimally invasive approach.B.Standard approach.C.Traditional approach.D.All the above.sssss