Total Hip Arthroplasty. Hip joint anatomy What is THA Indications for THA ...
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Transcript of Total Hip Arthroplasty. Hip joint anatomy What is THA Indications for THA ...
Total Hip Arthroplasty
CONTENTS Hip joint anatomy What is THA Indications for THA Characteristics/Clinical presentation of
indications Diagnostic Fx Radiological Fx Surgical procedures Contraindications Post op.characteristics/ Clinical presentation Complications
Post op. physical therapy Ex Physicaltherapy Mx Principles of rehabilitation Mx protocols of THA (APTA) Modalities supported by research DON'TS and DO’S Post op. precautions Long term followup
HIP JOINT
General anatomical overview
DESCRIPTION OF THR An invasive surgical procedure that is
used to remove a diseased hip joint (most commonly due to osteoarthritis) and replace it with an artificial joint or prosthesis.
INDICATIONS FOR THA Disabling pain secondary to severe osteoarthritis
Inflammatory arthropathy
Avascular necrosis
Ankylosis secondary to prior infection or surgery
Trauma such as a fall – most commonly post menopausal women
Juvenile rheumatic arthritis
Benign/malignant tumors around the hip joint, and hip fractures.
complications with the internal fixation of a fracture to the femoral neck- if articular cartilage in the acetabulum is lost or when endoprosthesis have failed in acute fractures
CLINICAL PRESENTATION OF INDICATIONS Hip fracture: Often unable to walk, complains of vague pain in the knee, thigh,
groin, back or buttock and difficulty of weight bearing.
Osteoarthritis: Crepitations are sensible or audible when the hip is moved, all
the inflammatory signs.
Rheumatoid arthritis: Range of all hip movements is impaired, movement is painful,
pain and stiffness when the activity is resumed after resting. Redness, joint effusion.
DX PROCEDURES No specific diagnosis.
Differentiate from referred pian from the spine or pelvis.
Most helpful ways to diagnose if the patient really needs a THR - MRI, X-Ray and physical Ex specific to the particular condition.
RADIOLOGICAL FX
Osteoporotic bones
SURGICAL PROCEDURES Anterior, lateral and posterior approach.
The articulating couples (head and cup) used by surgeons are made of metal-on-polyethylene (PE), ceramic-on-PE, metal-on-metal and ceramic-on-ceramic
Important components of prosthesis are friction-coefficient, survival, stability against dislocation and fixation in bone tissue.
Osteonecrosis due to erosion of the two components rubbing against each other
SURGICAL PROCEDURE
CONTRAINDICATIONS Active local or systemic infection.
COMPLICATIONS
1) Medical complications
• Delayed wound healing or wound dehiscence• Renal and urinary complications.• Cardiovascular complications, VTE including DVT and pulmonary embolism(PE).• Myocardial infarction, or bleeding.• Pneumonia and other respiratory complications.• Blood loss requiring transfusion.• Allergic reaction to medications.
2) Specific complications
• Infection• Fracture of the femur or pelvis• Damage to the nerve / blood vessels• DVT• Wound irritation• Leg length discrepancy • Wear- more active the sooner the wear• Failure to relieve pain• Pressure sores• Limp due to muscle weakness/ fearful gait
POST OP.CHARACTERISTICS/ CLINICAL PRESENTATION
Muscular atrophy and loss of muscle strength, particularly in the gluteus medius muscle and ipsilateral quadriceps
There is a major risk associated with joint instability and prosthetic loosening.
Gait dysfunction may persist for many months after joint replacement.
POST OP. PHYSICAL THERAPY EX
Muscle strength volume and pressure sores (and other 2ry complications).
ROM and circulatory status of the injured and the healthy limb.
General physical and psychological status of the patient- explaining procedure and monitoring after surgery as well as how to use the crutches will reduce anxiety and help build up confidence.
PHYSICAL THERAPY MX Considered according to the surgical approach and the state of
the patient.
Patient desires to gain physical fitness or wishes to recover for recreational activity
Posterior approach- precautions should be taken against dislocation when exercises combining flexion, endorotation and adduction are given.
Anterior approach- combination of extension, exorotation and abduction (probability of dislocation is less great than for the posterior approach)
PRINCIPLES OF REHABILITATION Assessment
Reduce pain
Reduce swelling
Increases range of movement
Improve muscle strength
Aid proprioception
Mobilize patient
Prevent complications
Educate patient and family
POSTOPERATIVE DAY 1:
Post operative assessment – subjective and objective
Check operation notes and post operative instructions
Observations - HR, BP, Drainage, Temperature
Analgesia – useful to use 0-10 scale for pain assessment
Physical observation of pain, range of movement and muscle strength
Respiration and circulation
MX PROTOCOLS OF THA (*APTA)
Acute phase (1-4 days) Educate on dislocation precautions
Increase independence with function
Prevent or reduce post operative impairments.
Treatment occurs bedside, Evaluation, dangle, stand or ambulate as tolerated, Bedside exercises, THA precautions instructed (APTA)
Static contraction of the M. Quadriceps in order to have a muscular and circulatory effect.
Flexion/extension/rotation of feet and toes to prevent edema.
Education of muscular relaxation.
Upper limb exercises to stimulate the cardiac function.
Maintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilization on the operated hip.
Bed exercise following total hip replacement is important prevent edema, improve cardiac function, etc…
POSTOPERATIVE DAY 2: Treatment occurs bedside, Transfer training, Progress ambulation
distance as tolerated with walker, Review exercises and precautions, High chair sitting and bathroom privileges. (APTA)
POSTOPERATIVE DAY 3: Continue transfer training, Attempt gait progression to cane or
crutches and stair training, Treatment session in PT gym, Progression of exercise program, Review Precautions, High chair sitting and bathroom privileges. (APTA)
POSTOPERATIVE DAY 4: Continue transfer training, Continue gait progression and stairs,
Treatment session in PT gym, Review home exercise program and ADL technique, Discharge if appropriate. (APTA)
FIRST POSTOPERATIVE WEEK: Active/passive mobilizations to gain ROM Progressive resistance exercises
Progressive weight bearing exercises according to tolerance
Equilibrium exercises including walking with crutches/2 canes/1 cane.
Early exercises including full weight bearing exercises have shown different positive effects on the recovery of patients after THA
Amount of activity is linked to the general state of the patient.
Motion Phase (week 1-6) This phase includes therapeutic exercise and modalities as needed.
Goals of this phase include: Muscle strengthening of the hip girdle of the operative extremity Proprioceptive training to improve body awareness for functional training Endurance to increase cardiovascular fitness Gait training; discontinue assistive device approx. 4-6 weeks when there
are no signs of an antalgic gait, or trendelenburg sign. Increase ROM Increase Strength Return to functional activities
Weeks 1-4 AA/A/ PROM for all hip motions Isometric quadriceps,
hamstrings, and gluteal exercises
Heel slides Balance training : weight
shifting activities and closed kinetic chain activites
Gait training Stationary bike, weeks 3-4 as
advised by MD
Therapeutic Exercises:
Weeks 4-6 Continue above exercises Front and lateral step up and
down 4 way straight leg raise; if not
contraindicated by precautions ¼ lunge Sit to stand exercises Pushing and pulling exercises Aquatic program
Criteria for progression: AROM 0-110 degrees
Voluntary quadriceps control
Independent ambulation of 800ft without an assistive device, antalgia, or deviations
Minimal complaints of pain and inflammation
Intermediate Phase (week 7-12)
Goals for this phase include: Good Strength for all lower extremity musculature
Return to most functional activity and participation in light recreational activities
Progress exercises in Movement phase by adding resistance and repititions.
Assess lower extremity and trunk stability, provide open and closed chain exercises as necessary to fit the needs of the individual patient
Initiate endurance program ( pool or walking)
Initiate age appropriate balance and proprioception training
Criteria for progression: 4+/5 MMT on all lower extremity musculature
Minimal to no complaint of pain and swelling
Advanced strengthening and higher level function stage (week 12-16)
Goals for this phase include: Return fully to appropriate recreational activities
Enhance strength, endurance, and proprioception
Therapeutic Exercises: Continue to progress previous exercises
Increase duration of endurance activities
Carrying, pushing, pulling activities
Return to specific recreational activities ( golf, tennis, walking, biking)
Return to work tasks
Criteria for progression: Non-antalgic independent gait
Independent step over step stair climbing
Pain free AROM
4+/5 MMT on all lower extremities
Independent with home exercise program
Age appropriate balance and proprioception
MODALITIES SUPPORTED BY RESEARCH Cryotherapy
Thermotherapy
Electrical stimulation
DONT’S DO’S
POST OP. PRECAUTIONS
LONG TERM FOLLOW UP wear is not a short term problem
Overweight and overuse are favorable factors for polyethylene wear, or breakage.
loosening is not a short term problem
Overweight and trauma are favorable factors for bone loosening
Tell your doctor or dentist that you have a prosthetic device so that in case of infection he gives you adaquate treament with antibiotics to prevent an infection of the prosthetic joint.
Do exercises at home. Sports activities are possible
According to comorbidity, age, range of motion and stability ; waiting 3 to 6 months after a THA is a current recommended waiting time for return to sporting
Thank you!