Joint Arthroplasty Flashcards
Primary Causes of Joint Arthroplasty
- RA/OA - VERY COMMON
- Traumatic arthritis
- Avascular necrosis
- Fracture repair
Primary Indications for Joint Arthroplasty
#1 = marked, disabling pain #2 = decreased function
Others - marked impairment in ROM, instability and/or deformity, recurrent dislocations, & failure of prior surgeries/interventions
Contraindications for Joint Arthroplasty
- Infection - most significant because it very easily travels to prosthetic joint
- severe or uncontrolled HTN
- Progressive neurological disease (ALS, MS)
- Dementia
- Latent renal or respiratory insufficiency
Goals of Post-Surgical Rehab Joint Arthroplasty
- Restore function
- Decrease pain
(very aggressive pain control) - Gain muscle control/strength
- Return to previous levels of functioning
Bearing Surfaces of Hip Arthroplasty
-adv & disadv
- Metal-on-polyethylene
- ADV: cost effective, evidence & predictable lifespan
- DISADV: debris may lead to aseptic loosening & failure - Metal-on-metal
- ADV: low friction/wear, lower dislocation
- DISADV: possible carcinogenic effect of metal ions, metallosis - Ceramic-on-ceramic
- ADV: low friction/wear, inert material
- DISADV: expensive, requires expert insertion technique, possible joint noise
Uncemented vs. Cemented Fixation
-adv & disadv
Uncemented
- ADV: lower risk of CV and VTE events, bone conserving, more expensive, better long term outcomes?
- DISADV: increased risk of peri-prosthetic fracture, lack of good long-term outcome data
Cemented
- ADV: more stable initially, better short- and mid-term outcomes, less residual pain?
- DISADV: longer operative time, more difficult to revise, potential for adverse reaction to cement
Mini-Incision Arthroplasty
1-2 smaller incisions (2-6inches vs. 8-10inches)
Evidence shows possible short term advantages (less pain and bleeding –> quicker discharge) but no striking evidence that it provides a huge advantage in long term
Hip Resurfacing
For younger, more active patients
Reshapes the femoral head & a skinny stem sticks down into the femoral neck (conserves bone) + acetabular component
–>head is larger and more mimics normal joint congruency = better function
Hip Resurfacing vs. Arthroplasty
Resurfacing
- ADV: lower dislocation risk, bone conserving, low wear/friction, quicker recovery & return to high demand activity
- DISADV: higher early failure rates, metallosis, difficult procedure, little long-term data
Arthroplasty
- ADV: well studied, easier to perform, suitable for wider range of populations, better long term outcomes
- DISADV: higher dislocation risk, more difficult to revise, more functionally limiting (removes more bone)
Early Post-Op Rehab for Hip Arthroplasty
Acute to subacute
- Ice & positioning
- Education - movement & WB precautions
- Strengthening -
- AAROM –> AROM –> RAROM
- isometrics good to wake up muscles but should progress to isotonic ASAP (heel slides, SAQ, LAQ, ankle pumps)
- closed chain & functional mvmts asap - Mobility (precautions)
- Edema management
- Equipment recommendations
- Discharge planning
Late Post-Op Rehab for Hip Arthroplasty
Chronic stage
- Emphasize functional activities
- Strengthen hip flexors, extensors & abductors & include resistance if possible
- Wean away from assistive device
- Limit high impact activity or activities w/ rotational forces
Types of Knee Arthroplasty
- Tibial Osteotomy
- Unicompartmental Arthroplasty
- Total knee arthroplasty
Tibial Osteotomy
-what is it, indications
Surgical realignment of the tibia and the femur
-cut a wedge in the bone at proximal end of tibia & stabilize w/ artificial or graft
WHY?
takes pressure off medial or lateral compartment, delays TKA (est. about 9 years)
Indications - unicompartmental disease, angular deformity, & younger population
Allows for reasonable joint stability & an active lifestyle
Unicompartmental Arthroplasty
-defn, indications
Replacement of one compartment
Indications - flexion >90, full extension, < TKA
Total Knee Arthroplasty
-defn & indications
Complete replacement of femoral condyles & tibial plateau
Indications - >60 years old, <180lbs w/ severe ROM & functional limitations
Potential Complications of Knee (& hip) Arthroplasty
-risk factors for each
- Infection –> easily spreads to prosthetic
- can be at surgical site or deep peri-prosthetic
- 20% associated w/ MRSA (@ knee)
- Risk factors: obesity, anemia, malnutrition, & diabetes - Venous thromboembolism (DVT & PE) –> most common of joint replacements
- everyone should receive prophylaxis or risk increases
60% DVT & 20% chance of PE w/o &
5% DVT & 25, a-fib, anemia, depression & history of DVT
- Use WELLS Score
Early Post-op Rehab for Knee Arthroplasty
- Ice & positioning
- ROM - discharge goal of 0deg extension & 90deg flexion (including AAROM)
* *must document! - Strengthening - isometrics –> isotonic & closed chain/functional activities asap
- Mobility - focus on normalizing gait (reinforce achieve functional ROM for walking)
- Education
- Edema & pain management
- Discharge planning & recommendations
Late Post-op Rehab for Knee Arthroplasty
Chronic stage
- Emphasize functional activity & normalization
- Increase ROM using modalities & soft tissue mobilization
- Strengthening, muscle control & balance
- Limit high impact or activities w/ heavy rotational forces
What is Pre-hab & Fast Tracking
- 4 areas of focus
dynamic process that ensures best outcome w/ faster early functional recovery & reduced morbidity by giving best clinical treatment
- Pre-op education:
reduce anxiety, pain, post-op pain management & reduce length of stay - Nutritional supplementation:
malnutrition associated w/ infection & delayed wound healing; anemia associated w/ LOS & infection - Pain management:
spinal anesthesia + NSAIDS w/ acetaminophen - Early mobilization:
earlier & higher intensity of activity, prescribed according to physiological principles (not 3 sets of 10), & should be targeted, documented & well described
Outcomes of Fast Tracking
more rapid return to function reduced opiod consumption shorter LOS reduced risk of blood transfusion reduced mortality
no changes in rates of readmission, falls or adverse affects
Types of Shoulder Arthroplasty
- Conventional
- cemented or un-cemented
- indicated for OA & intact RTC
- NORMAL anatomical alignment - Reverse
- indicated if RTC is torn, cuff tear arthropathy is present, or hx of failed replacement
- REVERSE anatomical alignment - concave humeral head and convex glenoid fossa
- allows for the the deltoid to lift the arm instead of RTC
Plan of Care for Total Shoulder Arthroplasty
Phase I (2-4weeks) - PROM/AAROM
- No AROM or flexion >120, ER >30, or abd >45
- immobilization
Phase II (4-6 weeks) - AAROM/AROM
- PROM into full ER, flexion <140, but no OP
- initiate AROM esp into flexion
Phase III (6-12weeks +) - AROM/Strengthening
- AROM into flexion & ER
- strengthen shoulder girdle
- avoid overhead activity & forceful stretching
