JOINT REPLACMENTS: KNEE & HIP ARTHROPLASTIES Flashcards
Types of joint replacements /arthroplasties
- Knee replacement
- Hip replacement
- Shoulder replacement
KNEE ARTHROPLASTIES
Types of Knee replacements
- Total Knee replacement
- Partial Knee replacement / Uni-compartmental Knee replacement
Usually medial compartment
Knee replacement (TKR) Criteria for knee replacement
• End stage OA
• Severe tibiofemoral pain and persistent swelling
• Loss of general function and/ knee mob (Stiffness++, pain++,
instability++)
• Severe knee deformity / contractures
• Failure of conservative Mx
• ↓QOL
• Functional restrictions experienced pre-operatively
Typical functional restrictions pre-op :
• Walking on even/uneven surfaces
• Climbing stairs
• Getting up from a seated position/toilet
• Standing for prolonged periods
• Getting in and out of the bath
• Bending to pick something up from the floor
• Putting on socks, shoes
• Stiffness in the morning and after resting later on the day
KNEE ARTHROPLASTIES
• Protocols used for rehabilitation
Different protocols (Conservative): • Post-op High Care • Vitals monitored • Urine catheter • Drainage bottle: Porto-vac/ Palin drain • Compression bandage • DVT stocking 6/52 • Wound –clips. Removed 2/52 post-op • Patient start mobilization POD1 • LOS: 3-4 days
Different protocols (Advanced):
• Decreased opioids- decrease sleepiness, nausea and dizziness.
• Post-op ward patient
• Vitals monitored
• No Urine catheter or drainage bottle
• Only thin compression bandage
• No DVT stockings. IPCP( Intermittent Pneumatic Compression Pump)
• Wound – no clips. Use wound adhesives. Dressing stay on for 2/52
• Patient start mobilization POD 0
• LOS: 2 days
KNEE ARTHROPLASTIES
• Patient education
- Pre-op
- Pain full operation. Exercise and Ice.
- Expectations from Physio and patient
- Gait re-education with crutches/walking frame
- Navigating stairs with crutches/walking frame
• Post-op exercises
• Signs of DVT/PE : Calf pain, groin pain, chest pain, SOB, severe
swelling
• Crutches 6/52
• 120° knee flexion and full knee extension at 6/52 post-op
KNEE ARTHORPLASTIES
• Precautions
- PKR – PWB 1st 2/52 and then FWB.
- TKR – PWB as pain allows and progress to FWB
- Monitor for signs of deep vein thrombosis (TTS), pulmonary embolism (SH) and loss of peripheral nerve integrity (derm, myo). In these cases, notify the Dr immediately.
- Avoid torque or twisting forces across the knee joint especially when WB on involved limb.
- Monitor wound healing and consult with referring Dr if signs and symptoms of excessive bleeding and poor incision integrity are present.
- No exercises with weights or resistance.
KNEE ARTHROPLASTIES
• Discharge criteria
Criteria for discharge for TKR
• Independent SLR
• Active knee range of motion (AROM) 0-90’
• Minimal pain and inflammation
• Independent transfers and ambulation at least 30 m with appropriate
assistive device.
• Safe and independent stair mobility (relevant level of mobility)
• Medically stabile and wound dry
• Someone at home to help the patient
KNEE ARHTROPLASTIES
• When a Knee Replacement is not indicated/ recommended
- Current knee infection
- Morbid obesity (+130kg)
- Paralysis of the quadriceps femoris muscle
- Severe mental dysfunction
- Severe PVD or neuropathy affecting the knee
KNEE ARTHROPLASTIES
• Outcome measures used
- WOMAC Questionnaire – pain, stiffness and function
- KOOS
- VAS
- ROM
KNEE ARTHROPLASTIES
• General advice
• No driving 6/52
• No physical hard labour or exercises 6/52
• No pillow under knee when sleeping
• May sleep on non-operated side with pillow between knees
• Low impact sport after 3 months – swimming, cycling, hiking, golf
• Only drink meds prescribed by Dr. If unsure, phone the Dr.
• Patients should not brace the leg. Gravity is your friend!!!
• Swelling normal for first 3 months.
• Pain over medial aspect of knee and sensation loss over Lateral side is
common
• It takes 6 months to a year to recover fully.
KNEE ARTHROPLASTIES
• Outpatient treatment
- Physio 1 x per week for 6/52
- Strengthening and work for Flex/Ext ROM
- Foot pumps, Stat Quads, SLR, Ext over roller, Flex /ext over side of bed
- Prone knee flexion – Contraction, relax
- Capsule stretches, Hamstring and calf stretches
- Gait re-education, Balance, proprioception.
- Strengthening – Quads, Hamstrings, Gluts med and Max, Gastrocs, Soleus and core.
- Soft tissue and pain management
- ICE
- HEP. 5 x per day. 1 set of 10 repetitions.
KNEE ARTHROPLASTIES
TREATMENT POD 0/1:
- Pre-op education
- Post-op check – Heel doughnuts, DVT socks/IPCP, pulse, motor function, Vitals, Drip, wound and check that Palin drain is open.
- Encourage pt to sit more upright - ↓ Postural hypotension
- Encourage pt to eat and drink
- Make sure toilet raiser is in place
- Start bed exercises. Foot pumps, Static Quads, Heel slide, Hip abd/add, SLR.
- Sit over side of bed, feet on the ground
- Teach pt knee locking and demonstrate crutch walking
- Stand up with help of 2 people in case the patient experience drop in BP.
- Test knee –locking
- If safe, proceed to mobilize to toilet
- Never leave patient by themselves in case of dizziness
- Correction of walking pattern. Heel toe, knee flexion and full extension
- Back to bed or sit out in chair
- Progress to navigating stairs with the next session
- Sit out in chair for breakfast, lunch and dinner
- Mobilize in between treatment sessions with nursing staff.
- ICE
HIP ARTHROPLASTIES
TYPES OF HIP ARTHROPLASTIES
- Total Hip Replacement – Head of femur is replaced and the Acetabulum is lined with a synthetic joint surface
- Partial Hip Replacement – Only the Femur head is replaced.
HIP ARTHROPLASTIES
INDICATIONS
- Pain & loss of function and mobility
- End stage OA, RA
- Avascular necrosis
- Post traumatic arthritis and joint stiffness
- Irreversible destruction
- Degenerative changes
- Displaced femur neck fractures
- Failed femur neck ORIF’s and Revision surgery
HIP ARTHROPLASTIES
Surgical Approaches
- Posterior approach- piriformis & short external rotators of the femur. Most preferred. Good visualisation of femur and acetabulum and spare the abductor muscle group.
- Lateral approach- lift gluteus medius & glut minimus, osteotomy of greater trochanter and reattached afterwards.
- Anterolateral approach- space between tensor fascia latae &gluteus medius.
- Anterior approach- space between sartorius & tensor fascia latae
- AMIS (Anterior Minimally Invasive Surgery) latest surgical technique with good functional outcomes.↓ damage to muscles, ligaments, capsule and nerve. Also less dislocations than other approaches
HIP ARTHROPLASTIES
COMPLICATIONS
- Dislocation. Post≥ Ant
- Wear, loosening of prosthesis
- Venous thrombus
- Fracture intra-op
- Post op thigh pain
- Failure
- Infection wound/Resp
- Nerve injury
- Leg length discrepancy
- Abduction insufficiency –Lat app
HIP ARTHROPLASTIES
CONTRAINDICATIONS & PRECAUTIONS
Posterior approach (PWB)
• Do not cross legs (i.e. no hip adduction past midline)
• Do not remove abduction pillow
• Avoid combined hip flexion, adduction and internal rotation at least for 6/52
• Hip internal/external rotation >45°
• No hip flexion > 90°
• No SLR
• No side lying 6/52
• Cemented – FWB, Un-cemented – Toe-touch
• seats
Posterior approach (continued) • Abduction pillow post-operative • Elevated toilet seat • Elevated chair with arm rests • 1st 6/52 only sleeping on back. After 6/52 pt may sleep on unoperated side with pillow between the knees and only after 12/52 pt may sleep on operated side again with pillow between the knees. • No driving for 6/52
Anterior approach (WBAT)
• No combination of hip extension, Abd and ER
• No excessive hip ranges
• No hip ext rotation > 45°
Lateral approach (WBAT)
• Do not cross legs (i.e. no hip adduction)
• Do not remove abduction pillow
• Keep leg in neutral- no excessive adduction/crossing legs.
AMIS
• Weight bearing as pain allows (PWB to FWB) initially with walking aids
• No other contraindications for sitting or hip physiological movements.
HIP ARTHROPLASTIES
FUNCTIONAL RESTRICTIONS
Typical functional restrictions pre-op :
• Walking on even/uneven surfaces
• Climbing stairs
• Getting up from a seated position/toilet
• Standing for prolonged periods
• Getting in and out of the bath
• Bending to pick something up from the floor
• Putting on socks, shoes
• Stiffness in the morning and after resting later n the day
HIP ARTHROPLASTIES
PROTOCOLS
Different protocols (Conservative): • Post-op HC • Vitals monitored • Urine catheter • Drainage bottle: Porto-vac/ Palin drain • DVT stocking 6/52 • Abduction pillow • Wound –clips. Removed 2/52 post-op • Patient start mobilization POD1 • LOS: 3-4 days
Different protocols (Advanced):
• Decreased opioids- decrease sleepiness, nausea and dizziness.
• Post-op ward patient
• Vitals monitored
• No Urine catheter or drainage bottle
• No DVT stockings. IPCP( Intermittent Pneumatic Compression Pump)
• Abduction pillow
• Wound – no clips. Use wound adhesives. Dressing stay on for 2/52
• Patient start mobilization POD 0
• LOS: 2 days
HIP ARTHROPLASTIES
Patient Education
Patient education NB NB NB:
• Pre-op. ↑Trust and confidence, ↓ anxiety and LOS
• Expectations from Physio and patient
• Precautions and abduction pillow
• Gait re-education with crutches/walking frame
• Navigating stairs with crutches/walking frame
• Pre-hab and Post-op exercises
• Signs of DVT/PE : Calf pain, groin pain, chest pain, SOB, severe
swelling
• Crutches/walking frame 6/52
• Good functional hip ROM at 6/52 post-op
HIP ARTHROPLASTIES
PHYSIOTHERAPY GUIDELINES
Treatment POD 0/1:
• Pre-op education including Precautions
• Post-op check – Heel doughnuts, Abduction pillow, DVT socks/IPCP, pulse, motor function, Vitals, Drip, wound and check that Palin drain is open.
• Encourage pt to sit more upright - ↓ Postural hypotension
• Encourage pt to eat and drink
• Make sure toilet raiser is in place
• Start bed exercises. Circulation drills UL’s and LL’s, Isom & A-A hip flex, abd and add. Then progress to active hip and knee flexion (Heel slide), Hip abd/add, knee flex and ext over side of bed.
• Sit over side of bed, feet on the ground. Patient get out on operated leg’s side of bed
• Demonstrate crutch walking
• Stand up with help of 2 people in case the patient experience drop in BP.
• If safe, proceed to mobilise to toilet
• Never leave patient by themselves in case of dizziness
• Correction of walking pattern. Heel toe, knee flexion and full extension
• Back to bed or sit out in chair (Raised chair with armrests)
• Remember to put abduction pillow back
• Progress to navigating stairs with the next session
• Sit out in chair for breakfast, lunch and dinner
• Mobilize in between treatment sessions with nursing staff.
Treatment POD 1/2: • As above • Navigating stairs with crutches/walking frame • Progress walking distance • Sit out in chair • HEP • 6/52 post-op: Full ROM, balance, proprioception, endurance, strengthening and functional exercises.
HIP ARTHROPLASTIES
DISCHARGE CRITERIA
- Minimal pain and inflammation
- Independent transfers and ambulation at least 30 m with appropriate assistive device.
- Safe and independent stair mobility (relevant level of mobility)
- Patient should know precautions
- Medically stabile and wound dry
- Someone at home to help the patient
HIP ARTHROPLASTIES
OUTCOMES MEASURES
- WOMAC Questionnaire – Pain, function and stiffness
- Harris Hip Score
- HOOS
- 6 min walk test
