ortho hip Flashcards
Surgical procedures to restore joint motion (hip function) and manage pain.
Damaged sections of the hip are removed.
New sections are constructed of metal, ceramic and hard plastic.
Hemiarthroplasty & Total Hip Arthroplasty (THA)
Most often for hip fracture.
Hemiarthroplasty
Hemiarthroplasty involves replacing what portion of the hip joint?
ball!
hip socket
acetabulum
covers the surface of the femoral head and the inside of the acetabulum
About ½” thick
Made of tough, slick material-allows surfaces to slide
articular cartilage
Blood supply can be damaged with hip fracture: Avascular necrosis (AVN) which can lead to
death of femoral head; bone can not maintain itself
Total Hip Arthroplasty (THA) replace the
Replace the acetabulum and the femoral head.
Total Hip Arthroplasty (THA)
Surgery performed to relieve arthritis pain or repair hip fracture.
Considerable improvement in function
Total Hip Arthroplasty (THA) is one of the most….
One of the most cost effective and successful interventions in medicine
Reliable relief of pain
in patients suffering with hip osteoarthritis or inflammatory arthritis
Quality of life (QOL) improvement from THA
THA can offer the osteoarthritis or inflammatory arthritis patient tremendous improvement in:
Pain, energy levels, sleep, social, and sexual function
Oxygen demands on activity
Walking ability
Overall quality of life
Most improvements seen within three months of surgery
Functional gains allow independence
Conditions That may Lead to a THA
Osteoarthritis (age related wear and tear) Rheumatoid arthritis Osteonecrosis (avascular necrosis: AVN) Injury Infection Fracture Bone tumors
THA Indications
Dull ache pain to groin and buttock areas pain (especially at night) is the principal indication
post op relief as early as 1 week
Functional limitations
walking and particularly walking upstairs become difficult
bending at hips, putting on shoes, pedicure, etc.
Stiffness
Hip stiffness
Ankylosing spondylitis:
Abnormal stiffening/immobility of the joint due to fusion of the bones can leave patients with tremendous functional disability in the absence of pain.
Disability in this group can be caused by back pain
Pain in the knees or the
opposite hip (why do you suppose this occurs? Why the opposite knee?)
Disability imposed by the stiff hip
Other THA Indications (continued)
Age and radiographic change
Age
most hip replacements performed in patients between 60 - 80 years old
some surgeons consider age over 80 as a contraindication
however, patients who are elderly that underwent THA have greater life expectancy
Radiographic change
severity of the radiographic changes of arthritis within the hip joint may or may not be an indication
severity of symptoms a more important indicator
The Hip Replacement Rehabilitation Team
Physician, Nurse, PT, OT
OT role in hip replacment
Reviews total hip precautions with the patients related to daily activities (sitting, posture, sleeping, etc.)
Assesses, educates, trains the patient about the adaptive equipment that is available (elevated toilet seats, etc.)
Teaches adaptive ADL
Home modifications needed for safety
Anterior vs. Posterior Hip Replacement: Differ in location of the incisions:
Anterior: Incision in the front of the hip
Posterior: Incision on the side and back of the hip
Anterior vs. Posterior Hip Replacement: Muscles affected: muscles must be pushed to the side or cut to access the hip’s ball and socket joint:
Anterior: Surgery pushes muscles aside to get to hip joint; it is a natural separation, minimal or no muscle cutting.
Posterior: Muscles and other soft tissue is cut
Anterior vs. Posterior Hip Replacement: Technical ease of surgery:
Anterior: Limited view of the hip; more challenging.
Posterior: Better view of the hip.
Anterior vs. Posterior Hip Replacement: Post-operative status:
Anterior: Less pain; faster recovery, fewer post-surgical precautions
Potential disadvantages of anterior hip replacement:
Obese or very muscular people are sometimes not candidates
Technically demanding for the surgeon
Posterior Approach: Total Hip Replacement provides better…
Approach is from the posterior aspect
Better visibility of the joint for more precise placement of implants
More invasive than anterior approach
Total Hip Replacement (Posterior) Precautions
Keep toes pointed forward and slightly out (do not rotate the leg too far; no internal rotation)
Move leg or knee forward, don’t move leg back
Keep your knees apart; don’t cross legs/midline (some people even say don’t cross at ankles- that is more so they are not tempted to cross at the knee).
Maintain 90 degrees of hip flexion
Tools to maintain 90 degrees
Keep knees below level of hip joint while standing or seated
Avoid low seats, deep soft seat cushions, low beds, rocking chairs
Use elevated toilet seat (if needed to keep hip at 90)
Do not reach for tub controls (bathtub)
Do not sit on the tub floor
Do not bend, squat to wash legs and feet (use long handle brushes)
Preparing home for THA post-op recovery
Arrange furniture for safe maneuvering with a cane, walker, or crutches
Minimize use of stairs
Place items you use frequently within easy reach to avoid reaching up or bending down
Remove throw rugs or area rugs, secure electrical cords to reduce fall risk
A good chair has a firm cushion and has a higher seat height
Shower chair, grab bar, and raised toilet seat in the bathroom
Use assistive devices such as a long-handled shoehorn, a long-handled scrub brush, reacher, dressing aids
Post-op Activity Guide
Follow doctor’s instructions about use of ambulatory aids (cane, walker, or crutches) and weight bearing schedule
full weight bearing may be allowed immediately, or may be delayed by several weeks, depending on procedure
Sleeping instructions may include avoiding certain sleeping positions or to sleep with a pillow between your legs for a length of time
Torn Anterior Cruciate Ligament is located and controls what?
ACL: Located in the center of the knee
Controls rotation and forward movement of the tibia (shin bone)
ACL Tear Causes
Get hit very hard on the side of your knee, such as during a football tackle
Overextend your knee joint
Quickly stop moving and change direction while running, landing from a jump, or turning
Basketball, football, soccer, lacrosse and skiing are common sports linked to ACL tears
Avulsion fracture: More common in children, caused by knee hyperextesion; separation of the tibial attachment of the ACL
Types of ACL injury
Grade 1 Sprain
Ligament is mildly damaged
Slightly stretched, but is still able to help stabilize the knee.
Grade 2 Sprain
Stretches the ligament to the point where it becomes loose, often referred to as a “partial tear”.
Grade 3 Sprain
Most common ACL injury
Commonly referred to as a complete tear of the ligament
Ligament split into two pieces, and unstable knee joint
Torn ACL mechanism of injury
Typically torn in noncontact deceleration that produces a valgus twisting injury
e.g., when landing on the leg and quickly pivoting in the opposite direction
Other forces can disrupt ACL with minimal injury to other structures are:
Hyperextension
Marked internal rotation of tibia on femur
Pure deceleration
ACL and Patellofemoral DisordersGender differences
Rate of ACL injury 2 to 8 times higher in females than males who participate in the same sports.
Patellofemoral disorders can be divided into 3 categories:
Patellofemoral pain
Patellofemoral instability
Patellofemoral arthritis
Current studies do not answer the question of whether patellofemoral pain is more prevalent in females
however, clinicians have observed that anterior knee pain is more common among females
Gender differences: females have a
narrow intercondylar notch and a wider Q (quad angle)
ACL Surgical Treatment
Rebuilding the ligament
most ACL tears cannot be “sutured back” together
to restore knee stability, the ACL must be reconstructed with a tissue graft
graft acts as a scaffolding for new ligament to grow on
Graft sources
common source - patellar tendon, hamstring tendons
sometimes quadriceps tendon, or allograft (cadaver) graft
Post ACL Reconstruction Exercise and Activity Instructions (example)
Begin the ROM exercises once awake
Important to achieve full knee extension and flexion
Goal is to achieve a range of motion of 0 to 90 degrees 1-week post op. Straight leg raises.
Crutches for 6 weeks (some protocols say 2-3 weeks)
Keep knee straight while resting (no pillows under knee –why would this be important?)
PT rehab after 1-2 weeks
No swimming or running for 6 months
Meniscus Tear
Shock absorber
Helps optimize force across the knee
Protects the cartilage at the end of the femur
Meniscus tears are..
Among the most common knee injuries
Contact sports athletes are at higher risk, however, anyone at any age can tear a meniscus
Menisci tear in different ways, noted by how they look, as well as where the tear occur
Meniscus tears caused by
Squat and twisting the knee can cause a tear
Also direct force on the knee, e.g., a tackle
Older people are more likely to have degenerative meniscus tears
Cartilage weakens and wears thin over time
Meniscus tears - Treatment
Depend on the type of tear, size, and location
Outside 1/3 has rich blood supply
A tear in this “red” zone may heal on its own, or can often be repaired with surgery, e.g. longitudinal tear
Inner 2/3 of the meniscus lacks a blood supply so cannot heal
these are complex tears are often in thin, worn cartilage.
pieces cannot grow back together, so tears in this zone usually surgically trimmed away
Hip Fractures
Very serious injury for elderly
Rank in the top 10 of all impairments worldwide in terms of loss for people 50+ years old
Most often caused by a simple fall
often resulting in long-term functional impairment
nursing home admission
increased mortality
Incidence of hip fracture is 17 to 22% for 50-year-old women, 6 to 11% for men
Hip Fractures Contributing Factors
body size, decreased strength, inactivity
impaired cognition, impaired perception and vision
environmental circumstances, chronic illnesses, drugs, etc
Hip Fractures
90+% of hip fractures caused by falling
most often by falling sideways onto the hip
Large proportion of fall deaths are due to complications following a hip fracture
20% of hip fracture patients die within a year of their injury
linked to pulmonary embolism, infections, and heart failure
Hip Fractures - 3 Major Types
Specific location of the fracture: femoral neck intertrochanteric subtrochanteric fractures
Femoral neck fracture
fractures of the femoral neck can entirely disrupt the blood supply to the femoral head
resulting in major healing complications such as fracture nonunion
or avascular necrosis
or death of the femoral head bone tissue
Intertrochanteric hip fractures
Occur outside of the joint capsule and are therefore extracapsular
involve bone with good local blood supply
However, complicated by the pull of muscle attachments, which can pull fracture out of alignment
Healing complications may include
shortening of the length of the femur or malunion
Subtrochanteric fractures
Blood supply to subtrochanteric region not as good as the intertrochanteric region
heals more slowly
subject to competing muscular forces on the femur that tend to pull the fractured fragments out of alignment
Hip Fracture Medical Treatment
Treatment typically includes surgery and hospitalization
Short term goal of surgical treatment is to stabilize the hip fracture enough to withstand early mobilization and weight bearing
which prevents complications due to prolonged bed rest and aids in fracture healing
Hip Fracture Treatment
Many hip fractures are treated with internal fixation
But if optimal realignment of the fracture is not possible or practical, then a partial or THA is considered
Frequently followed by admission to a nursing home and extensive rehabilitation
Hip Fractures (Risk factors)
Women sustain 75% of all hip fractures
White women are much more likely to sustain hip fractures than are African-American or Asian women
In both men and women, hip fracture rates increase exponentially with age
85 and older are 10 to 15 times more likely to sustain hip fractures than are those age 60 to 65
Osteoporosis increases risk
Hip Fracture Prevention
Take adequate calcium and vitamin D
Do weight bearing exercise
Get screened and treated for osteoporosis
Fall prevention strategies:
Exercise regularly to increase leg strength and improve balance
Dr. should identify medications that cause dizziness, drowsiness, and interactions
Have vision checked regularly to maximize vision
Home safety improvements - reduce tripping hazards, grab bars strategically placed where needed, stair railings, and improve lighting
study questions
at end of ppt!
