Patient 1 Flashcards
What is OA?
Osteoarthritis is a degenerative joint disease caused by wear and tear of the joint
Pathophysiology of OA
Normal cartilage has a balanced level of degradation and synthesis to maintain it, in OA the level of degradation out weighs the level of synthesis, resulting in a breakdown of cartilage.
Fibrosis, erosion and cracking occur in the cartilage. There is a loss in volume of cartilage which results in loss in joint space.
There is sclerosis, which is thickening of the surrounding chondral bone and osteophyte formation as result of the bodies attempt at increasing surface area of the joint to decrease pressure.
There is also a loss of synovial fluid which cause an increase in friction at the joint.
Severity of OA
Severity of OA is graded on the kellgren and Lawrence scale
Grade 1 - slight joint space narrowing, possible osteophytes
Grade 2 - small osteophytes, slight narrowing
Grade 3 - multiple moderate size osteophytes, definite narrowing joint space, possible deformation of bone ends
Grade 4 - multiple large osteophytes, severe joint space narrowing, marked sclerosis and definite bony end deformity
What is a Total hip replacement?
A total hip replacement is considered one of the most successful operations in all of medicine.
In England and Wales alone there are 76,000 performed each year.
NICE recommends THR as the gold standard treatment for end-stage OA.
Involves replacement of the articulate surfaces of the head of femur and the acetabulum with protheses which can be cemented or un-cemented.
Indications - OA where conservative management has failed and hip fracture
What are the different approaches of THR?
The direct lateral and posterior approaches account for 96% of all hip replacements in the UK.
The direct lateral approach involves going the abductor compartment of the hip which involves splitting the tendons of gluteus medius and minimus which affects abduction post-op but does have a reduced risk of dislocation compared to posterior approach.
The posterior approach involves going through gluteus maximus and removing the insertions of the external rotators on the femur has been know to affect extension and external rotation.
Research on different approaches of THR
Despite the differences in approach, Physiotherapy programmes are often the same and do not target the muscle groups in need of strengthening.
A review of the literature was undertaken by Daniel Tadross to find the functional differences and Physiotherapy implications with the two approaches. He found that neither had a definitive advantage as the results of the studies depending on which outcome measure was being tested, for example during gait analysis the posterior approach was superior while using the timed get up and go test found that the direct lateral came out on top.
He concluded that lateral and posterior approaches were found to be associated with certain functional deficits but there was a lack of research concerning the adaptation of Physiotherapy programmes affecting the different approaches.
Does physical activity increase after THR
It has long been know that THR are effective at reducing pain and increasing ROM through extensive research.
It is assumed however that this directly correlates to increased physical activity, this is not the case.
In a systematic review comparing physical activity pre-operatively and up to a year post-operatively. There was no statistically significant difference in the activity levels in any of the outcome measure used in the studies.
It was hypothesised that to increase physical activity levels was more of a behavioural issue and the implementation of CBT should be used with post THR.
Anaemia
Normal Hb ranges- male: 13.5-18 g/dl, female: 12-15.2 g/dl
Normal anaemia is cause me by the bodies inability to produce red blood cells.
Post-operative anaemia is where there is loss of blood volume due to bleeding during surgery.
Treatment - post-operative anaemia usually resolves itself but if levels drop to the 8-10g/dl range and the patient is experiencing symptoms then a blood transfusion will be called for
Symptoms - fatigue, low energy, SOB, headaches, dizziness
Affect Rx - be aware of the risk of fainting, affect duration/intensity of treatment plan, do not mobilise if below 8 g/dl
DVT
Deep vein thrombosis is a condition where blood clots form in the deep leg veins. Causing serious symptoms itself or leading to a life threatening PE.
Increased risk factors of DVT are post-surgery, stroke victims, paralysis, trauma patients, obesity, any condition where the calve muscle aren’t active and do not aid venous return from the lower leg.
NICE guidelines suggest using Wells 2-level DVT score for probability of DVT, if they score 2 or more it is likely they have DVT and should be referred for a leg vein ultrasound scan within 4 hours.
Treatment - anti-coagulant drugs to thin the blood and prevent any further DVT
Affect Rx - emphasise circulation exercises so calve muscles are working aiding venous return. Ensure they are wearing the compression stockings.
Fragmin
Is a anti-coagulation drug used to thin the blood and help prevent DVT
Precautions - if there is any active bleeding, or they have low level platelets prior, history or haemorrhagic stroke, hypertension
Side effects - unusual bleeding (nose), easy bruising, bloody stools, back pain, numbness or muscle weakness in the lower body.
Patients can take home and self dose if taught how to. Injected directly under the skin in the stomach.
General Anaesthetic
Purpose - analgesia, amnesia, immobility, unconsciousness, skeletal muscle relaxation
After a GA there is a 16-20% reduction in FRC, which can cause airway closure, reduce airway compliance and V/Q matching. Which combined with opioids which depress respiratory drive can lead to hypoxia and acute respiratory failure.
During GA patients can’t maintain their airways and have to be ventilated which can lead to ventilator acquired pneumonia.
GA also paralyses the mucocillary escalator which increase risk of chest infection.
Important to perform DBE’s to increase lung volumes post-op and any chest Physio if there is any sign of respiratory infection.
Oramoph
Morphine is an opioid medication used to treat moderate to severe pain by blocking the transmission of pain signals sent by nerves to the brain.
Precautions - asthma/respiratory problems, hypotension, decrease kidney/liver function
Side effects - nausea/vomiting, drowsiness, confusion, headache, dry mouth, hypotension, reduced respiratory drive, bronchospasm
Spinal block
Injection of anaesthetic into the sub-arachnoid space in the lumbar spine.
Provides a significant neuromuscular block to act as immediate analgesia when the patient comes round from GA
No real precautions apart from abnormalities in lumbar anatomy
Affects treatment - if the block has not warm off patient will have decreased neuromuscular control, therefore mobilising will have an increased falls risk. So you would assess the strength by doing a SLR before standing patient.
Gentamicin
An antibiotic that fights bacteria
Used as a preventative measure against wound infection
Side effects - nausea/vomiting, dizziness
Cryotherapy
Pain relief - there are a number of theories as to why cryotherapy reduces pain: decreased nerve transmission in pain fibres, the cold sensations override the pain sensation (pain gait theory)
Reduce swelling and bleeding - the cold cause the blood vessels to vasoconstrict leading to decreased blood flow to the area. The decreased swelling allows more movement at the joint. Also the decrease in pressure and inflammatory chemicals reduces pain.
The evidence suggests intermittent 10 minute applications is most beneficial at reducing symptoms compared to prolonged application.
