TKA & THA Flashcards
What is the Comprehensive Care for Joint Replacement Model
- Moves away from payment per patient and more toward outcomes
- Hospitals given a target price that includes all costs of surgery and all related care 90 days s/p
- Encourages hospitals to coordinate care and collaborate
Required hospital reporting for CJR
- Risk Standardized Complication Rate
- Patient Satisfaction Survey
CJR Implications for Rehab - Recommended outcomes
- Pt reported outcome measurement information system (PROMIS)
- Hip disability and osteoarthritis outcome score
- knee injury and osteoarthritis outcome score
why is prevalence of osteoarthritis increasing?
- Expanding age population
- obesity
- trauma
- higher participation in high impact sports
Ceramic on Ceramic
- Wear and scratch resistant
- Decreased revision rates, osteolysis, aseptic loosening, dislocation
Different types of implants
- short stem total hip arthroplasty
- hip resurfacing
- total hip arthroplasty
what is hip resurfacing?
- Femoral head preserved
- no femoral stem
- capped head
- fastest growing orthopedic procedure in the world
Hip resurfacing candidate
- male, <60 years old
- Normal functioning kidneys
- active lifestyle
- BMI <30
Hip resurfacing benefits
- higher ROM
- decreased chance of dislocation
- significant gains in ROM by 6 mo and 1 year
- not as many restrictions
Anterolateral THA
- anterior 1/3 of glute med and min released and repaired; ERs usually left intact
Posterolateral THA
- short ERs and piriformis released and repaired; glute med and TFL intact
Minimally invasive surgery THA
- posterior approach: incision between interval between glute meds and piriformis; short ERs may/may not be released and repaired
- Anterior approach: all muscles left intact; sartorus and RF retracted medially; TFL laterally
Traditional Anterolateral THA precautions
no hip flex past 90
no ext, Abd. and ER past neutral
Traditional posterolateral THA precautions
- no hip flex past 90
- no ADD past neutral
- no IR past neutral
Minimally invasive surgery THA approaches precautions
may have some, may not have some
ask surgeon
hip resurfacing precautions
not usually any
ask surgeon
max protection phase
- prevent vascular complications
- prevent dislocation/sublux
- achieve independent functional mobility
- maintain functional level of strength in non-op extremities
- regain active mobility and control of op limb
mod protection phase
- regain strength and muscular endurance
- improve cardiopulm endurance
- restore ROM with precautions
- improve postural stability, balance, gait
min protection phase
- continued training for restoration of strength, muscular, and cardiopulmonary endurance, balance, and symmetrical gait pattern
- gradual resumption of functional/rec activities
designing a rehab program for athroplasty
- maximize strength
- maximize flexibility
- limit abnormal forces across the hip or knee
- prevent hip dislocation
- prevent excessive wear
full squat ROM
- flex: 130
- ER: 5-36
- Abd: 10-30
Cross legged ROM
- flex: 90-100
- ER: 35-60
- abd: 40-45
structure leg length discrepancy
a true leg length difference
functional leg length discrepancy
most due to:
- pelvic obliquities
- mm contractures
- tight capsular structures
- other joint abnormalities
** usually responses by 12 mo s/p THA
muscular-balance length and strength
- abd/add contracture
- quad lumborum tightness
- hamstring tightness
- hip flex tightness (psoas, RF, TFL)
faulty gait patterns secondary to:
- pre-op gait pattern
- implant design
- decreased joint proprioception due to OA
- PT related issues (muscle weakness, decreased muscle flexibility, capsular changes)
Gait: chronic locomotion issues one year after THA
- decreased gait speed
- decreased hip ext early push off
- decrease hip ext moment of force during early stance
- decrease peak abd moment at end of weight bearing
- decrease peak ER moment during mid-stance
rehab for gait
- address specific joint limitations
- incorporate exercise into gait activities
- CKC
- eccentric training
- Symmetry: arm swing, strength, pelvic, WB
- posture
- flexibility
- coordination
- agility
- proximal and distal joint
theres some research stuff if you wanna look at it
I dont
important considerations for recreational activity post THA
- pre-op activity
- surgical reconstruction, anatomic and biomechanic reconstruction, well-designed implant, properly balanced
- implant failure/fracture
- implant fixation/loosening
- joint bearing surface wear
- traumatic complications
- load, repetition, frequency, risk of fall, risk of contact
return to activity
- start slowly, build stamina
- minimize joint loading
- no jumping
- no extreme motion
- pain free for 24 hours after activity
recommended activities post THA
Golf
Swimming
Doubles tennis
Stairclimber
Walking
Stationary Skiing
Bowling
Treadmill
Station Bicycling
Elliptical
Low-Impact Aerobics
Rowing
Dancing
Weight Machines
Activities not recommended post THA
Jogging
Racquetball
Squash
Contact sports
High impact aerobics
Baseball/Softball
Snowboarding
Martial Arts
Singles Tennis
Waterskiing
Handball
Types of knee arthroplasties
- Unicompartmental Knee Arthroplasty
- TKA: 90% cases successful, survivorship 12-13 years, newer polyethylene approach (20 years)
- LPS- Flex Fixed Bearing Knee (Hi-Flex TKA)
- LPS- Flex Mobile Bearing Knee (Hi-Flex TKA)
knee flexion activities that require less than 120 degrees
sitting
walking
stairs
knee flexion activities that require more than 120 degrees
sitting criss cross apple sauce
kneeling
gardening I guess
advantages of unicompartmental knee arthroplasty (UCKA)
- replace only diseased bone (preservation of bone stock, more normal kinematics because cruciate preserved)
- decreased blood loss and extent of surgery
- feels more like a normal knee
- greater arc of motion
- shortened hospitalization
- normalized giat
- mobile UCKA
arc of motion of UCKA vs TKA
- UCKA: 0-135
- TKA: 0-120
UCKA indications
- osteoarthritis
- single compartment disease (most often medial)
- activity and rest pain
- > 120 degrees ROM
- No instability: ACL INTACT
- Age: usually <55 years
- Informed patient
if a patient does not have an ACL can they have UCKA
N O N O N O N O N O
NO
LPS-Flex Fixed and Mobile Bearing Knee (Hi-Flex TKA)
TKAs designed to mechanically sustain the loads during flexion angles up to 155 degrees and to accommodate patients tat have the requirements, need and ability to continue their flexible lifestyle
(younger, more active)
Considerations for Hi-Flex TKA
- patients activity level
- need for high flexion
- adherence to rehabilitation
- surgeons judgement that the patient will flex beyond 125 post op
LPS-Flex Mobile Bearing Knee
beneficial for active patients, preferable for those who have the desire and ability to kneel, squat or sit cross-legged
Parameters for Hi-Flex TKA patient
younger
more active
more flexible to begin with
TKA general guidelines - max protection phase
- control pain and swelling
- achieve independent ambulation and transfers using AD
- prevent early post op complications
- regain quads strength and improve knee ROM
TKA general guidelines - mod protection phase
- achieve approx 110 flex and 0 ext
- regain LE strength and muscular endurance, balance, cardio endurance
TKA general guidelines - min protection phase
- task specific strengthening
- proprioceptive and balance training
- advanced functional training
what a PT should know from surgeon
- ligament stability
- soft tissue status
- extensor mechanism integrity
- intraoperative ROM
key point in rehab - emphasize terminal ext ROM
- when possible measure in prone
- quiet standing is energy efficient
- instancing, WB line falls slightly ant to axis of knee
TKA - knee flex contracture
- excessive load on femoral and polyethylene components
- increased quads force during WB
- 30 degree flex contracture = quads demand rises to 50% of max contractile effort
- impaired endurance
- impaired function clinically
TKA ROM loss etiology
- pre op ROM
- underlying disease (RA)
- primary vs revision TKA
- post op pain
- CRPS
- Aseptic loosening or infection
- arthrofibrosis
- technical errors
ROM loss results in
- altered gait mechanics
- quads fatigue
- increased VO2 demand
- hip/back discomfort
- unhappy patient/poor outcome
TKA reg flags
- no increase in ext range
- hard end feel in flexion
- increase co-contraction of Q+H
Patellar instability post TKA
- sublux or dislocation
- 2-7% incidence
- malalignment with increased Q angle and lateral pull
- contact surgeon
if there isnt at least 90 degrees of knee flex by week 3-4 what should you do
call the surgeon
intervention - STM
- myofascial release
- patellar/ scar mobilization
talk about importance of hip abductors
- they have higher correlation w/ measures of physical function than did demographics, anthropometric measures, or Quad strength
whats the most important determinant of the likelihood of sports participation after TKA
pre-op participation in the sport itself
what does UCKA more predictably allow
return to low impact sports
