Total hip and knee replacements Flashcards
week 3 session 1
What would be indicators for THR surgery
Trauma and femoral neck fractures
Most common OA
AVN
Severe pain and reduced quality of life
Developmental hip dysplasia
Failure of internal fixations of fractures
Perthes disease
What are the surgical approaches to THR and what is the benefits and disadvantages for each one
Anterior approach: so where your sartorious muscles are and the femoral artery etc.
- better early recovery
- lower risk for dislocation
- less tissue damage,
- disad: its a new approach and not used widely, limited lit to support
posterior ADD:
most common
spares the hip abductors
disad: technical for surgeons
higher risk for dislocations
lack of comfort because of the insision sight.
Anterolateral ADD:
+ lower risk of dislocation
Disad: trendelenburg gat, because the incision is close to the gluteal nerve.
what should be done on days 2-3 of post THR surgery, from a physio perspective
- progression of bed exercises. e.g. Ankle Pumps, glute squeezes, Diaphragmatic Breathing and heel slides.
- progression of distance walking, longer walking distances
- bring in balance exercises, side stepping
mobility aids e.g walking aids
stairs climbing for home requirements
what are the discharge criteria’s for THR
Independent mobility with assisted devices
Stairs with supervision
Independent transfer in out of bed/chair etc
Independent ADLs
Appropriate home assistance ( spouse, family, short term carers)
Home pre-planning/OT assessment
what should physios do 6 weeks post THR surgery
Gain any loss of AROM of hip
Gait re-education
Stabilization and proprioception
Endurance
Functional exercises
Return to sport activity at least 6 months after surgery – low impact preferred, high impact only on surgeons recommendation
What are outcome measures for THR
Harris Hip Score
Oxford Hip Score (OHS)
6 Minute Walking Test
Timed Get Up & Go Test
Western Ontario and McMaster universities osteoarthritis index (WOMAC)
SF-36
Fear Avoidance Belief Score
Hip Disability & Osteoarthritis Outcome Score (HOOS)
International Hip Outcome Tool
what conditions would lead to total knee replacements
Knee OA
RA
knee deformities
severe knee injury
Gout
haemophilic arthropathy
severe knee injuries
problems with blood supply in the joint- AVN/ fatty deposits or sickle cell anaemia
OA risk factors
age
high BMI
trauma
infection
repetitive motions from work-related activities
Gold standards x- ray Kellgren and Lawrence system classifications of OA
Grade 0: (none) = definite absence of x-ray changes of OA
Grade 1: (doubtful) = doubtful joint space narrowing and possible osteophytes
Grade 2: (minimal) = definite osteophytes and possible joint space narrowing
Grade 3: (Moderate) = moderate multiple osteophytes, definite narrowing of joint space and some sclerosis and possible deformity of bone ends.
Grade 4: (Severe) = large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bony ends.
management of OA
pharmacological
non- pharmacological
surgical approach
what is a total knee replacement
the medial condyle and the lateral condyle and the tibial plateau are replaced with an artificial implant and crossed-linked polyethylene plastic
the patella can be replaced on resurfaced
one of the polyethylenes is used as a shock absorber between the femur and the tibial surfaces
cruciate ligaments are sometimes preserved
what is a partial knee replacement
unicompartmental replacement removes a small part of the diseased tibia and then does the same part to the femur.. Then the artificial implants are placed in
candidates for TKR
if quality of life is severely affected
cant do ADL’s and walking
radiographic changes
age 60 plus
BMI less than 35
what is the goal of TKR
improve quality of life
restore function of normal function of AROM
pain relief
restoration of normal limb alignment
what is the role of inpatient physio of someone who has just had knee replacement, when should physios start working on the pt and when is the follow up after pt has been discharged
start within 24 hours of the surgery
PROM AND AROM exercises advice on strengthening and gait education
follow-up is within 1 week of inpatient discharge
what subjective and objective assessment should you look out for after knee replacement surgery
Subjective:
post-op complications
hx of MSK related issues
PMH and comorbidities
social life and home set up
HEP (home exercise program)
pain control
expectation of surgery and rehab
PT SMART goals
Objective:
Observations of wound/ scarring
Knee swelling - measurements
DVT (deep vein thrombosis)
Infection around the area
Muscle testing/ AROM
Gait retraining
what are outcome measures for outpatient physiotherapy after knee replacement surgery
what is phase 1 of TKR physiotherapy management (week 1-3)
pt education = pain science, importance of home exercise, setting rehab goals and expectations.
Achieve active and passive knee flexion to 90 degrees and full knee extension.
try to achieve minimal pain and swelling
get them to full weight bearing
try to achieve independence for ADL and mobility
gait re-education
phase 2: 4-6 weeks post TKR surgery
achieve 105 degrees of active knee flexion range of motion
achieve full knee extension
achieve minimal to no pain and swelling
achieve to have no quadriceps lag with good voluntary quad muscle control
phase 3: 6-8 weeks post TKR surgery
strength exercises to make sure of hypertrophy that is beyond neural adaptation ( so different ways to stimulate muscle growth, e.g. increase in sets, reps.
lower limb functional exercises
balance and proprioception training
phase 4: 8-12 weeks, up to one year
continue regular exercises involving strength, balance and proprioception training.
try to achieve independent exercise in community settings e.g. the gym =
include strategies for behaviour change to increase overall physical activity. For example, goal settings, social support getting friends to join you to stay consistent
what is the discharge criteria for TKR
be individual to that person but:
- achieve ambulation( the ability to walk from place to place without assistance)
- HEP (home exercise programme should have 2-3 times/week of strength training
Achieve full knee extension
and active 110 knee flexion minimum
competency and compliance in home Exercise Programmes.
6-12 months post surgery of commitment to independent training programme should be recommended
what are general complications and contraindications post knee surgery
infection
nerve damage
bone fracture
persistent/ chronic pain (intra-operative or post-operative)
increased risks of falls (this is because of muscle weakness and reduced propioception)
DVN
stiffness - most common
