Total Hip Replacement - THR

Question 1

Femoral Neck Fractures (Describe)

Answer 1

• Includes subcapital (just below ball), transcervical (mid betw ball and grt trochanter), and basilar (just above grt trochanter) fractures
• Common in adults over 60; more frequent in women
• Osteoporotic fracture may result from slight trauma or rotational force
• Tx complicated by poor blood supply, osteoporatic bone not suited for metallic fixation, and thin periosteum covering the bone
• Surgery type based on amt of displacement and vascular supply in femoral head, plus age, health, activity level of client:

Question 2

Subcapital Fx

Answer 2

Femoral neck fracture that is just below the ball/head of the femur.

Question 3

Transcervical Fx

Answer 3

Femoral neck fracture that is midway between the ball/head of the femur and the greater trochanter.

Question 4

Basilar Fx

Answer 4

Femoral neck fracture that is just above the greater trochanter.

Question 5

Tx for Minimal to Moderate Displacement Femoral Neck Fx

Answer 5

Minimal to moderate displacement with intact blood supply: INTERNAL FIXATION or HIP PINNING (application of compression screw and plate)
• Can usually begin out-of-bed activity about 1 day post-op
• Weight-bearing restrictions may be necessary, walker/crutches for 6-8 wk
• Weight-bearing may be limited beyond 6-8 wk if precautions not observed or delayed union

Question 6

Tx for Severe Displacement Femoral Neck Fx

Answer 6

Severe displacement or poor blood supply (avascular), nonunion (poorly healing site), or DJD: femoral head surgically removed/replaced by ENDOPROSTHESIS (or, prosthesis) called hemipolar arthroplasty/HEMIARTHROPLASTY.
• Several types of prostheses shaped to best fit client’s size and needs
• Weight-bearing restrictions may be needed
• May perform total joint replacement depending on joint integrity/activity level of client
• THR has better outcomes for active people
• Depending on hemiarthroplasty, THR, and whether posterolateral or anterolateral approach, precautions and positioning will be advised (precautions always same as for THR).
• Can usually begin out-of-bed activity about 1 day post-op

Question 7

Intertrochanteric Fx

Answer 7

• Fracture is just below greater trochanter; betw grt trochanter and lesser trochanter
• Extracapsular (outside of articular capsule of hip joint), so blood supply not affected
• Occur mostly in women but slightly older
• Usually by direct trauma or force over the trochanter, such as a fall
• Preferred tx is ORIF: nail or compression screw/plate used
• Weight-bearing restrictions must be observed up to 6-8 wk w/gradual increases in affected leg over this time period
• Client usually allowed out of bed 1 day post-op

Question 8

Subtrochanteric Fx

Answer 8

• Occur 1-2 inches below lesser trochanter, usually from direct trauma/falls, MVA, or other direct blow to hip
• 10-30% of hip fractures
• Most common in younger than 60, or older clients with osteopenia (significant bone loss) after low velocity fall
• Most challenging to repair due to muscle attachments that can put force on site/impact healing
• ORIF most common tx; nail with long side plate or intramedullary rod (inserted through central part of shaft to maintain alignment) are used
• Same THR precautions
• Weightbearing should be allowed as tolerated. Patients usually protect themselves by self-restricting weightbearing and movement.

Question 9

Osteopenia

Answer 9

Significant bone loss (higher risk of fx)

Question 10

Intramedullary Rod

Answer 10

Used in femoral fx ORIF; inserted in central shaft of femur to maintain proper alignment).

Question 11

Anterolateral Hip Surgery

Answer 11

Surgery performed/opened from the front of body. Muscles displaced are weak post-op. Client unstable in ext rotation, add, and ext of operated hip and typically prevent these mvmts 6-8 wk. Less likely to have posterior dislocation with this approach. (Minimally invasive technique uses small vertical incision with hip placed in hyperextension; faster recovery and less risk of dislocation/post-op limp.)

PRECAUTIONS (6-8 wk):
• No external rotation
• No adduction (crossing legs/feet); possibly also no abduction
• No extension

Question 12

Posterolateral Hip Surgery

Answer 12

Surgery performed/opened from rear of body. Muscles displaced are weak post-op. Client unstable with hip flexion, internal rotation, adduction. Requires ~10 inch incision and muscles detached to get to joint. (Also a minimally invasive technique that uses 2x 2” incisions and not detachment; more stable post-op.)

PRECAUTIONS (6-8 wk):
• No hip flexion > 90˚
• No internal rotation
• No adduction (crossing legs/feet)

Question 13

Goal of Surgical Interventions

Answer 13

Surgical approaches are chosen with the goal of choosing the technique that will provide the best STABILITY for the client and reduces occurrence of COMPLICATIONS. Chosen based on:
• Skill of orthopedic surgeon
• Severity of joint involvement
• Anatomic/biomechanical structure of client’s hip
• History of past surgery to hip

BIGGEST GOALS:
• Restore optimal joint function
• Decrease pain
• Retain joint position/alignment
• Allow for proper healing

Question 14

Hip Resurfacing

Answer 14

Another method of repairing a damaged/painful hip. Less commonly used; variation on THR. For younger clients. Resurfacing preserves more of the bone of femur should THR be needed later. Surface of femoral head reshaped and capped w/metallic shell. Acetabular cavity also receives metallic cup/socket. Both held in place with methylmethacrylate (acrylic cement). No weight-bearing restrictions for this procedure.

Question 15

Weight Bearing Restrictions

Answer 15

• NWB – Non Weight Bearing – no weight at all on involved extremity
• TTWB – Toe Touch Weight Bearing – Only toe can be placed on ground for balance while standing; 90% of weight on unaffected leg. (Imagine an egg under the foot.)
• PWB – Partial Weight Bearing – Only 50% of body weight placed on affected leg
• WBAT – Weight Bearing At Tolerance – Client allowed to judge how much weight can be placed without pain that limits function
• FWB – Full Weight Bearing – Client able to put 100% of weight on affected leg

Question 16

Degenerative Joint Disease (DJD)

Answer 16

Also known as osteoarthritis (OA), is a common “wear and tear” disease. MOST COMMON REASON FOR THR. The underlying cause of this condition is typically chronic repetitive motion that results in inflammation and structural joint damage. Inflammation causes pain, redness, and swelling. The tiniest amount of trauma triggers inflammation as the body attempts to clean-up/protect damaged tissue. Can also be caused by trauma, congenital deformity, or disease affecting articular cartilage. This cycle of joint damage and inflammation leads to the break-down of cartilage that serves as a smooth gliding surface and cushion in the joints. Any joint can be affected, but frequently found in the hands and weight-bearing joints (knees, hips, and lumbar spine). More than 50% of adults over 65 affected by DJD. In hip, cartilage loss occurs centrally and osteophytes form on periphery of acetabulum, producing joint incongruity. Pain/movement limitation causes muscles to shorten, resulting in flexed/adducted/int rotated hip position and limp.

Question 17

Causes of Traumatic Fracture

Answer 17

Caused by some type of accident, fall, or other kind of force (ie: MVA, forceful overextension, or strike by heavy object).

Question 18

Pathological Fracture

Answer 18

Fracture caused by a disease such as OA, osteomyelitis (bone infection), other bone disease, metabolic abnormalities, or cancer. Everyday things, such as coughing, stepping out of a car, or bending over can fracture a bone that’s been weakened by an illness.

Question 19

THR vs. Hemiarthroplasty

Answer 19

Total Hip Replacement (THR): (Also called arthroplasty or bipolar arthroplasty.) Used in severe displacement of femoral head fractures, but with less joint integrity. Better outcomes for younger/very active people. Femoral head AND acetabulum are replaced. Also used for cases of chronic disease processes (OA, DJD, RA, etc.). MOST COMMON REASON IS DJD.

Hemiarthroplasty: Also used in severe displacement of femoral head fractures. Femoral head surgically removed and replaced by endoprosthesis.

Question 20

Hemovac

Answer 20

Plastic drainage tube at site for post-op blood drainage. May be connected to portable suction machine. Should not be disconnected bc may create a blockage in system. Usually in place 1-2 days post-op.

Question 21

Abduction Wedge

Answer 21

Large/small wedges to use when supine to maintain LEs in abduction (put between legs).

Question 22

Balanced Suspension

Answer 22

Fabricated by orthopedic tech, used for 3 days post-op. Balances weight of elevated leg by weights placed opposite end of pulley system. Supports affected LE in first few post-op days. Leg taken out for exercise only.

Question 23

Reclining Wheelchair

Answer 23

Has adjustable backrest to allow reclining when hip flexion precautions must be maintained while sitting.

Question 24

Commode Chair

Answer 24

Aids in safe transfers and allows client to observe necessary hip flexion precautions.

Question 25

Sequential Compression Devices (SCDs)

Answer 25

Used post-op to reduce risk of DVT; inflatable, external leggings that provide intermittent pneumatic compression of legs (I had these after my arthroscopy).

Question 26

Antiembolus Hose

Answer 26

Thigh-high elastic hosiery worn 24 hr/day and removed only for bathing. Assist circulation, prevent edema, and reduce rist of DVT.

Question 27

Patient-Controlled Administration IV

Answer 27

Patient-controlled analgesia (PCA) delivered through IV; patient-controlled epidural analgesia (PCEA) delivered through epidural line. Prescribed amt of meds programmed by doc/nursing staff to allow client to self-administer pain meds w/button. Machine does not administer past a safe amount.

Question 28

Incentive Spirometer

Answer 28

Portable breathing apparatus to encourage deep breathing and prevent development of post-op pneumonia.

Question 29

Common Complications Post Hip Surgery

Answer 29

• Dislocation of hip joint (which can require additional surgery to repair)
• Degeneration of components of prosthesis
• Fracture of bone next to implanted parts
• Loosening of prosthetic parts
• Infection of joint after surgery
• Some high-risk of dislocation clients may have adduction brace to immobilize the hip joint (adds extra movement restrictions).
• Must take prophylactic antibiotics if any other dental procedures/surgeries to prevent infection in joint (parts make joint more susceptible to infections)
• Post-op pain managed with regimen of meds (ie: epidural/periarticular anesthetics; PCA; oral analgesics/opioids; peripheral nerve blocks)
• May also manage pain with superficial cold modalities, proper positioning during transitional movements, and balance of rest/activity.

Question 30

Bed Positioning Post Hip Surgery

Answer 30

• Supine with abduction wedge or pillow is recommended in bed.
• Side-liers should sleep on operated side if tolerable
• When sleeping on non-op side, keep legs abducted with abd wedge or large pillows supported operated leg to prevent hip abd and rotation.
• To get out of bed, initially, may be easier to observe precautions if moving toward non-op leg
• May use leg-lifter or trapeze bar overhead (wean off bar for d/c)
• To go supine-sit EOB, support upper body on elbows, then move LEs to side of bed in small increments, following with trunk and UEs. Lower legs out of bed and push trunk to sitting.
• If posterior surgery was used, client should not flex hip more than 90˚. Can extend knee out front to lessen hip flex and widen hip angle.

Question 31

Biologic Fixation

Answer 31

Method used to secure prostheses by bony in-growth in hip replacement; hybrid technique used in younger people; acetabular socket not cemented but femoral component is. Increases the strength of fixation and can decrease possibility of loosened part. New bone grows into openings in prosthesis, securing it to bone. Can be used for both components. Identical post-op precautions to traditional THR, but may have addtl weight bearing restrictions.

Question 32

Osteoporosis - Most Compromised Bones

Answer 32

• Vertebral bodies
• Neck of femur
• Humerus
• Distal end of radius

(These have the most decreased bone density.)

Question 33

OT Role in Fall Prevention

Answer 33

Provide education and training: teach adaptive strategies; make environmental recommendations; explore community resources; teach exercises that address strength, mobility, and balance. Provide client/family with info on community programs such as CDC’s Stopping Elderly Accidents, Deaths and Injuries (STEADI) Program.