Total Joint Replacement

Question 1

Osteoarthritis

Answer 1

• Single most common joint disease in middle aged and older people
• Afflicts 60 million people in the US
• 60-85% of people over 60 have articular cartilage and subchondral bone damage
• Also called DJD

Question 2

Clinical Implications of OA

Answer 2

• Difficulty with ADLs
• Loss of functional independence
• Difficulty continueing to work if the involved joints can no longer handle the demands of the job

Question 3

Etiology of OA

Answer 3

• Involves mechanical, metabolic, genetic factors
• Dynamic process characterized by imbalance of tissue repair and degradation
• Leads to chronic pain, joint deformity, and loss of mobility and function

Question 4

Clinical tests for osteoarthritis

Answer 4

Bony osteophytes (Spurs in spinal canal)
Loss of cartilage
Blood tests if systemic problem is suspected

Question 5

ABC

Answer 5

Alignment
Bone (Density)
Cartilage (How does joint space appear)

Question 6

Risks for total joint replacement

Answer 6

PE
Urinary tract infection
Nausea and vomiting related to medication
Chronic hip/knee pain and stiffness
Bleeding in the joint
Infection
Risks of anaesthesia

Question 7

Risks of anaesthesis

Answer 7

Heart, lung, kidney damage

Question 8

Medical pre-operative evaluation

Answer 8

Joints above and below are evaluated
Review of medications
-warfan and anti-inflammatories discontinued about 72 hrs before
Blood tests of liver and kidney function, urine tests
Chest x-ray and EKG

Question 9

Indications for TKR

Answer 9

• Tibiofemoral joint damaged by progressive or severe OA, trauma, or destructive disease
• Marked deformity
• Severe pain
• Joint swelling
• Feeling of “giving way”
• Severe loss of motion
• Loss of function

Question 10

Choices for TKR

Answer 10

• Cemented, Uncemented, or hybrid
• Metal-backed tibia or all polyethylene tibia
• Metal-backed patella or all polyethylene patella
• Patella resurfaceing or retaining
• Posterior stablilization or cruciate retraining
• Flat on flat, round on round, or mobile bearing surfaces

Question 11

Tight in flexion and extension

Answer 11

Remove more tibial bone and/or use smaller polyethylene

Question 12

Tight in flexion only

Answer 12

Remove more posterior femoral bone and or use smaller femoral component

Question 13

Tight in extension only

Answer 13

Remove more distal femoral bone

Question 14

Loose in flexion and extension

Answer 14

Use larger polyethylene

Question 15

Loose in flexion only

Answer 15

Use larger femoral component and/or use posterior femoral augments

Question 16

Loose in extension only

Answer 16

Use distal femoral augments

Question 17

Cemented procedure usually allows for…

Answer 17

Partial WB immediately post-op

Question 18

Non-cemented procedure allows for

Answer 18

bone to grow through the prosthetic components and gives greater long term stability. Requires NWB for up to 6 weeks post-op

Question 19

Procedure TKR

Answer 19

1. Distal end of the femur is removed and replaced with a metallic shell
2. Proximal tibia is removed and replaced with a channeled plastic component with a metal stem
3. Plastic button may be added under the retropatellar surface

Question 20

Post-OP TKR

Answer 20

• Procedure may last 1.5 to 3 hrs
• Vital organs monitored in recovery room
• Foley catheter is inserted into urethra
• PT 48 hours after surgery
• Pain, discomfort, stiffness expected
• Knee immobilizers used to stabilize knee
• Consistent monitoring of the wound is required

Question 21

Physical therapy role in TKR

Answer 21

• Examination
• Chart review, inspection of incision, upper quarter function
• AROM/PROM, resisted tests, neuro screen
• Function
• Ambulation

Question 22

Sequential Functional Tests

Answer 22

Walking (TUG test)
Ascending and Descending stairs
Transfers

Question 23

Post-op TKR goals

Answer 23

Independent transfers
Independent abulation
90-100 degrees of knee flexion

Question 24

Therapeutic exercises TKR

Answer 24

Upper Extremity strength
CPM
Knee AROM
Quad sets
Straight leg raising
Heel slides
Ankle pumps
Deep breathing and coughing

Question 25

Duration of TKR

Answer 25

- Implants may eventually wear, but function well in 90--95% of patients 15 years post-op - Potential complications can decrease the lifespan of the implant - Replacement before 60 increases likelihood of wearing out

Question 26

Indications for THR

Answer 26

Acetabulofemoral joint damaged by progressive and severe OA, trauma, or destructive disease - Markedly antalgic gait - Severe pain - Referred pain (L3 dermatome, but not myotome) - Difficulty standing or walking - severe loss of motion - loss of function

Question 27

Choices for THR

Answer 27

Cemented or uncemented | -Acetabular shell portion and femoral component

Question 28

Hemiarthroplasty

Answer 28

Replaces femoral side of joint

Question 29

Resurfacing of hip

Answer 29

Resurfaces head of femur Preserves more bone Not working as well as thought in the long term

Question 30

THR approaches

Answer 30

Posterior or anterior approaches - posterior has more precautions and cuts through glut medius - cant exceed 90 degrees hip flexion or adduct hip

Question 31

Anterior Approach THR

Answer 31

- Tissue sparing alternative to traditional posterolateral approach - Potential for less pain, faster recovery, and improved mobility - Small anterior incision used to expose joint

Question 32

Post-op THR

Answer 32

- Avoidance of hip adduction and IR for posterolateral approach - Avoidance of hip extension for anterior approach - Monitoring of LE pulses for possible DVT

Question 33

Duration of THR

Answer 33

Same as TKR

Question 34

THR Therapeutic Exercise

Answer 34

``` UE strength Hip AROM Quad sets Heel slides Ankle pumps Deep breathing and coughing Progress to functional exercise in standing ```