Flashcards in Joint Arthroplasty Deck (62):
What is the prevalence of JA?
4.7 million Americans living with a TKA
2.5 million Americans living with a THA
What are pre and post op interventions for osteoarthritis?
PT intervention indicated for patient education, correction of biomechanical factors, exercise programs, and therapy after surgery
What are the goals of rehabilitation?
Restore function (#1)
gain muscle control/strength
return to previous levels of functioning
What are primary causes of JA?
OA, RA, traumatic arthritis, avascular necrosis, fracture repair
What are primary indications for JA?
1) Marked, disabling pain 2) Decreased function, marked impairment in ROM, instability and/or deformity, recurrent dislocation, failure of prior interventions/surgeries
What are contraindications for JA?
infection, severe of uncontrolled HTN, progressive neurological disease, dementia, latent renal or respiratory insufficeincy
What are relative contraindications for JA?
obesity, diabetes, age 90
What are complications of JA?
Venous thromboembolism (DVT, PE), infection (acute an d long term), arthrofibrosis, CRPS, component loosening/failure, allergic reaction, pneumonia, hematoma, surgical fracture, malalignment of prosthesis, fracture of prosthesis, limb length discrepancy, dislocation, neural injury, thermal damage/laceration, heterotrophic ossification
What are advantages of metal on polyethylene bearing surface?
cost effective, evidence supports use, predictable lifespan
What are disadvantages of metal on polyethylene bearing surface?
polyethylene debris may lead to aseptic loosening
What are advantages and disadvantages of metal on metal bearing surfaces?
advantages: low friction/wear, lower dislocation risk
disadvantages: possible carcinogenic effect of metal ions, metallosis
What are advantages and disadvantages of ceramic on ceramic bearing surfaces?
advantages: low friction/wear, inert material
disadvantages: expensive, requires expert insertion technique, possible joint noise
What are the advantages of uncemented fixation?
lower risk of cardiovascular and VTE events, bone conserving, more expensive (?), better long term outcomes (?)
What are disadvantages of uncemented fixation?
increased risk of peri-prosthetic fracture, lack of good long term outcome data
What are advantages of cemented fixation?
more stable initially, better short and mid term outcomes, less residual pain (?)
What are disadvantages of cemented fixation?>
longer operative time, more difficult to revise, potential for adverse reaction to cement
What are the approaches for JA?
direct anterior, anterolateral, direct lateral, lateral transtrochanteric, posterolateral, posterior mini, anterior mini
What is mini incision arthroplasty? Advantages? Disadvantages?
performed through 1-2 smaller incisions (2-6 vs. 8-10 inches)
possible short term advantages (less pain and bleeding, quicker time to d/c)
little long term evidence, technically demanding
What is total hip resurfacing?
not really new (first attempted in 1950s)
widespread use since 2000 ( in Europe)
Approved by FDA in May, 2006
Generally indicated for younger more active patients
patient advisory issued in 2011 to high 5 year failure rate
What are advantages to resurfacing?
lower dislocation risk (<1%), bone conserving, low wear/friction, quicker recovery and return to high demand activity
What are disadvantages to resurfacing?
higher early failure rates (?), metallosis (?), technically difficult, little long term data
What are advantages to arthroplasty?
well studied, easier to perform, suitable for wider range of patient populations, better long term outcomes
What are disadvantages to arthroplasty?
higher dislocation risk (approx. 5%), more difficult to revise, more functionally limiting (?)
What are precautions for posterior-lateral approach?
AVOID: adduction beyond neutral, hip flexion >90 degrees, hip internal rotation
What are precautions for anterior-lateral approach?
AVOID: abduction, hip extension, hip external rotation
Patients may assume they have posterior precautions based on their own "research" or the experiences of friends/family
If a dislocation is going to occur when will it most likely happen?
60-70% of dislocation occur within 6 weeks of surgery
What is incidence of dislocation?
0.3-10% for primary THA procedures
may increase to as much as 28% with revision
What are risk factors for dislocation?
neuromuscular impairment, cognitive dysfunction, fracture, history of surgery, posterior approach, small femoral head size, prosthetic alignment, surgeon experience
What happens in the event of recurrent dislocation?
spica brace may be required
may also require weight bearing restrictions and strict movement precautions
education,ADL, and home evaluation
communication with patient, family, medical team
What are survival statistics for the prosthetic?
failure rate of <1% per year
90-95% survive 10 years
85% survive 20 years
What are factors associated with increased risk of revision?
younger age, male sex, multiple comorbidities, avascular necrosis (vs. osteoarthritis), femoral head size (?)
Is there evidence that PT helps after JA?f
insufficient evidence exists to establish the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis
What are early post op interventions (acute and sub-acute)?
ice and positioning
strengthening: AAROM, AROM (isometrics, heel slides, SAQ, LAQ, ankle pumps, abduction (?), caution with SLR)
Progress to closed chain and functional activities ASAP
Mobility: bed mobility, transfers, gait training, stair training, car transfer training or simulation (** MUST emphasize adherence to appropriate precautions during these activities)
What are late (chronic) interventions?
emphasize functional activities
strengthen hip flexors, extensors, and abductors
include resistance training if possible
wean from assistive device, if appropriate
limit high impact activity or activities with rotational forces
What are the outcomes for return to function?
approximately 80% of function is recovered within 8 months
90% report satisfactory outcomes at 10 years
as many as 60% return to athletic activities within 3 years
What is high tibial osteotomy?
surgical alignment of joint
delays TKA (estimated gain of 9 years)
indicated for unicompartmental disease or angular deformity
allows reasonable joint stability and an active lifestyle
When is unicompartmental arthroplasty used?
Indicated if- flexion >90, full extension, <15 varus or valgus deformity, mobile patells, intact tibial plateau and femoral condyles, and satisfactory ligamentous stability
ideal for ends of spectrum- older, lower demand patients, younger populations
What are advantages/disadvantages of unicompartmental arthroplasty?
obesity is associated with high failure rates
bone conserving procedure benefits younger patients
post-operative rehab is shorter than TKA
8-10 year survival of hardware
When are TKAs normally done?
patient ideally >60 years old
body weight ideally <180 lbs.
aware of potential risks vs. benefits
What are two possible complications of TKA?
infection and VTE
Where and when does infection occur in TKA?
approx. 1.8% risk in first two years
cumulative risk of 2.47% over ten years
surgical site or deep peri-prosthetic
approx. 20% associated with methicillin-resistant bacteria
What are risk factors for infection with TKA?
obesity, malnutrition, anemia, diabetes
What are statistics of people getting a VTE with and without prophylaxis?
Without: up to 60% will develop DVT, up to 20% will develop PE
With: up to 5% will develop DVT, <1% will develop PE
What are risk factors for VTE?
BMI >25, COPD, atrial fibrillation, anemia, depression, history of DVT
What is a better predictor of DVT? PE?
Wells score. not homans sign
80-90% sensitivity, a lot of false positives
Wells score for PE, validated for OP
What is rehab for TKA (acute and sub acute)?
ice and positioning (possible use of CPM is patient can't participate in any therapy)
ROM: discharge goal of 0 extension to 90 flexion, includes PROM/AAROM, must document knee ROM
strengthening: isometrics, ankle pumps, heel slides, SAQ, LAQ (with assist), SLR
Progress to closed chain, functional activities ASAP
mobility: gait training with emphasis on normalizing gait to reinforce/achieve normal and functional knee ROM
education: WBing precautions, gait quality
edema and pain management
discharge planning and recommendations
What is plan for late (chronic) intervention?
emphasize functional activity
interventions to increase ROM including modalities and soft tissue mobilization
strengthening, muscle control and balance
limit high impact activities or activities with heavy rotational forces
Is it possible to have multiple surgeries and revisions?
Bilateral TKA: more common than bilateral THA/THR, can be concurrent or staged, should be bilaterally WBAT (hopefully), longer recovery, may require inpatient rehab
How do you stage of bilateral THA?
usually staged by at least 1 week, but often >6 weeks between surgeries
increase risk for VTE
adherence to bilateral posterior hip precautions is difficult
How popular is shoulder arthroplasty?
initiatied in early 50s primarily for severe shoulder fractures
approx. 23,000 TSA each year (compared to 400,000 TKAs and THAs)
consists of humeral component and (optional) glenoid component
What is conventional type of TSA?
cemented or uncemented
indicated for OA and intact RTC
glenoid component omitted if cartilage is intact, bone quality is poor, or RTC tendons are irreparably torn
What is reverse type of TSA?
normal ball and socket arrangement is switched
allows use of deltoid to lift arm (vs. RTC)
indicated if RTC is fully torn, cuff tear arthropathy is present, or hx of failed replacement
What is phase 1 of TSA rehab?
PROM/AAROM (2-4 weeks)
no AROM of flexion >120, ER >30, or abd >45
What is phase 2 of TSA rehab?
AAROM/AROM (4-6 weeks)
PROM into full ER, flexion <140 (no overpressure)
initiate AROM, especially into flexion
What is phase 3 of TSA rehab?
AROM/strength (8-12 weeks)
AROM into flexion and ER
strengthen shoulder girdle
avoid overhead activity and forceful stretching >140 flexion, 45 ER, horizontal adduction beyond neutral
What are options for pain management?
PCA: patient controlled analgesia
Femoral nerve blocks: can be indwelling or single injection
Oral pain medications: often contribute to post-op nausea, dizziness, constipation, etc.
What are the areas of priority with fast track recovery?
What is the point of pre-op education in fast track recovery?
reduces pre-op anxiety and pain
reduces pos-op pain medication use
may reduce length of stay
What is point of nutritional supplementation fast track recovery?
malnutrition associated with infection, delayed wound healing, increased LOS and rehab time, and mortality
peri-operative anemia associated with infection and increased LOS
What is the point of managing pain with fast track recovery?
evidence supports use of spinal anesthesis and NSAIDs combined with acetaminophen
peripheral nerve blocks increase risk of muscle weakness and falls
anesthetic wound infiltration appears to be effective for TKA
How does early mobilization and activity play a role in fast track recovery?
earlier, higher intensity physical activity (including strength)
activities should be prescribed according to physiological principles
activities should be targeted to documented deficits, well described, and limited in number