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Orthopaedics > JOINT REPLACMENTS: KNEE & HIP ARTHROPLASTIES > Flashcards

JOINT REPLACMENTS: KNEE & HIP ARTHROPLASTIES Flashcards

1
Q

Types of joint replacements /arthroplasties

A
  1. Knee replacement
  2. Hip replacement
  3. Shoulder replacement
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2
Q

KNEE ARTHROPLASTIES

Types of Knee replacements

A
  1. Total Knee replacement
  2. Partial Knee replacement / Uni-compartmental Knee replacement
    Usually medial compartment
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3
Q 
Knee replacement (TKR) 
Criteria for knee replacement
A

• End stage OA
• Severe tibiofemoral pain and persistent swelling
• Loss of general function and/ knee mob (Stiffness++, pain++,
instability++)
• Severe knee deformity / contractures
• Failure of conservative Mx
• ↓QOL

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4
Q

• Functional restrictions experienced pre-operatively

A

Typical functional restrictions pre-op :
• Walking on even/uneven surfaces
• Climbing stairs
• Getting up from a seated position/toilet
• Standing for prolonged periods
• Getting in and out of the bath
• Bending to pick something up from the floor
• Putting on socks, shoes
• Stiffness in the morning and after resting later on the day

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5
Q

KNEE ARTHROPLASTIES

• Protocols used for rehabilitation

A 
Different protocols (Conservative):
• Post-op High Care
• Vitals monitored
• Urine catheter
• Drainage bottle: Porto-vac/ Palin drain
• Compression bandage
• DVT stocking 6/52
• Wound –clips. Removed 2/52 post-op
• Patient start mobilization POD1
• LOS: 3-4 days

Different protocols (Advanced):
• Decreased opioids- decrease sleepiness, nausea and dizziness.
• Post-op ward patient
• Vitals monitored
• No Urine catheter or drainage bottle
• Only thin compression bandage
• No DVT stockings. IPCP( Intermittent Pneumatic Compression Pump)
• Wound – no clips. Use wound adhesives. Dressing stay on for 2/52
• Patient start mobilization POD 0
• LOS: 2 days

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6
Q

KNEE ARTHROPLASTIES

• Patient education

A
  • Pre-op
  • Pain full operation. Exercise and Ice.
  • Expectations from Physio and patient
  • Gait re-education with crutches/walking frame
  • Navigating stairs with crutches/walking frame

• Post-op exercises
• Signs of DVT/PE : Calf pain, groin pain, chest pain, SOB, severe
swelling
• Crutches 6/52
• 120° knee flexion and full knee extension at 6/52 post-op

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7
Q

KNEE ARTHORPLASTIES

• Precautions

A
  • PKR – PWB 1st 2/52 and then FWB.
  • TKR – PWB as pain allows and progress to FWB
  • Monitor for signs of deep vein thrombosis (TTS), pulmonary embolism (SH) and loss of peripheral nerve integrity (derm, myo). In these cases, notify the Dr immediately.
  • Avoid torque or twisting forces across the knee joint especially when WB on involved limb.
  • Monitor wound healing and consult with referring Dr if signs and symptoms of excessive bleeding and poor incision integrity are present.
  • No exercises with weights or resistance.
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8
Q

KNEE ARTHROPLASTIES

• Discharge criteria

A

Criteria for discharge for TKR
• Independent SLR
• Active knee range of motion (AROM) 0-90’
• Minimal pain and inflammation
• Independent transfers and ambulation at least 30 m with appropriate
assistive device.
• Safe and independent stair mobility (relevant level of mobility)
• Medically stabile and wound dry
• Someone at home to help the patient

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9
Q

KNEE ARHTROPLASTIES

• When a Knee Replacement is not indicated/ recommended

A
  • Current knee infection
  • Morbid obesity (+130kg)
  • Paralysis of the quadriceps femoris muscle
  • Severe mental dysfunction
  • Severe PVD or neuropathy affecting the knee
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10
Q

KNEE ARTHROPLASTIES

• Outcome measures used

A
  • WOMAC Questionnaire – pain, stiffness and function
  • KOOS
  • VAS
  • ROM
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11
Q

KNEE ARTHROPLASTIES

• General advice

A

• No driving 6/52
• No physical hard labour or exercises 6/52
• No pillow under knee when sleeping
• May sleep on non-operated side with pillow between knees
• Low impact sport after 3 months – swimming, cycling, hiking, golf
• Only drink meds prescribed by Dr. If unsure, phone the Dr.
• Patients should not brace the leg. Gravity is your friend!!!
• Swelling normal for first 3 months.
• Pain over medial aspect of knee and sensation loss over Lateral side is
common
• It takes 6 months to a year to recover fully.

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12
Q

KNEE ARTHROPLASTIES

• Outpatient treatment

A
  • Physio 1 x per week for 6/52
  • Strengthening and work for Flex/Ext ROM
  • Foot pumps, Stat Quads, SLR, Ext over roller, Flex /ext over side of bed
  • Prone knee flexion – Contraction, relax
  • Capsule stretches, Hamstring and calf stretches
  • Gait re-education, Balance, proprioception.
  • Strengthening – Quads, Hamstrings, Gluts med and Max, Gastrocs, Soleus and core.
  • Soft tissue and pain management
  • ICE
  • HEP. 5 x per day. 1 set of 10 repetitions.
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13
Q

KNEE ARTHROPLASTIES

TREATMENT POD 0/1:

A
  • Pre-op education
  • Post-op check – Heel doughnuts, DVT socks/IPCP, pulse, motor function, Vitals, Drip, wound and check that Palin drain is open.
  • Encourage pt to sit more upright - ↓ Postural hypotension
  • Encourage pt to eat and drink
  • Make sure toilet raiser is in place
  • Start bed exercises. Foot pumps, Static Quads, Heel slide, Hip abd/add, SLR.
  • Sit over side of bed, feet on the ground
  • Teach pt knee locking and demonstrate crutch walking
  • Stand up with help of 2 people in case the patient experience drop in BP.
  • Test knee –locking
  • If safe, proceed to mobilize to toilet
  • Never leave patient by themselves in case of dizziness
  • Correction of walking pattern. Heel toe, knee flexion and full extension
  • Back to bed or sit out in chair
  • Progress to navigating stairs with the next session
  • Sit out in chair for breakfast, lunch and dinner
  • Mobilize in between treatment sessions with nursing staff.
  • ICE
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14
Q

HIP ARTHROPLASTIES

TYPES OF HIP ARTHROPLASTIES

A
  1. Total Hip Replacement – Head of femur is replaced and the Acetabulum is lined with a synthetic joint surface
  2. Partial Hip Replacement – Only the Femur head is replaced.
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15
Q

HIP ARTHROPLASTIES

INDICATIONS

A
  • Pain & loss of function and mobility
  • End stage OA, RA
  • Avascular necrosis
  • Post traumatic arthritis and joint stiffness
  • Irreversible destruction
  • Degenerative changes
  • Displaced femur neck fractures
  • Failed femur neck ORIF’s and Revision surgery
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16
Q

HIP ARTHROPLASTIES

Surgical Approaches

A
  • Posterior approach- piriformis & short external rotators of the femur. Most preferred. Good visualisation of femur and acetabulum and spare the abductor muscle group.
  • Lateral approach- lift gluteus medius & glut minimus, osteotomy of greater trochanter and reattached afterwards.
  • Anterolateral approach- space between tensor fascia latae &gluteus medius.
  • Anterior approach- space between sartorius & tensor fascia latae
  • AMIS (Anterior Minimally Invasive Surgery) latest surgical technique with good functional outcomes.↓ damage to muscles, ligaments, capsule and nerve. Also less dislocations than other approaches
17
Q

HIP ARTHROPLASTIES

COMPLICATIONS

A
  • Dislocation. Post≥ Ant
  • Wear, loosening of prosthesis
  • Venous thrombus
  • Fracture intra-op
  • Post op thigh pain
  • Failure
  • Infection wound/Resp
  • Nerve injury
  • Leg length discrepancy
  • Abduction insufficiency –Lat app
18
Q

HIP ARTHROPLASTIES

CONTRAINDICATIONS & PRECAUTIONS

A

Posterior approach (PWB)
• Do not cross legs (i.e. no hip adduction past midline)
• Do not remove abduction pillow
• Avoid combined hip flexion, adduction and internal rotation at least for 6/52
• Hip internal/external rotation >45°
• No hip flexion > 90°
• No SLR
• No side lying 6/52
• Cemented – FWB, Un-cemented – Toe-touch
• seats

Posterior approach (continued)
• Abduction pillow post-operative
• Elevated toilet seat
• Elevated chair with arm rests
• 1st 6/52 only sleeping on back. After 6/52 pt may sleep on unoperated side with pillow between the knees and only after 12/52 pt may sleep on operated side again with pillow between the knees.
• No driving for 6/52

Anterior approach (WBAT)
• No combination of hip extension, Abd and ER
• No excessive hip ranges
• No hip ext rotation > 45°

Lateral approach (WBAT)
• Do not cross legs (i.e. no hip adduction)
• Do not remove abduction pillow
• Keep leg in neutral- no excessive adduction/crossing legs.

AMIS
• Weight bearing as pain allows (PWB to FWB) initially with walking aids
• No other contraindications for sitting or hip physiological movements.

19
Q

HIP ARTHROPLASTIES

FUNCTIONAL RESTRICTIONS

A

Typical functional restrictions pre-op :
• Walking on even/uneven surfaces
• Climbing stairs
• Getting up from a seated position/toilet
• Standing for prolonged periods
• Getting in and out of the bath
• Bending to pick something up from the floor
• Putting on socks, shoes
• Stiffness in the morning and after resting later n the day

20
Q

HIP ARTHROPLASTIES

PROTOCOLS

A 
Different protocols (Conservative):
• Post-op HC
• Vitals monitored
• Urine catheter
• Drainage bottle: Porto-vac/ Palin drain
• DVT stocking 6/52
• Abduction pillow
• Wound –clips. Removed 2/52 post-op
• Patient start mobilization POD1
• LOS: 3-4 days

Different protocols (Advanced):
• Decreased opioids- decrease sleepiness, nausea and dizziness.
• Post-op ward patient
• Vitals monitored
• No Urine catheter or drainage bottle
• No DVT stockings. IPCP( Intermittent Pneumatic Compression Pump)
• Abduction pillow
• Wound – no clips. Use wound adhesives. Dressing stay on for 2/52
• Patient start mobilization POD 0
• LOS: 2 days

21
Q

HIP ARTHROPLASTIES

Patient Education

A

Patient education NB NB NB:
• Pre-op. ↑Trust and confidence, ↓ anxiety and LOS
• Expectations from Physio and patient
• Precautions and abduction pillow
• Gait re-education with crutches/walking frame
• Navigating stairs with crutches/walking frame
• Pre-hab and Post-op exercises
• Signs of DVT/PE : Calf pain, groin pain, chest pain, SOB, severe
swelling
• Crutches/walking frame 6/52
• Good functional hip ROM at 6/52 post-op

22
Q

HIP ARTHROPLASTIES

PHYSIOTHERAPY GUIDELINES

A

Treatment POD 0/1:
• Pre-op education including Precautions
• Post-op check – Heel doughnuts, Abduction pillow, DVT socks/IPCP, pulse, motor function, Vitals, Drip, wound and check that Palin drain is open.
• Encourage pt to sit more upright - ↓ Postural hypotension
• Encourage pt to eat and drink
• Make sure toilet raiser is in place
• Start bed exercises. Circulation drills UL’s and LL’s, Isom & A-A hip flex, abd and add. Then progress to active hip and knee flexion (Heel slide), Hip abd/add, knee flex and ext over side of bed.
• Sit over side of bed, feet on the ground. Patient get out on operated leg’s side of bed
• Demonstrate crutch walking
• Stand up with help of 2 people in case the patient experience drop in BP.
• If safe, proceed to mobilise to toilet
• Never leave patient by themselves in case of dizziness
• Correction of walking pattern. Heel toe, knee flexion and full extension
• Back to bed or sit out in chair (Raised chair with armrests)
• Remember to put abduction pillow back
• Progress to navigating stairs with the next session
• Sit out in chair for breakfast, lunch and dinner
• Mobilize in between treatment sessions with nursing staff.

Treatment POD 1/2:
• As above
• Navigating stairs with crutches/walking frame
• Progress walking distance
• Sit out in chair
• HEP
• 6/52 post-op: Full ROM, balance, proprioception, endurance, 
strengthening and functional exercises.
23
Q

HIP ARTHROPLASTIES

DISCHARGE CRITERIA

A
  • Minimal pain and inflammation
  • Independent transfers and ambulation at least 30 m with appropriate assistive device.
  • Safe and independent stair mobility (relevant level of mobility)
  • Patient should know precautions
  • Medically stabile and wound dry
  • Someone at home to help the patient
24
Q

HIP ARTHROPLASTIES

OUTCOMES MEASURES

A
  • WOMAC Questionnaire – Pain, function and stiffness
  • Harris Hip Score
  • HOOS
  • 6 min walk test
25
Q

HIP ARTHROPLASTIES

General advice

A
  • Remove loose mats at home
  • No climbing ladder
  • Avoid loose sand
  • Bedside table should be on the operated leg’s side
  • Use high chair with arm-rest. No camping chairs or lazy boys
  • Don’t pivot on the hip. Lift feet when turning around
  • Shower instead of bathing
  • Golfer’s lift to pick something up from the floor
  • Don’t bend forward when sitting to pick up handbag from the floor
  • Don’t stretch for the blanket at the foot of the bed, use a braai tong.

Orthopaedics (21 decks)

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