Lec 7

Question 1

Types of arthroplasty

Answer 1

Resection arthroplasty

Interposition arthroplasty

Replacement arthroplasty

Question 2

True or false

The hip was the 1st joint to be successfully replaced.

Answer 2

True

Question 3

Classification according to the part replacement

Answer 3

1. Total arthroplasty (full joint replacement):
   replaces both sides of the joint e.g. acetabulum & head of the femur.
2. Hemiarthroplasty (partial joint replacement): restore the aspect of the joint that is damaged

 N.B. all partial replacements may be upgraded to a full replacement at a future date if necessary.

Question 4

Classification according to stability

Answer 4

1. Constrained: there is a link between the two components and all anatomical movements are restricted to a greater or lesser extent.
   ( high stability, restrictive movement)
2. Semi-constrained: some movement is allowed in all planes.
   (Allow stability and movement)
3. Unconstrained: permits free movement in all anatomical planes. The joint is prone to dislocation until 6 weeks post-operation
   ( low stability, free movement)

Question 5

Material of the prosthetic parts

Answer 5

Prosthetic parts are made out of inert metals of low friction coefficient
(6 times > natural joint) e.g.
1. Stainless steel
2. Chrome-cobalt-molybdenum alloys
3. High density polyethylene

Question 6

Indication for Prosthetic

Answer 6

1. Pain
2. Loss of function
   e.g. OA, RA, post-traumatic joint stiffness, avascular necrosis

N.B. the recommended age is 60+

Question 7

Fixation by Acrylic cement

Answer 7

can sustain compressive stress
well but cannot control shear or torsional stress.e.g. Thompson hemiarthroplasty.
(Early partial weight bearing )

Question 8

Fixation by Bioingrowth

Answer 8

relies on natural growth of bone
around or through the prosthetic implant and no cement is used.e.g. Austin More hemiarthroplasty.

Non-cement technique need a period of non or partial weight bearing to allow stabilization of the component.

 Cementless technique is preferred in younger patients under 65 years

Question 9

Incision sites for prosthetic

Answer 9

1. Anterolateral: between tensor fascia lata and glutei
2. Posterolateral: through the posterior capsule
3. True lateral: greater trochanter is excised and re-atttached with wire fixation

Question 10

Common complications

Answer 10

1. Dislocation
2. Venous thrombi
3. Fracture
4. Postoperative thigh pain
5. Failure
6. infection

Question 11

Dislocation

Answer 11

Anterolateral & true lateral:
hip will dislocate if placed in excessive extension, external rotation, and adduction or a combination of all three

• Posterolateral: hip will dislocate in excessive flexion, internal rotation & adduction or a combination of all
  three.
• 6-12 weeks these positions should be avoided.
• Anteriorly Dislocated hip is shorter, externally rotatedand in extension

Posteriorly dislocated hip is shorter, flexed and internally rotated

Question 12

Treatment of the dislocation

Answer 12

relocation of the hip under general
anaesthesia & traction for 6 weeks

Question 13

Rehabilitation

Answer 13

 Both cemented & uncemented replacements follow a similar regime except for time of weight bearing.

• Uncemented prosthesis will remain partially or non-weight bearing for 6-12 weeks.
• Cemented prosthesis begins weight bearing 1st day postoperatively.

 Abduction pillow or wedge should be used while patient is lying supine or on the non-operated side

Question 14

True or false

SLR is courage until full quadriceps and iliopsoas control has returned

Answer 14

False

SLR is discouraged until full quadriceps and iliopsoas control has returned

Question 15

Treatment goals

Answer 15

 Restoration of :
1. Joint motion
2. Muscle strength

• Maintainance of:
  1. Vascular function
  2. Respiratory function
• Education about:
  1. Joint preservation techniques
  2. Bed mobility
  3. Weight bearing

Question 16

Weight bearing

Answer 16

 Patient with lateral or posterolateral incisions can start weight bearing from day 1

 Patients with anterolateral incision is delayed 2 days postoperatively.

 Start of sitting is delayed for patients with posterolateral incision to prevent dislocation

 In cemented joints weight bearing is increased until minimal assistance is required from a walking aid.

 Uncemented prosthesis will remain on cruthes or a frame for 6-12 weeks.

Question 17

Patient should avoid until 6 weeks postoperatively

Answer 17

1. Excessive extension, external rotation & adduction
   with anterolateral & true lateral incision.
2. Excessive flexion, internal rotation & adduction with posterolateral incision
3. Sitting in low chairs (less than 53 cm in height)
4. Bending forward to put on shoes , socks, cut toenails, etc
5. Crossing the legs in sitting or lying
6. Twisting the legs in sitting or lying
7. Driving
8. Jumping or running
9. Contact sports

Question 18

Preoperative training session

Answer 18

 Safe transfer technique
 Proper use of assistive devices
 Postoperative exercises e.g.
1. Ankle pumps
2. Quadriceps sets
3. Gluteal sets
4. Active hip and knee flexion
(heel slides)
5. Isometric hip abduction
6. Active hip abduction

Question 19

Goals of day of the surgery

Answer 19

A- protect healing tissues,
B- prevent postoperative complications,
C- improve volitional control of involved lower extremity

1. Respiratory exercises
2. Ankle pumps
3. Quadriceps sets
4. Gluteal sets
5. Repositioning of the patient every 2 hours with the abductor pillow in place

Question 20

Postoperative day one

Answer 20

1. Same previous exercises
2. Upper extremity exercises
3. Transfer training from supine
   to sitting, and from sitting to
   standing, while observing precautions and emphasize the use of upper extremity in shifting weight, avoid pivoting on the affected leg
4. If not complaining of excessive
   pain, fatigue, or dizziness, gait
   training may begin.

Question 21

Postoperative day 2

Answer 21

1. Hip ROM exercise
2. Heel slides
3. Isometric or active assisted hip abduction
4. Active assisted short arc quadriceps sets
5. Gait training (front wheeled walker for older patients & 3-point crutch pattern for younger patients) start with 50% of body weight or less

Question 22

Day 3 to 7 until discharge

Answer 22

 Goal: improve UL & LL strength

1. Heel slides
2. Hip abduction
3. Terminal knee extension
4. Resisted shoulder exercises
5. Stair training (upstairs with unaffected & downstairs with
   affected)

Question 23

Discharge criteria

Answer 23

1. Patient is able to demonstrate & state precautions
2. Independent with transfers
3. Independent with the exercise program
4. Independent with gait on level surfaces to 100 feet
5. Independent on stairs

Question 24

1-6 weeks after discharge

Answer 24

 Goals:
A- improve strength of LL
B- improve balance
C- promote return to activities
1. CKC exercises
2. Pool therapy
3. Treadmill
4. single point cane. (starts 3-4 weeks after surgery & discontinued after 3-4 more weeks)).
5. Step over step stair climbing
6. Driving is allowed 3-4 weeks after surgery

Question 25

Sports recommended after joint replacement

Answer 25

 Low-impact non-contact sports

1. Sailing
2. Swimming
3. Cycling
4. Golfing
5. bowling

Question 26

Prohibited sport ممنوعه

Answer 26

 High-impact or contact sports

1. Running
2. Water-skiing
3. Football
4. Basketball
5. Hockey
6. Martial arts

Question 27

Myofascial release

Answer 27

Involves traditional effleurage, pétrissage, and friction massage strokes with stretching of the muscles and fascia to obtain relaxation of tense and/or adhered tissues

Stretch + breaks adhesion tissue

Question 28

The technique of myofascial

Answer 28

Basic technique involves pulling the tissues in opposite directions,

 stabilizing the proximal or superior position with one hand while applying a stretch with the opposite hand,

Or using the patient body weight to stabilize the extremity or the body part while a longitudinal stress is applied