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Clin Med > Total Joint Replacement > Flashcards

Total Joint Replacement Flashcards

1
Q

Osteoarthritis

A
  • Single most common joint disease in middle aged and older people
  • afflicts 60 million people in the US
  • 60-85% of people over 60 years of age have articular cartilage and subchondral bone damage
  • also called degenerative joint disease (DJD)
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2
Q

RA vs OA

A 
RA= systemic, shows up in bloodwork
OA= trauma, certain joints
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3
Q

Complications of OA

A
  • difficulty with ADLs
  • loss of functional independence
  • difficulty continuing work if the involved joints can no longer handle the demands the job places on them
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4
Q

Etiology of OA

A
  • involves mechanical, metabolic, genetic factors
  • dynamic process characterized by imbalance of tissue repair and degradation of synovial joint structures and secondary inflammation of synovial membrane
  • leads to chronic pain, joint deformity, and loss of mobility and function
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5
Q

clinical tests for osteoarthritis

A
  • bony osteophytes (spurs)
  • loss of cartilage
  • blood tests if systemic problem is suspected such as RA
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6
Q

James cyriax

A

-Capsular patterns to describe pt based on movements

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7
Q

Degenerative disorders OA- imaging

A
  • Decreased patellar femoral joint space
  • decreased tibiofemoral joint space
  • ** diagnostics do not reveal functionality
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8
Q

Risks for total joint replacement

A
  • Pulmonary embolism
  • UTI: b/c of catheter
  • Nausea and vomiting related to meds
  • chronic hip/knee pain and stiffness
  • bleeding in the joint: hemiarthrosis
  • infection
  • risks of anesthesia: potential heart, lung, kidney, lung damage
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9
Q

Medical pre-op evaluation

A
  • Joints above and below evaluated
  • review of medications- warfan (blood thinner), and anti-inflammatory meds may be adjusted or discontinued 72 hours preop
  • blood tests of liver and kidney function, urine tests
  • chest x-ray and EKG
  • tests tricep strength
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10
Q

PT pre-op instruction

A
  • expectations regarding the postoperative period and level of function
  • instruction in ambulation with assistive devices
  • instruction in transfers
  • therapeutic exercises: deep breathing and coughing, heel slides, ankle pumps, AROM, continuous passive motion device (CPM for knee)
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11
Q

Indications for total knee replacement (TKR)

A
  • may be considered when the tibiofemoral joint has been damaged by progressive and severe OA, trauma, or destructive disease
  • Marked deformity- Valgus females, varus in males
  • severe pan
  • joint swelling
  • feeling of knee “giving way”
  • severe loss of motion
  • loss of function
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12
Q

Choices for TKR

A
  • Cemented, uncemented, or hybrid
  • metal backed tibial or all-polyethylene tibia
  • metal backed patella or all polyethylene patealla
  • patella resurfacing or patella retaining
  • posterior stabilization or cruciate retaining
  • Flat-on-flat, round on round, or mobile bearing surfaces
  • an uncemented prosthesis has a fine mesh of holes on the surface that allows tissue to grow in the mesh and attach to prosthesis
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13
Q

Choices in TKR: tight in flexion and extension

A
  • remove more tibial bone and/or use smaller polyethylene
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14
Q

Choices in TKR: tight in flexion only

A

-Remove more posterior femoral bone and/or use smaller femoral componenet

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15
Q

Choices in TKR: tight in extension only

A
  • remove more distal femoral bone
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16
Q

Choices in TKR: loose in flexion and extension

A

-use larger polyethylene

17
Q

Choices in TKR: loose in flexion only

A
  • use larger femoral component and/or use posterior femoral augments
18
Q

Choices in TKR: loose in extension only

A
  • use distal femoral augments
19
Q

The prosthesis

A
  • cemented procedure usually allows for partial WBing immediately post op
  • non-cemented procedure allows for bone to grow through prosthetic components and gives greater long term stability ; this requires non WBing for up to 6 weeks post op
20
Q

The operative procedure TKR

A
  • the distal end of the femur is removed and replaced with a metallic shell
  • the proximal tibia is removed and replaced with a channeled plastic component with a metal stem
  • depending on condition of patella, a plastic button may be added under the retropatellar surface
21
Q

The postoperative period -TKR

A
  • procedure may last from 1.5 to 3 hours
  • vital organs are monitored in recovery room
  • Foley catheter is inserted into the urethra to allow free passage of urine until ambulating
  • PT 48 hours after surgery
  • pain, discomfort, and stiffness are to be expected, but gradually diminish
  • knee immobilizers are used to stabilize the knee when up and walking
  • consistent monitoring of wound is required
22
Q

Physical therapy Post TKR

A
  • exam
  • chart review, inspection of incision, upper quarter function
  • hip or knee: AROM, PROM, resisted tests, neurological (dermatomes/myotomes)
  • function (transfers, raised toilet seat)
  • ambulation with walker if NWB, with quad cane if PWB
23
Q

Lower quarter exam

A
  • history
  • functional questionnaires
  • functional tests
  • structural exam (inspection)
  • AROM
  • PROM
  • joint mobility tests
  • muscle performance
  • neurologic tests
  • palpation (pulses)
  • special tests
  • the above tests will most likely be modified for the post-op patient
24
Q

Sequential functional test

A
  • Walking
  • ascending and descending stair
  • transfers
  • Timed up and go (TUG)
25
Q

Goals

A
  • independence in transfers
  • independence in ambulation
  • non-cemented hip and knee replacements may require a walker to maintain NWB status for up to 6 weeks
  • cemented replacements may allow for earlier partial WBing
  • independence on stairs may be challenged by NWB status
  • 90-100 degrees of knee flexion ROM for TKR
26
Q

Therapeutic exercises

A
  • Upper extremity strengthening
  • CPM for knee replacement
  • Knee AROM (particularly flexion) for TKR
  • quad sets
  • straight leg raising for TKR
  • Heel slides
  • Ankle pumps
  • deep breathing and coughing
27
Q

Duration of replacement-TKR

A
  • implants are functioning well in 90-95% of pts between 10-15 years post surgery
  • potential complications can decrease the lifespan of the implant, for that reason knee replacement reserved for older pts with significant arthritic signs and symptoms
  • Replacement before age 60 increases the likelihood that the replacement will wear out, requiring a revision that tends not to be as successful
28
Q

Indications of total hip relacement (THR)

A
  • may be considered when acetabulofemoral joint has been damaged by progressive and severe OA, trauma, or destructive disease
  • markedly antalgic gait
  • severe pain
  • Referred Pain> L3 dermatomal area> painful in hip/knee but L3 dermatome not at the hip
  • difficulty standing or walking
  • severe loss of motion
  • loss of function
29
Q

Choices for THR

A
  • cemented or uncemented
  • both types are made up of two parts:
      • the acetabular shell (socket portion) replaces the acetabulum and is made of metal shell with a medical grade plastic or metal inner socket liner
      • the femoral component (stem portion) replaces the femoral head and is made of metal or ceramic
  • an uncemented prosthesis has a fine mesh of holes on the surface that allows tissue to grow into the mesh and attach to prosthesis
30
Q

Total hip replacement

A
  • acetabular and femoral components replaced
31
Q

Hemiarthroplasty

A

replaces femoral side of joint

32
Q

Resurfacing

A

younger pts

  • preserves more anatomy of the femur
  • does not have good long term results
33
Q

THR traditional procedures

A
  • posterolateral through gluteus medius
  • hip flexion/adduction precaution after surgery which makes getting out of bed and ambulating hard
  • greater flx of hip= greater post translation of femoral head which could disrupt new joint
  • anterior approach done more often now
34
Q

Anterior approach to THR

A
  • tissue sparing alternative to traditional posterolateral approach
  • potential for less pain, faster recovery, and improved mobility because the gluteus medius is spared
  • smaller anterior incision is used to expose the joint
  • does not detach muscles or tendons from bone
  • high tech table often used to help improve access
  • intraoperative x-ray or computer navigation typically used to confirm implant position and leg length
  • larger,heavier pts may be candidates for this technique
  • more pts candidates for this b/c enters body closer to hip with less tissue between skin and bones of the hip
35
Q

The post op period THR

A
  • avoidance of hip adduction and IR for posterolateral approach
  • avoidance of hip extension for anterior approach
  • monitoring of LE pulses for possible deep vein thrombosis (DVT)
36
Q

THR percautions- posterolateral approach

A
  • no hip flexion beyond 70-90 degrees
37
Q

Duration of replacement- THR

A

implants may eventually wear, but studies have shown that replacement implants are functioning well in a high % of pts between 10-15 years post op

  • potential complications can decrease lifespan of implant, for that reason replacement is reserved for older pts with significant arthritic signs/symptoms
  • replacement before age 60 increases likelihood that the replacement will wear out, requiring a revision that tends to be less successful
38
Q

Therapeutic exercises -THP

A
  • upper extremity strengthening
  • Hip AROM (avioding adduction)
  • quad sets
  • heel slides
  • ankle pumps
  • deep breathing and coughing
  • progress to functional exercise in standing

Clin Med (3 decks)

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