Week 2- Orthopaedic Management of the Lower Limb (Elective & Trauma) Flashcards
What are common conditions for elective orthopaedic surgeries?
- osteoarthritis/ rheumatoid arthritis of the hip
- osteoarthritis and meniscus lesions of the knee
- ligamentous instability of the knee eg ACL
- subluxing/ painful patella-femoral joint
- toe deformities
What is the goal of a total hip replacement?
To attain a durable, painless, functional hip
What are the most common prosthesis for THR?
Originally was metal on metal however had poor results due to friction and metal fragments
Now:
- metal on polyethylene: ball is metal, socket is plastic or plastic lined (polyethylene)
- ceramic on polyethylene: ball is ceramic, socket is plastic or plastic lined (polyethylene)
- ceramic on ceramic: ball is ceramic, socket is ceramic lined
- ceramic on metal: ball is ceramic, socket is metal lined
What are the two surgical approaches for THR?
- posterior
- anterior & antero-lateral
Posterior approach to THR:
- most commonly used
- advantage: easier for surgeon
- disadvantage: dislocation is a possibility during sitting and excessive hip flexion
- dislocation position: Flexion> 90 degrees, adduction past neutral, internal rotation past neutral; combined flexion, adduction and internal rotation
Anterior and anterior-lateral THR approach:
-becoming more common
-advantage: decrease chance of posterior dislocation as posterior capsule not affected
-disadvantage: more difficult for surgeon
—dislocating position: forced extension; flexion or extension with add and er
-may be indicated for alcoholics or other patients who may be unable to adhere to routine hip precautions postoperatively
What are the post operative complications of THR?
- DVT
- Dislocation
- Infection
- Loosening of components
What are the peri-operative complications to THR?
- Sciatic nerve (posterior approach) damage can lead to short term neuro praxis and subsequent ‘foot drop’
- poor positioning of acetabular component could increase chance of dislocation
- fractured acetabulum; fracked femoral shaft; excessive blood loss
What is the post operative presentation of a THR?
- Epidural, PCA, nerve block +/- O2
- IVC, IDC
- Abduction wedge, heel wedge
- SCUDs
What are the post op goals after a THR?
- Independent mobility with appropriate aid
- Independent with home exercise programme
- Independent mobility on stairs and car transfer
What are day 0/1 exercises for post op management after a THR?
• Commence Circulo-Respiratory exercises Day 0
• Commence hip ROM and quads exercises Day 0-1
• Active/assisted hip flexion and abduction on powder board
-Note – hip flexion limited to 90 degrees
• Inner Range Quads (IRQ)
• Bridging and bed mobility
• Note - SLR may be used as an assessment test for LL strength but is not a
recommended strengthening exercise post THR due to the high acetabular
pressures created
What is day 0/1 mobility post operative management of a THR?
- Routine uncomplicated THR will be FWB
- Day 1 – aim to mobilise
- Out of bed on un-affected side - care not to flex > 90 degrees
- Rollator/ESF initially
When can a patient sit after a THR?
Day 1-2, 30mins initially, dependant op pts symptoms
What are day 2 after a THR exercises and mobility?
Exercises:
• Progress ROM and strength functionally e.g. standing hip/knee flexion, abduction, extension; mini squats etc
• Balance exercises
Mobility: • Progress mobility from -Rollater/ESF to -4ww/crutches/SPS • Stairs • Car transfers
What are THR advice and education on discharge?
Hip precautions – to be adhered to lifelong (strictly for first 12wks)
• Avoid combination of dislocating positions
• Do not sit in low chairs
• Do not cross legs
• Do not lie on affected side
• Do not squat down to ground
• Do not bend from hips to pick things up
• No twisting on the affected leg in standing
• No driving first 6/52 until cleared by Drs
Considerations for Discharge Planning:
• Aim for discharge day 3-5
• Occupational Therapy review for ADLs before discharge. Home environment eg bathroom rails, raised toilet seat etc
• Home Exercise Program handout
• Consider F/U Physiotherapy - Home physio or outpatients appointment
What is a revision THR?
- failed or loose prosthesis is removed and replaced by new prosthesis
- staged (septic vs 1 op (aseptic)
What is the Birmingham hip replacement?
A conservative approach to hip arthroplasty: an all-metal bearing couple is used to preserve, rather than replace, a patient;s femoral head and neck
Features include:
- less bone resection than conventional total hip arthroplasty
- excellent long term clinical outcomes
- functionally optimised metallurgy and design
What are the goals of a TKR?
- independent mobility with appropriate aid
- independent with home exercise programme
- independent with mobility on stairs and car transfer
What is arthroscopic knee surgery?
Performed through small portals to allow an irrigation cannula, a fibre optic viewer and light source, and surgical instruments into the joint
Uses:
- to establish or define accuracy of diagnosis
- help decision making and planning of surgery
- observe and record progression of knee joint disorder
- perform operative procedures
Advantage of Arthroscopic surgery:
- rapid recovery
- no hospitation and usually WBAT (weight bear as tolerated)
What are 4 types arthroscopic knee surgery procedures and describe them?
- Menisectomy: loose fragment exercised, flap or oblique tear
- management: FWB, rapid rehabilitation including ROM exercises, SLR, IRQ, limit walking to manage swelling - Meniscus repair: only if located in periphery of meniscus as adequate blood supply for healing
- management: mobilised PWB or NWB crutches, other rehabilitation as above
- advantages: by retaining some meniscal integrity aim for reduction in incidence of degenerative joint changes that commonly occur following a total menisectomy - Chondroplasty: removal or repair/ smoothing of cartilage
- management: WB dependent on extend or surgical repair, other rehabilitation as above - Ligament repair and replacement: eg ACL reconstruction
- management: Dr, dependant, most FWB, close chain exercises for 3/12
What are the 3 way patella realignment, arthroscopic knee surgery and what is the management?
- Tibial tuberosity transfer
- surgically moving the tibial tuberosity medially - Lateral release
- used in isolation or as adjunct to other procedures
- releases tight lateral retinaculum and Vastus lateral is
- may be performed arthroscopically or as open procedure - Medial plication
- “plication” is the folding in and suturing of tucks
- tightening of medial
Management:
• Immobilised in extension in Richard’s Splint for 6 weeks
• No active Flexion, Extension or SLR for up to 6/52
• Only Knee or quads exercise - static quads
• Generally WBAT
Lateral release without tibial tuberosity transfer • Management
• Early activation of quads and ROM exercises
• Mobilise FWB and progress exercises as pain and swelling allow
Describe high tibial osteotomy?
Aim:
- to divide the bone nad reposition the fragments to realign the tibia and distribute weight bearing forces more evenly through the knee
- medial tibiofemoral compartment osteoarthritis
Advantages:
- does not destroy articular cartilage as tibio-femoral joint not directly operated on
- can later progress to TKR
- reduces OA pain
Disadvantages:
- Causes considerable discomfort and long period of rehabilitation
- Not a cure for OA but may slow deterioration
- Symptoms may reoccur
Favourable result factors:
- <65 years of age or ‘long life eexpectancy’
- not overweight
- 90 degrees of flexion
- <15 degrees flexion contracture
- higher activity level (HTO instead of TKR)
- early uni-compartmental OA with corresponding virus or vagus deformity
- ligamentous stability
- No-smoker
Post op management:
-Commence circulo-respiratory exercises day 0
-Commence rehab exercises day 1
• May SLR in Richard’s splint
• If staple fixation - no knee flexion 4-6 weeks
• If plate / screws fixation - may commence gentle knee flexion day 1 or 2
- Mobilise day 1 - NWB with Richard’s splint
- Management can vary dependent on Dr
What are the general WB guidelines for hip fractures?
