7. Post-op joint replacement

Flashcards about Post-operative Rehabilitation: Joint Replacements

What is Joint Replacement Surgery (Arthroplasty)?

Treatment of painful and/or disabling joint pathologies; Replacement of a joint with a synthetic joint.

What is the aim of prehabilitation?

To maximize the patient’s physical and psychological function to support them before, during and after surgery.

What are the different phases of rehabilitation after joint replacement surgery?

Phase 1: maximal protection (weight bearing, ROM and muscle contraction restriction, pain, swelling, and poor motor control)

Phase 2: moderate protection (controlled pain and swelling, close to normal ROM)

Phase 3: minimal protection (unrestricted ADL function)

Phase 4: return to activity

What are the ACI recommended principles for NSW pathway for knee and hip replacements?

Establishment of day-stay/short stay treatment team, patient selection criteria, pre-op care, intra-op care, post-op care, options for discharge

What is the physiotherapist’s role in managing hip and knee replacements in the hospital?

Prevent cardiovascular, pulmonary, and musculoskeletal complications; Check integrity of new joint and neuromuscular control; Mobilise and teach independence; Improve strength, joint range, coordination; Ensure safe physical function and plan for ongoing rehabilitation post discharge; Provide Patient-centred care, working in multi-disciplinary team.

What are the GOALS of TSA - Preoperative Phase?

Patient education, Independence with donning and doffing sling, Independence with home exercise program and precautions

What are the TREATMENT STRATEGIES for TSA – Preoperative Phase?

Measure for postoperative sling, Instruct patient in donning/doffing the sling, Instruct patient in ADL, Instruct patient in cryotherapy application, Instruct patient in appropriate exercises to address ROM and strength deficits

What are the GOALS of TSA - Postoperative Phase I (Weeks 0 to 4)?

Pain and oedema control; PROM to 120º of elevation, ER to 30º; Independent home exercise program (HEP) and light activities of daily living

What are the precautions of PHASE I post-op TSA?

avoid unnecessary lifting beyond normal ADL and limit ROM in IR direction and extension

What are the TREATMENT STRATEGIES for TSA – Post-operative Phase I (weeks 0 to 4)?

Sling immobilisation except for light ADL and therapeutic exercises; Pendulum exercise; Passive ROM progressing to active-assisted ROM exercises for F/ER within limits; Scapula strengthening; Cryotherapy as needed

What are the GOALS of TSA - Postoperative Phase II (Weeks 4 to 10)?

Pain control 0/10 with ADL, PROM (Elevation to 150º, ER to 45° )

What are the precautions of Phase III post-op TSA?

Avoid painful activities in ADL, ROM that encourage scapular hiking, poor biomechanics

What are the TREATMENT STRATEGIES for TSA – Post-operative Phase II (weeks 4 to 10)?

PROM, Active–assisted ROM , Active ROM; Humeral head control exercises; Pool exercises; Isometrics; Closed kinetic chain exercises; Upper body ergometry

What are the GOALS of TSA - Postoperative Phase III (Weeks 10 to 16)?

Pain control 0/10 with advanced ADL, PROM (Elevation to 160º, ER to 60º IR to T12); Restore normal scapulohumeral rhythm; Improve muscle strength 4/5, Independent in current HEP

What are the TREATMENT STRATEGIES for TSA – Post-operative Phase III (weeks 10 to 16)?

Flexibility exercises; Hydrotherapy exercises; Isometrics; Scapular stabilisation / Rhythmic stabilisation; Progressive resistance exercises using therabnd; Upper body ergometry; Progressive resistive equipment

What are the GOALS of TSA - Postoperative Phase IV (Weeks 16 to 22)?

Maximize ROM, Achieve adequate strength and flexibility to meet demands of ADL, Normal scapulohumeral rhythm , Independent in home and gym therapeutic exercise programs, RTW

What are the precautions of TSA phase IV surgery?

avoid painful activities in ADL, lifting heavy objects

What are the TREATMENT STRATEGIES for TSA – Post-operative Phase IV (weeks 16 to 22)?

Assess and address any remaining deficits in ROM, flexibility, strength; Flexibility program; Progressive resistive exercises program; Rhythmic stabilisation and Proprioceptive neuromuscular facilitation patterns; Individualize program; Discharge planning

What are some Prevention methods for rehabilitation protocol/plan post TKA Weeks 0-2?

Intermittent cryotherapy, Compression dressing, Ankle exercises to prevent DVT, Deep breathing exercises for basal atelectasis

What are some ROM and Strength Exercises for rehabilitation protocol/plan post TKA Weeks 0-2?

Quadriceps and Gluteal sets, SLR; Knee extensions seated/GoF; Passive and active assisted knee flexion/extension

What are some Functional Exercises for rehabilitation protocol/plan post TKA Weeks 0-2?

WBAT; Gait training with crutches; Transfers

What are some ROM and Strength Exercises for rehabilitation protocol/plan post TKA Weeks 3-6?

Isometrics of major muscles: Quadriceps, Gluteals, Adductors, Hamstrings; Active assisted knee flexion/extension; Heel raises, calf stretches, mini squats, hamstring curls; Hyrdotherapy (after week 3 if wound closed)

What are some Functional Exercises for rehabilitation protocol/plan post TKA Weeks 3-6?

Gait training with crutches → cane, Physical activity

What are some ROM and Strength Exercises for rehabilitation protocol/plan post TKA Weeks 7-12?

Core stabilising exercises; Squats (including SLS mini squats); Resisted exercises of LL muscles; Active and assisted ROM

What are some Functional Exercises for rehabilitation protocol/plan post TKA Weeks 7-12?

Gait (progress to no aid), Lateral stepping, Heel-toe walking, Exercise bike, Physical activity

What is considered a good outcome for rehabilitation protocol/plan post TKA Weeks 13+?

full extension and flexion >110°; normalized and unaided gait; good muscle balance

What are some exercises tailores for rehabilitation protocol/plan post TKA Weeks 13+?

Regular walking; Exercise bike; Hydrotherapy; Gentle gym workouts; Return to sport

Assessment of alternative treatment options for Total Hip Replacement

Completed pharmocological and non-pharmacological therapy for ≥3 months; Core elements of non-pharmacological therapy; patient education, exercise therapy,weight reduction for overweight/obesity

Diagnosis confirmation (objective requirements) for Total Hip Replacement

History (hip pain, morning stiffness <60 min.) and specific examination (painful internal rotation, reduced flexion); Radiologically confirmed osteoarthritis of the hip from KL grade 3; Radiologically confirmed avascular necrosis of the femoral head from ARCO Illc

Patient's subjective distress (personal need) for Total Hip Replacement

Symptoms of hip osteoarthritis: pain, limitations of function/ADL, restrictions of health-related quality of life, Assessment using validated instruments for patient-reported outcome measures (PROMs)

Contraindications for Total Hip Replacement

Previous, not eradicated infection of the hip joint; Active infection; Acute or chronic comorbidities; BMI ≥40 kg/m²

Optimization of modifiable risk factors for Total Hip Replacement

No nicotine use for ≥1 month; Diabetes mellitus: HbA1c <8%; Recommendation for weight reduction for BMI ≥30 kg/m²; Specialist consultation of suspected mental disorder; Anemia diagnostics and, if confirmed, treatment; No intra-articular corticosteroid injection for ≥6 weeks

Shared decision-making for Total Hip Replacement

Identification of individual treatment goals; Information on the feasibility of these goals; Patient-friendly information; Jointly reached decision

What are the Post-op precautions – Anterior approach for Total Hip Arthroplasty?

No hip extension past 20 degrees; No hip external rotation past 50 degrees

What are the Post-op precautions – Posterior approach for Total Hip Arthroplasty?

No hip flexion past 90 degrees; No hip internal rotation or adduction past neutral

What are the General precautions for Total Hip Arthroplasty?

WBAT, with use of assistive device (AD) as needed (crutches, walker); No crossing legs (crossing ankles OK); Use good bending/lifting mechanics; Keep hips above knees when sitting, avoid sitting in deep chairs

What are some Prevention exercises for rehabilitation protocol/plan post THA Weeks 0-2?

Intermittent cryotherapy, Compression dressing, Ankle exercises to prevent DVT, Deep breathing exercises for basal atelectasis

What are some ROM and Strength Exercises for rehabilitation protocol/plan post THA Weeks 0-2?

Quadriceps and Gluteal sets; Knee extensions seated/GoF; Active hip ROM exercises in supine (and standing when possible): hip flexion (<90), abduction, extension in standing

What are some Functional Exercises for rehabilitation protocol/plan post THA Weeks 0-2?

WBAT; Gait training with crutches; Transfers

What are some ROM and Strength Exercises for rehabilitation protocol/plan post THA Weeks 3-6?

Pelvic tilts; Bridges; Standing ROM exercises; Sit-to-stand/mini-squats/step-ups/lunges

What are some Functional Exercises for rehabilitation protocol/plan post THA Weeks 3-6?

Gait training progress to no aids; Exercise bike/hydrotherapy

What are some ROM and Strength Exercises for rehabilitation protocol/plan post THA Weeks 7-12?

Single leg squats/bridges; Resisted strengthening of major LL muscles; Gym program commencement

What are the ROM and Strength Exercises for rehabilitation protocol/plan post THA Weeks 13+?

Plyometric and return to sport plan (individualised)

Australian Orthopaedic Association: Consensus Position Statement on Rehabilitation after Hip or Knee Arthroplasty (Points 1-4)

Advances in joint arthroplasty have reduced the length of stay and requirement for rehabilitation; The majority of patients do not require inpatient rehabilitation after total knee and total hip arthroplasty; Routine referrals to inpatient rehabilitation are not appropriate; Self-rehabilitation after arthroplasty surgery is appropriate for many patients.

Australian Orthopaedic Association: Consensus Position Statement on Rehabilitation after Hip or Knee Arthroplasty (Points 5-8)

It is a misconception to believe that all patients having hip and knee replacement do better with in-patient rehabilitation; Social factors and patient’s beliefs are a significant driver of referral to inpatient rehabilitation; Referral to rehabilitation should be a shared decision between the patient and the medical team; Referral to rehabilitation should not be influenced by commercial relationships between hospitals, surgeons or health care funders.

Australian Orthopaedic Association: Consensus Position Statement on Rehabilitation after Hip or Knee Arthroplasty (Points 9-12)

Early mobilisation is appropriate for the majority of arthroplasty patients; Those who require impatient rehabilitation tend to be older and have greater co-morbidities than those who do not; Research is required into improving predicting before surgery who will benefit from inpatient rehabilitation; Research is required to determine if patients who receive outpatient physiotherapy have better outcomes to those who self-rehabilitate.

Australian Orthopaedic Association: Consensus Position Statement on Rehabilitation after Hip or Knee Arthroplasty (Point 13)

Patients who go to in-patient rehab incur increased investigations, increased adverse events and increased re-admission rates, however, this may be due to them being older and having more co-morbidities