Wk8 - joint replacement

Arthroplasty stats

THR- 40% of total replacements, TKR 50% total replacements, TSR 10% total replacement

Surgical procedure

Parts of arthritic / damaged joint are removed, replaced with metal, plastic, or ceramic device, designed to replicate movement of normal healthy joint

Reason for arthroplasty

Degenerative OA, traumatic arthritis, childhood conditions - developmental dysplasia of hip/Perthes, avascular necrosis, neck of femur #, rheumatoid arthritis

Rehabilitation in the home (RITH)

Visit Pt following D/C, assess mobility and ROM, R/V HEP and mobility, reinforce advice re general post op recovery, continue to reinforce use of analgesia prior to exercise and joint precautions

What is HEP?

Home exercise program. Can be developing Pt from WZF to EC or 2EC to 1EC

Risks in joint replacement surgery

Pt dissatisfaction, intrinsic and extrinsic risks

Intrinsic risks in joint replacement surgery

Pain, infection (wound, joint, systemic), #, dislocation, bleeding / haematoma, stiffness, loosening, leg length discrepancy

Extrinsic risks in joint replacement surgery

Thrombus/blood clot (DVT, PE, CVA), delirium, nerve damage, muscle weakness (direct damage), heterotrophic ossification

Blood issues with surgery

Deep vein thrombus (DVT), pulmonary embolism (PE), cerebrovascular accident (CVA)

Regional anaesthetic info

Nerve specific outside CNS, single dose/shot or catheter, blocking sensory and motor function unilaterally, under the level of injection. Used in joint replacement surgery, and can take 72 hr to wear off

Regional anaesthetic pros

Dec vomiting/nausea/drowsiness, better pain control, faster ‘bounce back’ following surgery, less respiratory complications, lower risks

Regional anaesthetic cons

Hypotension (sympathetic shock), trouble urinating after Sx (retinition), allergic reaction, headaches (dural puncture), risk of nerve damage (low but there)

General anaesthetic - controlled consciousness

Medically induced and monitored, via mask or IV

General anaesthetic - unconscious state

Body functions slow down- CV and respiratory, consider multisystem effects, possible breathing tube

General anaesthetic - possible respiratory complications

Geriatrics, obese, pre existing respiratory Dx

General anaesthetic - sedation

Lighter form, used for less invasive procedures, and in combination

General anaesthetic pros

Completely unconscious, no needle or catheter in spinal region, tired and true method

General anaesthetic cons

Intubation tube irritates throat, less pain control, vomiting/nausea, post op delirium, drowsiness, slower bounce back, may be risky for some individuals, riskier then regional

Spinal block

Small needle punctures dura, administered below L2 to avoid piercing spinal cord, drug injected into CSF once

Epidural

Delivered anywhere outside the dura, in epidural space. Larger dose then spinal block, good for sensory block, can be augmented. More segment specific - unilateral, cervical, thoracic, lumbar, indwelling catheter used - may be in Pt for up to 48/24

Revision of surgery

Stiffness, failure, infection, dislocation, #

Multimodal pain management

MMA- admin of 2+ drugs acting by different pharmacology tp target all pathways particpaing in pain response - pre emptive analgesia. Minimises post op mediations and side affets.

Pain management - PROSPECT

PROcedure SPEcific Post operative Pain MangemetnT

Pre op -  paracetamol + cox 2 inhibitor / NSAID  peripheral block

Intra op- dexamethasone + peri articular local infiltration

Post op- paracetamol +cox 2 inhibitor / NSAID +/- opioids

Native joint surgery

Primary joint replacement (partial/total), revision surgery - loosening or wear or recurrent dislocation, periprosthetic #, infection 1st / 2nd stage revision

OA

Gradual development, pain and ache, asymmetrical, loss of ROM (F/E KJ, R HJ), minimal joint swelling, muscle atrophy, morning stiffness, deformity, crepitus, no systemic involvement, night pain

Joint replacement timeline

Onset, progression -6/12, progression 6-12/12, operative 3-12/12, rehab and possible revision - 12-25/1

Joint replacement timeline - onset

GP, conservative management, medication

Joint replacement timeline- progression (stage1)

Ortho, non op injectables, symptom modifiers

Joint replacement timeline- progression (stage2)

Pre op, optimisation

Joint replacement timeline- operantive

Inpatient, recovery

OA in joint replacement

Causes muscle inhibition (atrophy/weakness), joint replacement reduces muscle activation. Weak joint inc OA symptoms, pain, reduced function.

OA management

Not all requires joint replacement, management of systemic issues, structured exercise programs, promoting conservative management. Health education and rehabilitation for OA (HERO)- pre op optimisation

OA pre/post op assessment

2-4/12 prior - MDT assessment, pre emptive DC planning, pre op optimisation, PT education

Pre op MDT assessment

Ortho- xray/ECG, nurse - bloods, pharmacist, OT/physio

Pre emptive DC planning

Start in pre admission, rehab in home community based care, barriers can inc Pt attitude/beliefs, MDT decision, often physio lef, consider rural Pt factors, aiming for day case surgery- length of stay (LOS)- 3-4/7. Specific goals and requirements dependent on surgery

Pt education regarding surgery

Videos on the surgery, set expectations, Pt dos/dont

Partial/noncompartmental KJ replacement

Replaces only one compartment of KJ, usually medial

Partial/noncompartmental KJ replacement indications

Both cruciate ligaments functionally intact, full thickness cartilage loss of affected compartments, intact cartilage in unaffected compartments, fixed flexion deformity <15 deg, good knee F >90 deg

Partial/noncompartmental KJ replacement disadvantages

Technically more challenging for surgeon, potential for more surgery due to wear or loosening

Partial/noncompartmental KJ replacement advantages

Restores more KJ motion, smaller incision, quads minimally disrupted, dec blood loss, less post op pain, quicker recovery, shorter hosp stay, excellent ROM, less expensive

Partial/noncompartmental KJ replacement indications

Primarily to OA, moderate to severe arthritis, mod to severe pain, impaired activity of ADL and ability to function, KJ deformity, chronic swelling/inflammation, failure of conservative treatment, suboptimal quality of life

Partial/noncompartmental KJ replacement contradictions

All forms of inflammatory arthritis, med/lat subluxation, significant KJ stiffness, ligament damage/deficiency

Total KJ replacement procedure

Prepare bone, position implants, resurface patella, insert spacer

Total KJ replacement post op pain Mx

Painful, optimal pain management regime required. Acute pain service (APS) leading management (anaesthetis / pain nurse), multimodal approach, individualised, common regime (opioids)- regional + paracetamol + NSADI+ slow release+ immediate release

Total KJ replacement indications

Primarily to OA, mod - severe arthritis, mod - severe pain, impaired activity of ADL and ability to function, KJ deformity, chronic swelling or inflammation, failure of conservative treatment, suboptimal quality of life

Total KJ replacement contradictions

Unstable mental illness, active infection in area / other parts of body, extensor mechanism dysfunction

Total KJ replacement disadvantage

Never as good as normal knee, dec F then native knee <130 deg, potential for more surgery- wear/loosening

KJ replacement overview

Education- precautions, complications, rehab expectations, pain management. Restore ROM and strength within expectations, progress toward normal function, promote independence, and early, supported return home (day3)

Day 0/1 TKR pain and swelling management

Education important, pain mediation, elevation and compression, cryotherapy, movement

Day 0/1 TKR multisystem management

Respiratory Ax, vascular Ax, neurological Ax, complication prevention and managemetn

Day 0/1 TKR general function

Mobility- bed mobility, transfers. Gait training- mobilise as soon as safe, WBAT, WZF 2xEC, step/step practice prior to discharge

Day 0/1 TKR local MSK ROM

Goal- active ROM knee, hip, ankle asap, active assisted ROM KJ E, no CPM for routine TKR

Day 0/1 TKR strength

Isometric quads to start, active contraction as soon as able (IQR), supine exercise to seated to stand

Day 0/1 TKR global MSK

Maintain AROM and muscle strength to unaffected limb

KJ replacement discharge criteria

Medically stable, wound clean and dry, quad leg ideally <10deg, AOM knee 10-80 deg, independently transferring bed and chair, independent STS transfer, safely and independently mobilised on steps/stairs, safely and independently mobilising with walking aid. Education and HEP issues, referral completed, appropriate home support

Robot assisted surgery

MAKO most common, aim to inc accuracy with partial and total knee replacement and total hip replacement. CT scan used to generate 3D model of Pt anatomy, creates personalise surgical plan, prevents surgeon from moving outside optimal boundaries

Total hip replacement procedure

Removal of femoral neck and head, replaced with metal and plastic prosthesis- metal / ceramic head and metal stem placed into femur, cup placed into acetabulum, liner in between maybe by plastic, ceramic or metal

Partial / hemiarthroplasty

Only femoral head replaced by metal or ceramic head and metal stem placed into femur. Acetabulum intact

Resurfacing hip replacement

Femoral head not removed, just reshaped and capped with metal, acetabulum replaced. Bone conserving option, typically <60yo, not common anymore

Total hip recon - indications

OA, moderate-severe arthritis, mod-severe pain, stiffness, impaired activity ADL and ability to function, failure of conservative treatment, suboptimal quality of life

Total hip recon surgery contradictions

Unstable medical illness, active infection in hip or rest of body

Total hip recon surgery risks

Infection (wound/joint), #, dislocation, bleeding/haemotoma, pain, stiffness, loosening, thrombus/blood clot, nerve damage, muscle weakness

Total hip recon surgery disadvantages

Leg length discrepancies, ongoing hip pain, potential for more surgery due to wear or loosening

Total hip recon surgery considerations

Surgeon preference, Pt profile, old incisions, Pt characteristics - age, BMI, activity levels. Implant selection, risk of dislocation

Total hip recon surgery post op pain Mx

Generally less painful then TKR, acute pain services (APS) involved, multimodal approached, individualised- regional + paracetamol + NSAIDS ± slow release+ immediate release

Total hip recon surgery anaesthesia

GA, reginal anaesthetic - cental (spinal), peripheral - lumbar plexus block (LPB), Fascia Iliaca Compartment Block (FICB), Femoral Nerve Block (FNB), Sciatic Nerve Block (SNB), Pericapsular Nerve Group (PENG)

Standard approaches

Direct anterior, anterolateral, direct Lateral, posterior

Standard - direct anterior - Structure affected

Anterior capsule, no muscle cut, between TFL and sartorius

Standard - direct anterior - advantages

Reduced dislocation rate, abductor mechanism not affected, quick recovery, shorter LOS

Standard - direct anterior - disadvantages

Requires special operative table, technically more difficulty, not ideal or complex cases or revision

Standard - direct anterior -complications/precautions

Lateral femoral cutaneous nerve paraesthesia, and to avoid combines hyperextension and external rotation

Standard - anterolateral - structures affected

Anterior capsule, gluteus medius and TFL ‘pulled out’ of way

Standard - anterolateral - advantages

Lower dislocation rates then posterior approach

Standard - anterolateral - disadvantages

Affects abductor mechanism may cause post op limp

Standard - anterolateral - complications and precautions

Potential damage to superior gluteal nerve, avoid hyperextension, adduction and ER

Standard - Direct Lateral- structures affected

Gluteus med/min cut

Standard - Direct Lateral- advantages

Lower chance of posterior dislocations, relatively short surgery

Standard - Direct Lateral- disadvantages

Lower chance of posterior dislocations, relatively short surgery

Standard - Direct Lateral- complications and precautions

Potential damage to sup gluteal nerve and vessels and avoid hyperextension, adduction and ER

Standard - posterior- structures affected

Posterior capsule disruption, gluteus maximus and external rotators cut

Standard - posterior- advantages

Abductor mechanism not affected, reduced post op limitations, excellent exposure to structures, good for complex case, incisions can be extended

Standard - posterior- disadvantages

Higher dislocation rate

Standard - posterior- complications and precautions

Risk of damage to sciatic nerve, avoid flexion >90 deg, adduction and IR

THR dislocation

2% risk, typically occurring 6-12/52, but can occur later, less common due to improved surgical techniques

Common dislocation mechanism

Falls, getting in and out of chair, getting onto /up from low chairs/toilets, putting on shoes or socks

Predisposing factors

Surgical - component positioning and size surgical approach structures repaired/spared, type of prothesis, surgeons experience

Management of THR dislocation

Revision/ relocation under anaesthetic

Leg length discrepancy (LLD) after THR

Leg can ‘feel’ longer post op, Pseudo LLD, 10mm of LLD well tolerated. Often leg is shorter pre op due to cartilage loss, muscle contractures , Pt will not notice. Surgery aims to restore normal motion and function, body feels limb is longer then it really is. Takes 6-9/12 for body to adjust, no shoe raised initially post op 6-9/12