total hip and knee arthroplasties and effects of anesthesia

joint arthroplasty indications

- no absolute age or weight restrictions

- based on person's pain and disability

- may be recommended if the person has: pain that limits everyday mobility, pain that is constant, failed conservative treatment

causes of joint pain/dysfunction

- OA

- RA

- post traumatic arthritis

- avascular necrosis hip

- childhood disease hip

- trauma/injury

goals of surgery

- relieve pain

- maintain or improve joint function/ROM

- improve quality of life

HIP

- total hip arthroplasties

- hip hemiarthroplasty

- hip resurfacing

- total hip revision

- ORIF

THA

- head of femur and a layer of the hip socket are removed

- a metal ball and stem are inserted in the femur and a plastic socket is placed in the enlarged pelvis cup

modular system components and materials

- cup

- liner

- head

- femoral stem

cemented

- used of cemented increases with age

- prosthesis fixated with cement

- provides immediate stability

- increased initial weight bearing orders

- generally used for older/less active patients

- also with patients with poor bone regneration

- disadvantage: loosens over time and with activity

cementless or press fit

- prosthesis have a porous metal coat on contact surfaces with a chemical to promote bony ingrowth

- may have decreased weight bearing status (PWB, TTWB)

- generally used on younger, more active populaiton

- patients with good bone regeneration

- less chance of loosening from wear

hybrid

- non-cemented acetabular component with cemented femoral prosthesis

- WB status per MD

risks and complications of THA

- DISLOCATION

- heart attack

- stroke

- PE

- DVT

- infection

- hematoma formation

- heterotypic ossification

- nerve injury

- fracture

- aseptic loosening

- change in leg length or apparent change in leg length

precautions to avoid dislocation risk based on surgical approach

- accessing the joint

- anteiror

- anterolateral

- lateral

- posterior

- posterolateral

posterior approach to THA

- most traditional and commonly used in US

- increased visibility for the surgeon

- requires splitting of the gluteus maximus and detachment of the external rotators

avoiding dislocation posterior approach

- no hip flexion beyond 90 degrees

- no IR past neutral

- no hip adduction past neutral

activity restrictions posterior dislocation approach THA

- avoid sitting on low surfaces

- no sleeping on operative side

- no turning on or towards the operated limb

anterior approach to THA

- continues to gain popularity

- smaller incision (restricted view of the hip joint)

- muscle sparing no detachment of muscles or tendons

avoiding dislocation anterior approach

- no hip extension

- no ER

if trochanteric osteotomy -

- no hip extension

- no ER

- no active/active-assissted hip abduction

activity restrictions to avoid dislocation anteiror approach THA

- avoid hip motion into prohibited ranges based on dislocation precautions dictated by the surgeon

- no sleeping on operative side

- no rotating on the operated limb

risk of dislocation

- <1-4% risk

- high risk in early rehab

- 6-8 weeks with clearance

signs of dislocation

- report sudden onset of pain in the hip and groin with snapping feeling

- leg shortening with either IR/ER

- unable to perform ROM

- unable to walk or weight bear on the leg

advocates for anterior approach

- lower pain levels post op

- faster functional recovery/more ADL potential

- lower dislocation risk

- shorter hospital stay

disadvantages to anterior approach

- longer procedure

- more demanding (steep learning curve - restricted view of hip joint)

- may not be appropriate for obese or very muscular patients (harder for surgeon to access joint)

- potential delay in incision healing

- some studies show higher surgical blood loss and fracture

- may be a reflection of. MD experience

advantages of lateral approach

- smaller incision

- good cup positioning --> decrease dislocation risk

- less sciatic nerve involvement

disadvantages of lateral approach

- superior gluteal nerve

- HO

- increased risk of antalgic gait (glute med, vastus lateralis)

posterior vs anterior vs lateral approach long term results

- no significant difference in clinical benefit in regards to pain, function, gait mechanics

indications for hip hemiarthroplasty

- performed when there is damage only to the femoral portion of the hip joint

- primarily frail elderly patients

- fractures involving the ball or displaced fracture of the femoral neck

- 10% of all hip arthroplasties

- unipolar vs bipolar prosthesis

- requires movement precautions

hip resurfacing

- 1% of hip procedures

- cemented femoral stem

- cementless press-fit acetabular cup

- conserves femoral bone

- caution with weight bearing, hip dislocation precautions may be warranted

hip revision types

- primary total joint replacement vs total joint revision

hip revision

- 10%

- performed due to damage of the joint from complications or normal wear and tear/life of the prosthesis

- complications from surgery same as with THA, higher risk of complications

prognosis of primary THA

- good to excellent results

- success reported to be greater than 95% for 10 year survival, can be much longer

prognosis of hemiarthroplasty

- bipolar with better outcomes than unipolar

hip resurfacing prognosis

97% survivorship at 8 years

Open Reduction Internal Fixation (ORIF) of the femur is

- NOT THE SAME as hip arthropasties

- 2 part surgery (broken bones reduced, hardware holds together)

- THA precautions do NOT apply

goals of rehabilitation post THA

- should begin day of or day after the surfery

- early post-op physical therapy is focused on functional mobility training, education, strengthening of hip musculature

education post hip replacement

- movement precautions and activity restrictions with mobility

- positioning

- encourage use of operated limb with functional activities

- signs/symptoms of complications

- handouts

exercise progression for hip

- deep breathing and anti-embolism exercises

- isometric quads and glutes (sub maximal)

- progress with prom --> prom --> prom quad activation in supine and sitting

- avoid straight leg raise

- progress to active, gravity only, hip flexion, abduction, extension OOB, as movements increase within precautions

- advanced strengthening programs with progressive resistive exercises (later phases and/or if cleared sooner)

total knee arthroplasty

- femoral condyles, tibial articulating surfaces and dorsal surface of patella replaced

- cemented, uncemented, or hybrid

- weight bearing per MD

- any additional procedures may impact PT with ROM limits (lateral reticular release)

TKA design

- cruciate-retaining

- cruciate - substituting

- hinged

- fixed bearing

- mobile bearing

minimally invasive TKA goal is to decrease

- tissue injury

- post op pain

- blood loss

- length of stay in hospital

- time for recovery/rehab

disadvantages/complications of minimally invasive TKA

- not used for complex joint replacements or revisions

- potential for Mal-aligned components

- limited research

partial knee arthroplasty

- medial compartment: medial femoral and tibial condyles

- lateral compartment: lateral femoral and tibial condyles

- anteiror compartmnet: patellofemoral

- conservative treatment if area of damage is confined

- spares cruciate ligaments

- normal kinematics of the knee is preserved

- most will eventually need an TKA secondary to continued degeneration

- WB per MD

total knee risks and complications

- heart attack

- stroke

- PE

- DVT

- infection

- nerve injury

- fracture

- joint instability

- component failure/loosening

- patellar tendon rupture

- patellofemoral instability

- INADEQUATE ROM

continuous passive motion machine CPM

- fit to patient's leg length

- initial setting usually 0-40 degrees

- to patients tolerance

- generally increase 10 degrees per day

- 6-8 hours/day

- needs to be watched for proper positioning

exercise progression for knee

- deep breathing and anti-embolism exercises (ankle pumps)

- isometrics for: gluteal, quad, and hamstring muscles in spine

- progress to aarom--> arom supine, sitting and standing

PROM, AAROM, AROM: exercise progressions or knee

- knee extension and flexion (heel slides, short arc quads, long arc quads)

- gentle stretching at end range within limits of pain in supine and sitting

- avoid tension at surgical site

- aarom --> arom straight leg raise

- hip abduction and adduciton

manipulation under anesthesia

- intervention for stiff knee (arthrofibrosis)

- focuses on gaining ROM (FLEXION)

- performed within the first 3 months post surgery

- research showing earlier decisions regarding ROM concerns may be more beneficial

manipulation under anesthesia ROM linked to functional activities:

- 93 degrees flexion (rise from a chair)

- 85-90 degrees (stair negotiation)

- 106 degrees (tying a shoelace)

- 125+ degrees (high level activities including squatting)

- goal: maximize ROM to 120 degrees as close to 0 degrees extension

bilateral total knee arhtroplasties

- places increased stress on cardiovascular system

- under the age of 70

- requires person to be fit with overall good strength and have good functioning cardiac, pulmonary and circulatory systems

benefits of B TKA

- one hospital stay (less expensive)

- one surgery (less anesthesia)

- ideally, total rehab process is shortened

- high importance on positioning and home set up

TKA prognosis

- 78% TKAs last 20 years

- >90% TKAs last for 10 years

- 90% have reduction in knee pain and improved ability to perform ADLs

goals of rehab post tKA

- should begin within 24 hrs post op

- improving knee ROM and strength

- exercise program

- positioning and edema control

- motor function training

- maximizing independence and safety with all mobility activities

education post knee surgery

- joint protection strategies

- no pivoting on the operated knee

- positioning of operated leg prior to sit/stand

- positioning in bed

- usual thought: no pillow under knee, avoid hip ER