Comprehensive Study Notes on Arthroplasty and Orthopedic Occupational Therapy

Case Study Part 1: Mrs. Hernandez Clinical Profile and Hip Fracture

• Patient Profile: Mrs. Hernandez is a $70$-year-old Latina grandmother with three small children.

• Incident Summary: She tripped on an entrance step while attending a senior center for exercise and sustained a femoral neck fracture of her right hip after being unable to catch herself.

• Prior Medical History: She had been experiencing increasing right hip pain due to osteoarthritis and degenerative joint disease prior to the fall, accompanied by weakness in the right leg.

• Surgical Intervention: The fracture was repaired with a total hip replacement using an anterior approach, which was a minimally invasive procedure.

• Post-Surgical Movement Precautions:

  • No hip extension.

  • No crossing the legs (adduction).

  • Weight bearing as tolerated (WBAT) on the right lower extremity.

• Occupational Context:

  • She is usually very active, attending swimming classes twice a week.

  • She assists her daughter in caring for three grandchildren.

  • She heads two committees at her church.

  • Her husband passed away $5$ years ago; her activities provide a sense of purpose and connection.

  • She lives alone in an apartment with elevator access.

  • Her daughter and grandchildren live $15$ minutes away and visit frequently.

• Occupational Therapy Referral: Referred due to difficulty with functional mobility and daily activities (ADLs).

• Patient Concerns: She fears losing her independence and becoming a burden. Her primary concerns are resuming swimming classes and driving to appointments and church activities.

Critical Thinking Questions and Evaluation Components

1. Additional Evaluation Information Required: When completing the occupational profile, the therapist needs specific details about the home environment (furniture arrangement), the level of support available from her daughter (willingness and current IADL assistance), history of prior falls or surgeries, and existing equipment or home modifications.

2. Addressing Occupations and Performance Skills: The priority focuses on ensuring the client understands and recalls hip precautions. Initial training should address bed mobility and toileting while maintaining precautions. Baseline physical assessments should cover strength, range of motion (ROM), sensation, cognition, and coordination.

3. Driving Prerequisites: Before addressing driving, Mrs. Hernandez must demonstrate independence in various transfers (especially car transfers) and obtain medical clearance from her surgeon. Community mobility resources should be explored as interim solutions.

General Medical Management and Etiology of Fractures

• Fracture Definition: Occurs when the bone's ability to absorb tension, compression, or shearing forces is exceeded.

• Physiological Healing Process:

  • Osteoblasts (bone-forming cells) multiply to mend the fractured area.

  • Adequate blood supply is essential for oxygen and proper healing.

• Surgical Fixation:

  • Internal Fixation: Uses pins, plates, screws, nails, rods, or wires.

  • External Abduction Brace: Used in rare cases for extra protection; extends around the pelvis and thigh to prevent movement/abduction.

• Healing Timeline: Complete healing may take several months, varying by age, health, nutrition, site, fracture configuration, initial displacement, and blood supply.

• Major Causes of Fractures:

  • Trauma: Resulting primarily from falls caused by hazards like poor lighting, throw rugs, and unmarked steps.

  • Osteoporosis: A disease resulting in decreased bone density, typically in vertebral bodies, femoral neck, humerus, and distal radius, making bones porous and fragile.

  • Pathologic Fracture: Occurs in bones weakened by disease (e.g., osteomyelitis) or tumors (metastasized cancers).

Surgical Management and Alignment Procedures

• Goals: Relieve pain, maintain bone position, allow healing, and restore optimal function.

• Reduction Types:

  • Closed Reduction: Restoring alignment through manipulation without surgery; maintained by cast, brace, traction, or skeletal fixation.

  • Open Reduction: Surgical exposure to align fragments, often involving Open Reduction and Internal Fixation (ORIF) with hardware.

• Protection: Both closed and open reductions must be protected from excessive forces during healing via weight-bearing restrictions.

Classification of Weight-Bearing Restrictions (Box 40.1)

• Non-Weight Bearing (NWB): $0\%$ weight placed on the involved extremity.

• Toe-Touch Weight Bearing (TTWB): Only the toe touches the ground for balance; $90\%$ of weight remains on the unaffected leg. Clients are instructed to imagine an egg under their foot.

• Partial Weight Bearing (PWB): Only $50\%$ of body weight is permitted on the affected leg.

• Weight Bearing at Tolerance (WBAT): Clients judge the amount of weight based on pain levels and functional limits.

• Full Weight Bearing (FWB): $100\%$ of weight is permitted.

Anatomical Types of Hip Fractures and Specific Medical Interventions

• Femoral Neck Fractures: Includes subcapital, transcervical, and basilar fractures.

  • Common in adults over $60$ years old (especially women).

  • Complications: Poor blood supply, osteoporotic bone unsuitable for metallic fixation, thin periosteum.

  • Treatment: Minimal displacement uses hip pinning (compression screw and plate). Severe displacement or poor blood supply requires an endoprosthesis (hemiarthroplasty).

• Intertrochanteric Fractures: Occurs between the greater and lesser trochanter; extracapsular.

  • Blood supply is usually not affected.

  • Typically caused by direct trauma (falls).

  • Treatment: ORIF with a nail or compression screw and side plate. Weight-bearing restrictions often last $6$ to $8$ weeks.

• Subtrochanteric Fractures: Located $1$ to $2$ inches below the lesser trochanter.

  • Account for $10\%$ to $30\%$ of hip fractures.

  • Seen in individuals younger than $60$ or those with severe osteopenia.

  • Treatment: ORIF using a nail with a long side plate or an intramedullary rod (inserted through the central shaft).

Fall Prevention and Psychosocial Factors

• Fear of Falling: Frequent falls can lead to a decline in function and loss of independence. Clients may hide falls to avoid being seen as a burden.

• Cycle of Decline: Fear leads to reduced activity, social isolation, decreased strength, and further falls.

• Fall Prevention Programs:

  • Education on adaptive strategies and environmental modifications.

  • STEADI Program: Stopping Elderly Accidents, Deaths and Injuries (CDC program).

  • Exercise classes geared toward strengthening and balance.

Hip Joint Replacement (Arthroplasty): Etiology and Approaches

• Indications: Chronic diseases such as Osteoarthritis, degenerative joint disease, Rheumatoid Arthritis (RA), lupus, cancer, or avascular necrosis (AVN).

• Prosthesis Components:

  • High-density polyethylene socket (acetabulum).

  • Metallic or ceramic prosthesis (femoral head/neck).

  • Fixed with methylmethacrylate (acrylic cement).

• Lifespan: Typically $15$ to $20$ years.

• Surgical Approaches and Precautions (Box 40.2):

  • Posterolateral Approach: No hip flexion greater than $90^\circ$; no internal rotation; no adduction (crossing legs).

  • Anterolateral Approach: No external rotation; no adduction; no extension.

• Minimally Invasive Technique: Uses smaller incisions ($2$ inches vs traditional $10$ inches), spares muscle detachment, and allows faster recovery.

• Hip Resurfacing: For younger clients; reshapes the femoral head and caps it with a metallic shell, preserving bone for future revisions. No weight-bearing restrictions apply.

Essential Medical Equipment for Orthopedic Care

• Hemovac: Plastic drainage tube at the surgical site; connected to suction; remains for $1$ to $2$ days. Do not disconnect.

• Abduction Wedge: Triangular foam used supine to maintain leg abduction.

• Balanced Suspension: Pulley system supporting the affected limb for the first $3$ postoperative days.

• Reclining Wheelchair: Used for clients with hip flexion precautions.

• Commode Chair: Raised seat with armrests for safe transfers while maintaining hip angles.

• Sequential Compression Devices (SCDs): Inflatable leggings providing intermittent pneumatic compression to prevent Deep Vein Thrombosis (DVT).

• Antiembolus Hose: Thigh-high elastic hosiery worn $24$ hours a day to assist circulation.

• PCA/PCEA: Patient-controlled analgesia (IV or Epidural) with limits programmed by staff.

• Incentive Spirometer: Portable breathing apparatus to prevent postoperative pneumonia.

Role of Occupational Therapy: Evaluation and Training

• OT Initiation: Typically begins the day of surgery or the day after.

• Evaluation Components: Occupational profile (history, prior status, contexts, goals), UE ROM, strength, sensation, cognitive status, and functional evaluation (ADL/IADL).

• Bed Mobility: Supine with abduction wedge. To sit up, clients prop on elbows and move legs toward the side in small increments followed by the trunk.

• Chair Transfers: Use firm chairs with armrests. Extend the operated leg forward, reach back for arms, and lower slowly. Avoid low, soft, or rocking chairs.

• Toileting: Use three-in-one commodes. Wipe from the front between legs sitting or from behind standing to avoid $90^\circ$ flexion or rotation.

• Tub/Shower Transfers:

  • Shower stall: Walker goes first, then operated leg, then nonoperated leg.

  • Tub shower: Use a tub transfer bench. Back up to the bench, reach for the backrest, extend the operated leg, and sit. Use a leg lifter to move legs into the tub while leaning back.

• Car Transfers: Avoid small cars with bucket seats. Push the front passenger seat back and recline the backrest. Back up to the seat, extend the leg, and sit while leaning back.

• Lower-Body Dressing: Use a reacher or dressing stick to bring pants over the foot. Dress the operated leg first. Use sock aids and long-handled shoehorns.

• Sexual Activity: Refrain for a few weeks; suggest side-lying on the nonoperated side with pillows between knees to maintain abduction.

Knee Joint Replacement (Arthroplasty): Etiology, Types, and Management

• Etiology: Primarily osteoarthritis in adults aged $50$ and older, trauma, or obesity.

• Unicompartmental Knee Arthroplasty (UKA): Partial replacement for medial or lateral damage; often minimally invasive.

• Total Knee Arthroplasty (TKA): Damage in two or more compartments.

  • Fixed Weight-Bearing Prosthesis: Polyethylene insert is locked into the tibial tray.

  • Rotating Platform (Mobile Weight-Bearing): Allows slight rotation; typically for younger, active people or women.

• Knee Precautions: Avoid excessive rotation for up to $12$ weeks. Usually no flexion/extension restrictions. Maintaining mobility is prioritized.

• Continuous Passive Motion (CPM) Machine: Mechanical device that moves the joint slowly through a designated range to improve motion and reduce edema.

• Knee Immobilizer: Supportive brace used if the joint is unstable during mobility.

Occupational Therapy for TKA

• Transfers: Similar to hip; stand with the operated leg extended. For bilateral TKA, clients take small steps forward and reach back for armrests.

• Lower-Body Dressing: Problems arise if the client cannot reach toes. Adaptive equipment or footstools are used. Avoid rotation/torque while dressing standing.

• Bathing: Sponge baths until the incision heals (approx. $7$ to $10$ days).

• Bed Mobility: Supine with the knee fully extended. Small bolsters under the knee are allowed only briefly for pain.

Case Study Part 2: Mrs. Green and Shoulder Joint Replacement

• Patient Profile: $80$-year-old with degenerative joint disease, prior bilateral knee replacements.

• Surgical Intervention: Reverse shoulder replacement (RTSA) on the dominant right arm due to weak rotator cuff muscles.

• Environmental Modifications: Moved microwave/dishes to countertop; hanging clothes on doorknobs; handheld showerhead.

• Outcome: After $6$ weeks, precautions were lifted. At $4$ months, she resumed knitting and driving.

• Discussion Questions:

  • Preoperative Preparation: She could have practiced using assistive devices with her nondominant arm before surgery.

  • Caregiver Role: Caregivers must learn movement and weight-bearing precautions and assist with mobility (bed, transfers) using proper body mechanics.

  • Problematic Tasks: Upper-body dressing/bathing and pulling up pants are difficult without active shoulder movement or rotation.

Shoulder Arthroplasty Classifications

• Hemiarthroplasty: Only the humeral head is replaced; common for fractures.

• Total Shoulder Arthroplasty (TSA): Humeral head replaced by a ball and the glenoid is resurfaced with a prosthetic component.

• Reverse Total Shoulder Arthroplasty (RTSA): Semicircular ball is placed in the glenoid and a cap is placed in the humerus. Stabilizes the joint using the deltoid when the rotator cuff is deficient.

• Compilations: Glenoid or humeral loosening, joint instability, or rotator cuff tears ($10\%$ to $16\%$ incidence over $3$ to $5$ years).

Shoulder Precautions and Post-Surgical Care (Box 40.3)

• Weight Bearing: Non-weight bearing (NWB) through surgical UE.

• Lifting Limit: No more than $1$ to $2$ pounds.

• Movement Limits:

  • No shoulder extension past neutral.

  • Shoulder abduction limited to $45^\circ$.

  • External rotation limited to $30^\circ$.

  • Internal rotation limited to $60^\circ$.

  • Passive Range of Motion (PROM) in flexion limited to $90$ to $100^\circ$.

• Sling and Swathe: Worn for $3$ to $4$ weeks when moving or sleeping to protect the joint.

Therapeutic Exercise and Performance Training

• Codman's Pendulum Exercises: initiated on day $1$ (with surgeon approval); client bends at hips, resting nonoperated UE on a surface, allowing the operated arm to hang and move via body weight shifts.

• Dowel and Table Exercises: Passive exercises where the nonoperated arm or gravity assists motion ($2$ to $4$ weeks post-op).

• Strengthening: Typically begins at $6$ weeks; full restoration of function can take up to $9$ months.

• Functional Training:

  • Stabilization: Use the hand of the operated limb for light tasks (holding toothpaste, buttoning lower buttons) without lifting.

  • Dressing: Sit and bend forward; put the sleeve on the operated arm first with the elbow extended; use the hand of the operated side only for assisting/buttoning once the sleeve is on.

  • Bathing: Sponge bath until sutures/staples are removed; use a long-handled sponge with the nonoperated arm.