Total Hip Arthroplasty

CONTENTS Hip joint anatomy What is THA Indications for THA Characteristics/Clinical presentation of

indications Diagnostic Fx Radiological Fx Surgical procedures Contraindications Post op.characteristics/ Clinical presentation Complications

Post op. physical therapy Ex Physicaltherapy Mx Principles of rehabilitation Mx protocols of THA (APTA) Modalities supported by research DON'TS and DO’S Post op. precautions Long term followup

HIP JOINT

General anatomical overview

DESCRIPTION OF THR An invasive surgical procedure that is

used to remove a diseased hip joint (most commonly due to osteoarthritis) and replace it with an artificial joint or prosthesis.

INDICATIONS FOR THA Disabling pain secondary to severe osteoarthritis

Inflammatory arthropathy

Avascular necrosis

Ankylosis secondary to prior infection or surgery

Trauma such as a fall – most commonly post menopausal women

Juvenile rheumatic arthritis

Benign/malignant tumors around the hip joint, and hip fractures.

complications with the internal fixation of a fracture to the femoral neck- if articular cartilage in the acetabulum is lost or when endoprosthesis have failed in acute fractures

CLINICAL PRESENTATION OF INDICATIONS Hip fracture: Often unable to walk, complains of vague pain in the knee, thigh,

groin, back or buttock and difficulty of weight bearing.

Osteoarthritis: Crepitations are sensible or audible when the hip is moved, all

the inflammatory signs.

Rheumatoid arthritis: Range of all hip movements is impaired, movement is painful,

pain and stiffness when the activity is resumed after resting. Redness, joint effusion.

DX PROCEDURES No specific diagnosis.

Differentiate from referred pian from the spine or pelvis.

Most helpful ways to diagnose if the patient really needs a THR - MRI, X-Ray and physical Ex specific to the particular condition.

RADIOLOGICAL FX

Osteoporotic bones

SURGICAL PROCEDURES Anterior, lateral and posterior approach.

The articulating couples (head and cup) used by surgeons are made of metal-on-polyethylene (PE), ceramic-on-PE, metal-on-metal and ceramic-on-ceramic

Important components of prosthesis are friction-coefficient, survival, stability against dislocation and fixation in bone tissue.

Osteonecrosis due to erosion of the two components rubbing against each other

SURGICAL PROCEDURE

CONTRAINDICATIONS Active local or systemic infection.

COMPLICATIONS

1) Medical complications

• Delayed wound healing or wound dehiscence• Renal and urinary complications.• Cardiovascular complications, VTE including DVT and pulmonary embolism(PE).• Myocardial infarction, or bleeding.• Pneumonia and other respiratory complications.• Blood loss requiring transfusion.• Allergic reaction to medications.

2) Specific complications

• Infection• Fracture of the femur or pelvis• Damage to the nerve / blood vessels• DVT• Wound irritation• Leg length discrepancy • Wear- more active the sooner the wear• Failure to relieve pain• Pressure sores• Limp due to muscle weakness/ fearful gait

POST OP.CHARACTERISTICS/ CLINICAL PRESENTATION

Muscular atrophy and loss of muscle strength, particularly in the gluteus medius muscle and ipsilateral quadriceps

There is a major risk associated with joint instability and prosthetic loosening.

Gait dysfunction may persist for many months after joint replacement.

POST OP. PHYSICAL THERAPY EX

Muscle strength volume and pressure sores (and other 2ry complications).

ROM and circulatory status of the injured and the healthy limb.

General physical and psychological status of the patient- explaining procedure and monitoring after surgery as well as how to use the crutches will reduce anxiety and help build up confidence.

PHYSICAL THERAPY MX Considered according to the surgical approach and the state of

the patient.

Patient desires to gain physical fitness or wishes to recover for recreational activity

Posterior approach- precautions should be taken against dislocation when exercises combining flexion, endorotation and adduction are given.

Anterior approach- combination of extension, exorotation and abduction (probability of dislocation is less great than for the posterior approach)

PRINCIPLES OF REHABILITATION Assessment

Reduce pain

Reduce swelling

Increases range of movement

Improve muscle strength

Aid proprioception

Mobilize patient

Prevent complications

Educate patient and family

POSTOPERATIVE DAY 1:

Post operative assessment – subjective and objective

Check operation notes and post operative instructions

Observations - HR, BP, Drainage, Temperature

Analgesia – useful to use 0-10 scale for pain assessment

Physical observation of pain, range of movement and muscle strength

Respiration and circulation

MX PROTOCOLS OF THA (*APTA)

Acute phase (1-4 days) Educate on dislocation precautions

Increase independence with function

Prevent or reduce post operative impairments.

Treatment occurs bedside, Evaluation, dangle, stand or ambulate as tolerated, Bedside exercises, THA precautions instructed (APTA)

Static contraction of the M. Quadriceps in order to have a muscular and circulatory effect.

Flexion/extension/rotation of feet and toes to prevent edema.

Education of muscular relaxation.

Upper limb exercises to stimulate the cardiac function.

Maintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilization on the operated hip.

Bed exercise following total hip replacement is important prevent edema, improve cardiac function, etc…

POSTOPERATIVE DAY 2: Treatment occurs bedside, Transfer training, Progress ambulation

distance as tolerated with walker, Review exercises and precautions, High chair sitting and bathroom privileges. (APTA)

POSTOPERATIVE DAY 3: Continue transfer training, Attempt gait progression to cane or

crutches and stair training, Treatment session in PT gym, Progression of exercise program, Review Precautions, High chair sitting and bathroom privileges. (APTA)

POSTOPERATIVE DAY 4: Continue transfer training, Continue gait progression and stairs,

Treatment session in PT gym, Review home exercise program and ADL technique, Discharge if appropriate. (APTA)

FIRST POSTOPERATIVE WEEK: Active/passive mobilizations to gain ROM Progressive resistance exercises

Progressive weight bearing exercises according to tolerance

Equilibrium exercises including walking with crutches/2 canes/1 cane.

Early exercises including full weight bearing exercises have shown different positive effects on the recovery of patients after THA

Amount of activity is linked to the general state of the patient.

Motion Phase (week 1-6) This phase includes therapeutic exercise and modalities as needed.

Goals of this phase include: Muscle strengthening of the hip girdle of the operative extremity Proprioceptive training to improve body awareness for functional training Endurance to increase cardiovascular fitness Gait training; discontinue assistive device approx. 4-6 weeks when there

are no signs of an antalgic gait, or trendelenburg sign. Increase ROM Increase Strength Return to functional activities

Weeks 1-4 AA/A/ PROM for all hip motions Isometric quadriceps,

hamstrings, and gluteal exercises

Heel slides Balance training : weight

shifting activities and closed kinetic chain activites

Gait training Stationary bike, weeks 3-4 as

advised by MD

Therapeutic Exercises:

Weeks 4-6 Continue above exercises Front and lateral step up and

down 4 way straight leg raise; if not

contraindicated by precautions ¼ lunge Sit to stand exercises Pushing and pulling exercises Aquatic program

Criteria for progression: AROM 0-110 degrees

Voluntary quadriceps control

Independent ambulation of 800ft without an assistive device, antalgia, or deviations

Minimal complaints of pain and inflammation

Intermediate Phase (week 7-12)

Goals for this phase include: Good Strength for all lower extremity musculature

Return to most functional activity and participation in light recreational activities

Progress exercises in Movement phase by adding resistance and repititions.

Assess lower extremity and trunk stability, provide open and closed chain exercises as necessary to fit the needs of the individual patient

Initiate endurance program ( pool or walking)

Initiate age appropriate balance and proprioception training

Criteria for progression: 4+/5 MMT on all lower extremity musculature

Minimal to no complaint of pain and swelling

Advanced strengthening and higher level function stage (week 12-16)

Goals for this phase include: Return fully to appropriate recreational activities

Enhance strength, endurance, and proprioception

Therapeutic Exercises: Continue to progress previous exercises

Increase duration of endurance activities

Carrying, pushing, pulling activities

Return to specific recreational activities ( golf, tennis, walking, biking)

Return to work tasks

Criteria for progression: Non-antalgic independent gait

Independent step over step stair climbing

Pain free AROM

4+/5 MMT on all lower extremities

Independent with home exercise program

Age appropriate balance and proprioception

MODALITIES SUPPORTED BY RESEARCH Cryotherapy

Thermotherapy

Electrical stimulation

DONT’S DO’S

POST OP. PRECAUTIONS

LONG TERM FOLLOW UP wear is not a short term problem

Overweight and overuse are favorable factors for polyethylene wear, or breakage.

loosening is not a short term problem

Overweight and trauma are favorable factors for bone loosening

Tell your doctor or dentist that you have a prosthetic device so that in case of infection he gives you adaquate treament with antibiotics to prevent an infection of the prosthetic joint.

Do exercises at home. Sports activities are possible

According to comorbidity, age, range of motion and stability ; waiting 3 to 6 months after a THA is a current recommended waiting time for return to sporting

Thank you!