Hip Arthroplasty PDF

The 2nd largest joint in the body Connect pelvic girdle to LE Provide good stability and mobility Transmit weight between axial and appendicular skeleton Commonly affected by arthritis Di-arthrodial, Ball and socket Femoral head is 2/3 of a perfect sphere Entire head is covered by cartilage...

The 2nd largest joint in the body Connect pelvic girdle to LE Provide good stability and mobility Transmit weight between axial and appendicular skeleton Commonly affected by arthritis Di-arthrodial, Ball and socket Femoral head is 2/3 of a perfect sphere Entire head is covered by cartilage (except fovea) femoral head most commonly faces medially, superiorly,and anteriorly. Acetabulum is incomplete near inferior pole (covered by transverse acetabular ligament  Motion of the Pelvis on the Femur Anterior and posterior tilting of the pelvis on the fixed femur produce hip flexion and extension, respectively. Iliofemoral lig Pubofemoral lig Ischiofemoral lig ligamentum teres  Resting position 30flexion, 30abduction, slight lateral rotation Close packed position Extension, medial rotation, and abduction Capsular pattern Flexion, abduction, medial rotation (order may vary)  Disorders of the Hip Joint for Which Total Hip Arthroplasty May Be Indicated Rheumatoid Arthritis Ankylosing spondylitis Femoral head prosthesis Avascular necrosis (AVN) Hemophilia Post fracture or dislocation Hereditary disorders Idiopathic Osteomyelitis (remote, not active) Bone tumor Postoperative osteotomy Osteoarthritis (OA) Renal disease Developmental dysplasia Cortisone-induced of the hip (DDH) Alcoholism Hip impingement Tuberculosis (femoroacetabular impingement)  Hip Arthritis  Arthritis of the hip can result from many causes.  About 30% of all patients have a mild form of acetabular dysplasia (a shallow socket), and 30% have a retroverted socket.  Both of these conditions reduce the contact area of the femoral head in the acetabulum, which increases the pressure and makes wear more likely.  Approximately 30% of patients have no obvious risk factors (unknown cause).  Arthritis of the hip is marked by: *Loss of articular cartilage *joint space narrowing and pain. *Stiffness ,development of osteophyte formation (bone spurs), which in turn lead to further stiffness Difficult for DLA (to put on socks and shoes). Pain reproduced by passive internal rotation of the hip. Tenderness over the anterior hip capsule (variable). Restricted ROM (rotation is usually affected first). Abductor limp (with severe involvement). Functional leg-length discrepancy (if abduction contracture has developed).  Treatment  A cane in the opposite hand helps to unload the hip  Stretching and strengthening exercises or joining a yoga class  Leg Rotations exercises  Leg Raises exercises  Knee Cross-Overs  Strengthening Exercises: using TheraBand  Straight Leg Lifts  Knee-to-Chest Lifts  Mini-squat exercises 1. Anterior dislocation 2. Posterior dislocation, more common 3. Central dislocation (direct thrust along the line of the femoral neck → fracture acetabulum → femoral head displaced into the pelvic cavity  Longitudinal thrust along shaft of femur when hip is flexed & adducted (dash board accident) → head of femur displaced backward out of the acetabulum  Clinically: The affected leg is: 1. Internally rotated 2. Adducted 3. Shortened Immediate complications: Sciatic nerve injury → drop foot & numbness over the outside of the calf Late complications: avulsion of ligamentum teres from the acetabulum → cut off blood supply to femoral head → avascular necrosis → OA  Force that abducts the extended hip → femoral head displaced below & in front of the acetabulum  Clinically: the affected leg is: 1. Abducted 2. Externally rotated  Treatment of post. dislocation: 1. Manipulative reduction 2. Traction (4 weeks) → healing of capsular tear 3. Weight bearing 4. Regular x rays monthly for the 1st 4 months for early detection of avascular necrosis  Treatment of ant. dislocation: 1. Manipulative reduction 2. 3 weeks traction Surgical construction of newly artificial, painless, movable and stable hip joint The first totally successful joint replacement in human subject took place in 1959. The hip was the 1st joint to be successfully replaced.  Total arthroplasty (full joint replacement): replaces both sides of the joint e.g. acetabulum & head of the femur.  Hemiarthroplasty (partial joint replacement): restore the aspect of the joint that is damaged  N.B. all partial replacements may be upgraded to a full replacement at a future date if necessary.  By the degree of control offered by the joint. 1. Constrained: there is a link between the two components and all anatomical movements are restricted to a greater or lesser extent. 2. Semi-constrained: some movement is allowed in all planes. 3. Unconstrained: permits free movement in all anatomical planes. The joint is prone to dislocation until 6 weeks post-operation Prosthetic parts are made out of inert metals of low friction coefficient (6 times > natural joint) e.g. 1. Stainless steel 2. Chrome-cobalt-molybdenum alloys 3. High density polyethylene  Modern hip arthroplasties use a combination of Chrome- cobalt molybdenum alloys or stainless steel femoral shafts with high density polyethylene acetabular cup 1. Pain 2. Loss of function e.g. OA, RA, post-traumatic joint stiffness, avascular necrosis N.B. the recommended age is 60+ 1. Acrylic cement : can sustain compressive stress well but cannot control shear or torsional stress.e.g. Thompson hemiarthroplasty. 2. Bioingrowth: relies on natural growth of bone around or through the prosthetic implant and no cement is used.e.g. Austin Moore hemiarthroplasty.  Non-cement technique necessitate a period of non or partial weight bearing to allow stabilization of the component.  Cementless technique is preferred in younger patients under 65 years 1. Anterolateral: between tensor fascia lata and glutei 2. Posterolateral: through the posterior capsule 3. True lateral: greater trochanter is excised and re-attached with wire fixation 1. Dislocation Anterolateral & true lateral: hip will dislocate if placed in excessive extension, external rotation, and adduction or a combination of all three Posterolateral: hip will dislocate in excessive flexion, internal rotation & adduction or a combination of all three.  6-12 weeks these positions should be avoided. - Anteriorly Dislocated hip is shorter, externally rotated and in extension - Posteriorly Dislocated hip is shorter, internally rotated and flexed Treatment: relocation of the hip under general anaesthesia & traction for 6 weeks 1.Wear 2. Venous thrombi 3. Fracture 4. Postoperative thigh pain 5. Failure 6. infection  Safe transfere technique  Proper use of assistive devices  Postoperative exercises e.g. 1. Ankle pumps 2. Quadriceps sets 3. Gluteal sets 4. Active hip and knee flexion (heel slides) 5. Isometric hip abduction 6. Active hip abduction  Restoration of : 1. Joint motion 2. Muscle strength - Maintainance of: 1. Vascular function 2. Respiratory function - Education about: 1. Joint preservation techniques 2. Bed mobility 3. Weight bearing 4. Start of sitting is delayed for patients with posterolateral incision to prevent dislocation Both cemented & un-cemented replacements follow a similar regime except for time of weight bearing. - Un-cemented prosthesis will remain partially or non-weight bearing for 6- 12 weeks. -Cemented prosthesis begins weight bearing at 1st or 2nd day postoperative  Abduction pillow or wedge should be used while patient is lying supine or on the non-operated side  SLR is discouraged until full quadriceps and iliopsoas control has returned  Goals: A- protect healing tissues, B- prevent postoperative complications, 1. Respiratory exercises 2. Ankle pumps 3. Quadriceps sets 4. Gluteal sets 5. Repositioning of the patient every 2 hours with the abductor pillow in place 1. Same previous exercises 2. Upper extremity exercises 3. Transfer training from supine to sitting, and from sitting to standing, while observing precautions and emphasize the use of upper extremity in shifting weight, avoid pivoting on the affected leg 4. If not complaining of excessive pain, fatigue, or dizziness, gait training may begin. 1. Hip ROM exercise 2. Heel slides 3. Isometric or active assisted hip abduction 4. Active assisted short arc quadriceps sets 5. Gait training (front wheeled walker for older patients & 3-point crutch pattern for younger patients) start with 50% of body weight or less  Goal: improve UL & LL strength 1. Heel slides 2. Hip abduction 3. Terminal knee extension 4. Resisted shoulder exercises 5. Stair training (upstairs with unaffected & downstairs with affected) 1. Patient is able to demonstrate & state precautions 2. Independent with transfers 3. Independent with the exercise program 4. Independent with gait on level surfaces to 100 feet 5. Independent on stairs  Goals: A- improve strength of LL B- improve balance C- promote return to activities 1. CKC exercises 2. Pool therapy 3. Treadmill 4. single point cane. (starts 3-4 weeks after surgery & discontinued after 3-4 more weeks)). 5. Step over step stair climbing 6. Driving is allowed 6 weeks after surgery  Total hip replacement Guidelines and Precautions  Activity Cemented Cemented-less Internal rotation Don’t perform for 3-6 Don’t perform for 3-6 of the hip joint. months months Adduction of the Don’t perform for 3-6 Don’t perform for 3-6 hip joint. months months Flexion of the hip Don’t perform for 3-6 Don’t perform for 3-6 joint beyond 90◦ months months Activity Cemented Cemented-less Isometric exercise Immediately postop Immediately postop as tolerated by the as tolerated by the patient. patient. Active exercise Initiation is Initiation is variable between variable between weeks 1 through 4, weeks 1 through 4, depending on the depending on the surgeon’s surgeon’s guidelines. guidelines. Ambulation Cemented Cemented-less Partial weight bearing Varies from weight (PWB) for bearing as tolerated approximately (WBAT) to touch- 3weeks. down weight bearing (TDWB) based on the Begin ambulation surgeon’s philosophy with cane at week 4 and the surgical postoperative. approach. Begin transition to full weight bearing at week 5.  Cemented-less Ambulation TDWB: WBAT: Progress to 1/3 weight bearing at week 6. Partial weight bearing for approximately 3 Progress to 2/3 weight bearing at week 8. weeks. Progress to full weight bearing at week 10. Begin translation to cane at week 12. Begin ambulation with cane at week 4. Progress to no assistive device when safe, and no Trendelenberg gait. Begin translation to full weight bearing at week 6. 1. Excessive extension, external rotation & adduction with anterolateral & true lateral incision. 2. Excessive flexion, internal rotation & adduction with posterolateral incision 3. Sitting in low chairs (less than 53 cm in height) 4. Bending forward to put on shoes , socks, cut toenails, etc 1. Crossing the legs in sitting or lying 2. Twisting the legs in sitting or lying 3. Driving 4. Jumping or running 5. Contact sports  Low-impact non-contact sports 1. Sailing 2. Swimming 3. Cycling 4. Golfing 5. bowling High-impact or contact sports 1. Running 2. Water-skiing 3. Football 4. Basketball 5. Hockey 6. Martial arts 7. Soccer