Mercy TJA(1) PDF

1/16/24 Total Joint Arthroplasty MEGAN LYONS PT, DPT, OCS 1 Facts and Figures u The goal of Total Joint Arthroplasty (TJA) is to relieve pain, improve function, correct deformity, preserve independent lifestyle, and contribute to psychological well being of the individual u Total Joint Arthroplasty...

1/16/24 Total Joint Arthroplasty MEGAN LYONS PT, DPT, OCS 1 Facts and Figures u The goal of Total Joint Arthroplasty (TJA) is to relieve pain, improve function, correct deformity, preserve independent lifestyle, and contribute to psychological well being of the individual u Total Joint Arthroplasty will continue to increase as a result of increased life expectancy, prevalence of osteoarthritis (OA), trauma, obesity, increase in “baby boomers” and the success rates of joint replacement u Between 2005 & 2030, Total Hip Arthroplasty (THA) in US is expected to increase 174% from 209,000 to 572,000. For Total Knee Arthroplasty (TKA) it is expected to increase 673% from 450,000 to 3,480,000 2 1 1/16/24 Total Hip Arthroplasty (THA) 3 (Blankstein 2020) 3 History of Total Hip Arthroplasty u 1891-Professor Themistocles Gluck performs first recognizable hip replacement surgery with ivory material u 1925- Marius Smith Petersen creates first mold arthroplasty out of glass u 1938- Efforts of Marius Smith-Petersen and Philip Wiles create the first THA that was fitted to bone with bolts and screws u 1953- George Mckee, the first to utilize metal-on-metal prosthesis on a regular basis u Early 1960’s-John Charley, father of the modern THA, created a low friction arthroplasty 4 4 2 1/16/24 Indications and Presentation u u Indications: u OA (most common dx) u Inflammatory arthritis (RA, psoriatic arthritis, Lupus) u Avascular Necrosis (AVN) u Hip fractures u Traumatic arthritis Clinical Presentation: u Groin pain u Radiating pain to the spine and/or knee u Loss of motion/decreased flexibility u Potential Trendelenburg gait pattern X-ray of arthritic hip with decreased joint space 5 Contraindications to THA u Active sepsis u Unstable medical condition u Bony ankylosed joint u Rapidly progressing neurologic diseases (i.e. ALS) u Insufficient musculature 6 3 1/16/24 Relevant Anatomy to a Total Hip Arthroplasty u u Bony landmarks: u Greater trochanter u Shaft of femur u PSIS u ASIS u Pubic symphysis 7 Nerves: see this after P-L approach u Sciatic nerve u Femoral nerve u Obturator nerve u Lateral femoral cutaneous nerve 7 Relevant Anatomy of THA (continued) u 8 Muscles u Gluteus Maximus u Tensor Fasciae Latae u Short External Rotators u Piriformis u Gemellus Superior u Gemellus Inferior u Obturator Internus u Gluteus Medius u Sartorius u Rectus femoris 8 4 1/16/24 Total Hip Arthroplasty Implants u Acetabular Component u Plastic Liner u Femoral Head u Femoral Stem 9 9 Components Of THA Implants u u u 10 Metal or Ceramic-On-Polyethylene u Metal or ceramic femoral head articulating with polyethylene liner within a metal acetabulum shell u Gold standard of THA u Current polyethylene material is more resistant to degradation Metal-on-metal u Metal femoral head articulating with metal acetabulum4 u Discontinued in the United States Ceramic-on-Ceramic: u Good durability u Risks: ceramic breaking, ceramic-on-ceramic hips can produce an audible squeak 10 5 1/16/24 Total Hip Arthroplasty Fixations u u 11 Cement u Use of polymethylmethacrylate (PMMA) to function as a grout u Produces an interlocking fit between cancellous bone and prosthesis Cementless Sometimes called press-fit prothesis u Prosthesis is specially textured to allow biological bone fixation u u Hybrid u Cement fixation of femoral component with cementless fixation of acetabular component 11 Cement Fixation In THA u Indications: Poor bone quality u Older individuals (>70 y/o) u u u u 12 u History of inflammatory arthritis u Diagnosis of osteoporosis and osteopenia Displaced femoral neck fracture Pros: u Ability to deliver antibiotics u Cost effective Cons: u Bone cement implantation syndrome u Increased risk of implant loosening u Increased risk of revision u Development of osteolysis 12 6 1/16/24 Cementless Fixation In THA u More commonly used in the United States u Indications: u u Younger individuals u Individuals with active lifestyle u Good bone quality u Patients classified as high risk 13 less OR time for pt candidates who are high-risk. Pros: u Decreased risk of revision u Decreased thromboembolic complications u Cons: u Increased cost 13 Surgical Approaches u Posterolateral Approach u Anterior Approach 2 major approaches nowadays 14 7 1/16/24 Posterolateral Approach u More commonly used approach u Provides surgeon excellent view of hip structures allowing for optimum placement of implants u Performed along fibers of the gluteus maximus u Gluteus maximus, medius and minimus are spared. u Capsule, piriformis, and short external rotators are released before dislocating the hip decreases hip stability u Abductors are spared 15 Posterolateral Approach (continued) u Over the years, the surgical approach has been refined to be less invasive by minimizing the size of incision while still maintaining safety and effectiveness u Small risk of sciatic nerve damage from excessive retraction during surgery Sciatic n. most at risk and most common u Precautions: u Posterior Lateral vs Pose Avoidance u Trochanteric No picking up off the ground dont cross the knee No pivoting of the foot Stand with legs apart. Make sure they dont kiss do not reach back behind your leg to Trochanteric precautions: Can't actively ABD, can't passively ADD Watch out for sidestepping/bring leg out when returning to bed Have pts repeat 16 8 1/16/24 Posterior Lateral vs Pose Avoidance 17 Superior Transverse Atraumatic Reconstruction (STAR) Approach u Same positioning as posterolateral approach u This approach proves a “full moon exposure”—360 degree of acetabulum u Muscles impacted: u u Obturator internus, superior & inferior gemelli Muscles spared: u Gluteus maximus and medius, obturator externus tendon, quadratus femoris, IT band and piriformis piriformis is spared which will increase hip stability 18 9 1/16/24 STAR Approach (continued) u Benefits of STAR approach: u Assists with complex primary THA u Allows for neurovascular safety u Improves hip stability u Bleeding and healing u STAR approach is related to earlier functional improvement, shorter hospital stays, decreased pain levels within 3 months post-op, better cosmetic outcomes, less transfusion needed u Precautions and/or restrictions? No precautions. 'Listen to your body' 19 Appropriate DME following Posterolateral Approach u For a patient with traditional posterior lateral precautions, appropriate durable medical equipment (DME) can include: u Hip Kit u Grabber/Reacher u Sock Aid u Long handled shoe horn u Long handled sponge u Raised Toilet Seat/Adjustable Commode u 4” or 6” Hip Cushion hip cushion 20 dressed instructions - PL - EOB, use grabber. Underwear on operative leg and bring leg into pants Undressed - pants down around knees, swing good legs out, use reacher to grab undies off floor Swelling post-op occurs day 5-10 how long does incision to heal? - 6 weeks 10 1/16/24 Anterior Approach u Has gained popularity over the years u Smaller visual field for the surgeon u Technically demanding procedure-minimally invasive, preserving lateral hip musculature u u Exposes hip without the detachment of muscle from bone u Performed through TFL, Sartorius and Rectus Femoris Can be considered to have a greater risk u Risk for femoral neck fracture Preserves posterior stability as posterior capsule is intact u Precautions: u u Hana Table Anterior vs No Precautions 21 Anterior Precautions 22 pts might dislocate when reaching OH and ERing the surgical hip 11 1/16/24 Posterolateral vs Anterior Approach Anterior Posterolateral u Implant Exposure- better u Implant Exposure- minimal u Fracture Risk- less u Fracture Risk- higher u Blood Loss- less u Blood Loss- more u Surgical Time- faster u Surgical Time- longer u Technically- straight forward u Technically- longer learning curve u Radiation Exposure- less u Radiation Exposure- more u Soft Tissue- “Muscle separating” u Soft Tissue- “Muscle sparing” u LOS- same u LOS- same u Pain- same u Pain- same u Recovery- same u Recovery- same u Typically has precautions u May not have precautions 23 Dislocation u Usually occurs immediate post op thru 4 weeks u After 1st year, incidence decreases u Re-discloations as high as 33% u u u Disruption of the forming soft tissue envelope Necessary to recognize and act quick u Immediate pain u Patient reports audible “pop” u Increased pain with weight bearing Presentation u Anterior: externally rotated u Posterolateral: slight adduction and internal rotation 24 If they dislocate, lie them down and call 911. 12 1/16/24 Dislocation Presentation 25 Rehabilitation Considerations Following THA u Acute Care Phase, Week 0-1, Treatment Recommendations u Review precautions u Strengthening exercises including quadriceps and gluteus isometrics, ankle pumps, seated knee extension, seated hip flexion (≤ 90° if posterior approach), standing hip abduction, standing knee flexion u Transfer training in and out of bed and sit to stand from chair u Gait training with weight bearing status as prescribed by MD with appropriate device, progressing from rolling walker to cane/crutches when patient demonstrates adequate weight bearing u ADL training u Cryotherapy and elevation of lower extremity to prevent swelling u Initiate and emphasize importance of home exercise program 26 13 1/16/24 Rehabilitation Considerations Following THA u 27 Post Operative Phase 1, Week 2-6, Treatment Recommendations u Review precautions u Restore ROM through active motion and functional movements u Multi-positional therapeutic exercise emphasizing strengthening of hip abductors and extensors, knee and ankle u Closed kinetic chain exercises for the hip and core u Short-crank bike, elliptical, treadmill as able u Cryotherapy/elevation/modalities as needed for control of swelling u Gait training with focus on active hip flexion and extension, symmetrical weight bearing, heel strike u Forward and lateral step up progression, step down progression (starting with 2 inches) u Proprioception/balance training: bilateral dynamic activities, unilateral stance u Improve AROM to allow for return to functional activities once precautions are lifted such as reaching to floor and donning/doffing shoes Week 6 - they're doing pretty well Rehabilitation Considerations Following THA u Post Operative Phase 2, Week 7-12, Treatment Recommendations u Review precautions u Progression of Phase 1 exercises Stretching of quadriceps, hamstring and appropriate muscle groups Progressive resistance exercises of bilateral lower extremities Leg press progression Continue step progressions for strength and function Core strengthening u u u u u u u u u u u Stationary bike, treadmill, elliptical Advance proprioception and balance exercise Address limitations in the kinetic chain Normalize kinematics for functional activities such as walking, squatting, stair climbing Pool therapy if available and approved by MD Diminish frequency of physical therapy and progress towards independent HEP 28 14 1/16/24 Hip Resurfacing 29 Hip Resurfacing u Alternative to conventional THA u Provides bone conservation u In a hip resurfacing procedure, your natural femoral head is retained and sculpted u Best suited for young active patients u Usually ≤60 years of age u Metal on metal eliminates polyethylene debris but chromium ions are created u More closely mimics normal femoral head/acetabular anatomical size u Greater hip ROM and improved hip stability u Able to return to impact activities after 4-6 months post-op, per MD agreement u Precautions: u Posterolateral vs None 30 15 1/16/24 Advantages vs Disadvantages u Advantages u Reduced risk of infection and hip dislocation u May offer a more stable hip joint than a traditional THA u Resurfacing can also improve the outcome of a revision surgery if you should need one later in life u u Important if you are very active Disadvantages u Possible femur fracture u Nerve injury or metal wearing inside the joint could result in having a revision surgery u Most likely a total hip replacement. 'conversion' = going for THA 31 Risks Associated with Hip Resurfacing u Risks specific to Hip Resurfacing: u Dislocation - decreased incidence as compared to conventional THA 0.5% vs. 3% u Chromium ion dispersal u Local inflammatory tissue response (metallosis) u Femoral neck fracture – most occur early in post-op period. Incidence