Hip Arthroplasty & Physiotherapy

Management

Dr. Dibyendunarayan Bid

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Arthroplasty

• This is non-specific term covering any surgical refashioning of a joint, with or without use of artificial materials.

• An arthroplasty is indicated for pain, deformity or instability in a joint where loss of motion is considered unacceptable, and sometimes for the deliberate mobilization of a previously fixed joint where this fixity by itself is the cause of significant symptoms, as, for e.g. , in the mobilization of a previously fused hip for intractable back pain.

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Three Types:

• Excision Arthroplasty

• Interposition Arthroplasty

• Replacement Arthroplasty

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Excision Arthroplasty• Here, one or both of the bone ends forming a joint are

excised. • Example- Keller's Arthroplasty- where the proximal

end of the proximal phalanx of the big toe is excised to treat a painful hallux valgus.

• Example- Girdlestone Arthroplasty of Hip.– After excision of bone ends, the hope is that a flexible scar will form

between them, and therefore an attempt may be made to preserve the gap between the bone ends during the early stages of healing.

– This is achieved with traction in the case of Girdlestone arthroplasty or with a Kirschner wire in the case of a Keller’s arthroplasty.

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Interposition Arthroplasty• This is of historical interest.• The joint is opened and material is placed between the

bone ends.• This material may be natural or artificial or a

prosthesis and the bone ends may or may not be reshaped.

• Fascia lata and silastic have been used.• Example- mould arthroplasty of hip- this procedure

involved a Vitallium Shell being interposed between the reshaped head of the femur and the reamed acetabulum.

• Requires- prolonged period of vigorous post-operative rehabilitation and results are unpredictable.

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Replacement arthroplasty

• This has completely superseded the other types of arthroplasty,

• and has greatly reduced the indications for osteotomy and arthrodesis in the Rx of symptomatic arthritis.

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Normal hip joint

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Osteoarthritis of the hip

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Total Hip Replacement

• Implant Design: subdivided into-

A. Choice of base implant material;

B. Geometry;

C. Method of Fixation; and

D. Materials used for the bearing

surfaces.

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• Choice of Base Implant Material:Hip replacement stem comprises of-

stainless steel, cobalt-chrome or Titanium alloy.

Choice of material is base on: strength, flexibility and biocompatibility.

Acetabular Component- comprised of High Density Polyethylene (HDP).

-Ceramic Cups- prone to be #ed.

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• Geometry1. Varies widely between implants. Femoral head is

made in several sizes ranging from 22 to 32 mm (22.25 was the original size chosen for Charnley THR).

2. The size of head influences the rate of wear of the bearing and, in conjunction with the size of the prosthetic neck, also influences the ROM allowed by the components before the head lifts out of the socket, causing dislocation.

3. Use of a collar in femoral stem.4. Surface finish and precise shape of the stem within

femoral canal – variation in thickness and taper

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5. Charnley Cup – has flange - is cut to fit the prepared skeleton and assist in cement pressurization.

6. Uncemented cups – wide variations in shape

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• Method of Fixation

Cemented

Uncemented - press fit Supplemented by various forms of rough or

porous surface and a hydroxyapatite (HA) coating- improves bone growth and bonding.

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• Materials The chief requirements of bearing surface

are that both friction and wear should be as low as possible.

The most common combination is metal against plastic.

Plastic wears - produces particles - particles are harmful - causes implant loosening from osteolysis.

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Clinical• The main symptoms and indications for

THR are : – pain, – loss of hip movement, – loss of function- principally the ability to walk

adequate distances - or a combination of these.

• Charnley modification of the D’Aubigne and Postel Hip Chart.

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• In this system , 6 points each are given for pain, walking ability and range of motion, normality being indicated by number 6.– Patients are also classified into three different

grades: A, a patient with one arthritic hip; B, a patient with two arthritic hips; and C, a patient who has some other limitation, e.g. angina, RA, such that even with perfect hips there would always be a significant functional deficit.

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• The system allows for an easy comparison between pre- and post- operative function.

• Secondary symptoms, such as analgesic requirements, the ability to put on socks or stockings, the use of walking aids, and the patient’s gait without walking aids, should also be recorded.

• Once patient is indicated for operation, a thorough preoperative screening is needed. This includes a complete medical assessment, a search for potential anesthetic difficulties, & elimination of potential sources of sepsis.

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• Attempt to eliminate potential sources of sepsis include attention to teeth, skin lesions & other possible remote sources.

• The condition of the peripheral circulation, & a history of prostatism in a male patient, should also be evaluated.

• Routine blood tests and urine tests.

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• Infection

Ultra-clean air of operation theatre using laminar flow and total body exhaust suits for surgeons

Prophylactic antibiotics + antibiotic mixed with bone cement to control infection

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• Orientation

The components of an implant are carefully orientated so that the range of motion allowed by their geometry comes within the motion likely to allowed by the patient.

Possibility of dislocation – because of more flexion.

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• Loosening Depends in the hands of surgeon- how strongly

components are fixed. Prophylaxis against venous thrombosis and

pulmonary embolism– mechanical devices allowing regular emptying of deep veins in the foot & / or lower leg. Sometimes these devices are used intra-operatively.

Use of elastic stockings.

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Surgery

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Step 1: Incision

• Minimal is preferred• Removal of

osteophytes• Avoid transverse

acetabular ligament

Ref: http://www.bonecement.com/application/totalhip.html

Ref: Desert Orthopaedic Center

http://www.desertorthopedic.com/mini.asp

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Step 2: Removal of Femoral Head

• Femoral head dislocated

• Femoral head removed at neck

See Reference Section

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Step 3: Prepare Acetabulum

• Drill and reamer used to remove cartilage and create cup shape

• Anchorage holes made (cemented case)

• Remove debris with brush

See Reference Section

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Step 4: Insertion of Acetabular Component

• Held in place by friction, screws or cement

• Pressurization carried out in cemented case

See Reference Section

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Step 5: Preparation of Femoral Canal

• Straight reamer creates hole

• Remove debris• Insert distal plug

See Reference Section

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Step 6: Insertion of Femoral Stem

• Friction fit or cement• If cement used

pressurize cement to create an even cement mantle

See Reference Section

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Step 7: Attachment of Femoral Head

• Attach femoral head to stem (by Morse taper)

See Reference Section

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Step 8: Insertion of Head into Acetabular Component

• Femoral head is located into acetabular liner

• Range of motion is verified

See Reference Section

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OR

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Hip replacement surgery: Step 1

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Hip replacement surgery: Step 2

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Hip replacement surgery: Step 3

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Hip replacement surgery: Final

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Post-operative Management Post-operative Management

• The patient is usually allowed to stand and walk within the first few days pot-operatively, sometimes from the day after surgery.

• This mobilization is carried out with careful supervision by a physiotherapist.

• A frame is usually needed . Walking aids are then progressively reduced, but patients may be recommended to continue on elbow crutches until 6 weeks post-operatively– especially for partial weight bearing in young patient.

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• Depending on the patient, at sometime between 6 weeks and 3 months it should be possible for all restriction on function to be lifted; improvement usually continues in a subtle way for many months.

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HIP REPLACEMENT IN SPECIAL CIRCUMSTANCES

HIP REPLACEMENT IN SPECIAL CIRCUMSTANCES

• In young patients: a hip replacement will wear out, come loose, or both. Will require revision surgery later.

• Hip resurfacing– in which a hemispherical cup is put onto the surface of the reamed femoral head rather than having a stem down the femoral shaft.

• Fundamental goal of hip resurfacing – as little bone as possible should be removed, thus preserving it for further surgery.

• Replacement of femoral side only with a bipolar component.

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• Avascular necrosis of femoral head in young – where acetabulum is normal – only femoral head is replaced (with a bipolar head).

• Neck femur fracture in elderly --where acetabulum is normal – only femoral head is replaced (with a bipolar head).

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• The post-operative management of these patients has to be individualized.

• It has been found that offloading the implant bone interface postoperatively increases the chance of through integration of the implant (as with the process of fracture healing).

• Therefore, young patients should be mobilized later and, wherever possible, kept partial or non-weight-bearing for the early post-operative weeks.

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THR & PHYSIOTHERAPYTHR & PHYSIOTHERAPY

• PT management of each patient varies slightly from all others.

• Some of the factors influencing this will include: the surgical approach, the surgical procedure, the surgeon’s preferences, and the patients predisposing limitations, past medical history and expectations from surgery.

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• Surgical approaches are:Lateral approach and Posterior approach• Lateral Approach: necessitates an incision over

the trochanter of the femur, & a trochanteric osteotomy. The bone is incised below the insertion of the abductor muscles, which allows the surgeon to work within the joint capsule of the hip. The final stage of the operation is to rewire the detached fragment of bone, with its muscle attachment intact, to the proximal end of the femoral shaft.

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• After surgery, it is essential that the hip is maintained in an abducted position. When mobilizing the patient, the Physiotherapist must ensure that the patient’s leg does not fall into adduction, and nurses must also be careful to ensure the abducted position is maintained in the bed.

• The patient is most vulnerable when transferring from a bed to a chair or if rolling to the unaffected side, as the upper leg naturally falls into adduction.

• These patients should be taught to roll to their operated side if this is required. Care must be taken until the bone & soft tissues around the wound have healed, usually 4-6 weeks.

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• Posterior Approach: In this posterior aspect of the capsule is incised to permit surgery to the joint. The capsule is sutured at the end of the operation but remains vulnerable throughout its protracted healing time of 4-6 weeks.

During this period , care must be taken to ensure the hip is not flexed beyond 45°.

Any flexion beyond this point will force the prosthesis posteriorly & there is risk of the patient suffering a posterior dislocation of hip.

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Pre-operative PhysiotherapyPre-operative Physiotherapy

If the patient has not already attended an out-patient pre-operative clinic, they are assessed fully & the rehab program discussed. The pre-operative clinic includes:

1. Instruction in the performance of post-operative breathing routines.

2. Lessons on how to move about the bed without straining the operation site.

3. Instruction on the most efficient and safest way to get in & out of bed.

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4. Exercises to maintain co-ordination & power of quadriceps, hip abductors & hamstrings. These are encouraged to ensure the patient is as fit as possible for surgery.

5. Exercises to maintain the circulation in the lower limbs. However, where foot pumps, anti-embolus stockings &/or anti-coagulation drugs are being administered or are anticipated to be required after surgery, circulatory exercises are reduced.

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Post-operative PhysiotherapyPost-operative Physiotherapy

• Once the patient has regained consciousness and is relatively comfortable, general bed activities are encouraged

• The Physiotherapist must be aware of surgical approach & procedures & instruct the patient carefully about movements & positions to be avoided during the early post-op days.

• As early as 24 hours after the operation, the patient may be allowed to get out of bed, exercise & mobilize under supervision, provided the surgeon's protocol is not compromised & there are no complications.

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• When getting out of bed for the first time, the patient chooses the side to which they wish to move.

• Care must be taken to ensure that the operated hip does not fall into adduction or flexion past 90° as these positions apply strain to weakened parts of the joint capsule & may lead to dislocation of the joint.

• On completion of the transfer from lying to sitting on the edge of the bed , patients should be allowed a short time to ensure there is no giddiness & that they are poised for next step.

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• When confident, the patient pushes up from the bed into a standing position , supporting their body weight with a walking frame.

• If the patients balance is satisfactory & there are no contraindications, e.g. low arterial blood pressure or a feeling of faintness, weight transference exercises can commence, followed by supervised walking.

• The patient may also be allowed to sit out of bed in a chair at this stage.

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• Patients gain confidence daily & increase activity levels at their own pace. The Physiotherapist supervises the exercise program, monitors/ evaluates progress, deals with patient concerns and progresses the patient’s rehab program.

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The rehab program should include teaching & supervised practice of:

1. Safe transfers from a bed or chair to a standing position.

2. Walking using appropriate walking aids , e.g. frame, crutches, stick.

3. Independent walking, i.e. with or without walking aids.

4. Gait re-education, with particular reference to the correct use of walking aids, stride length, timing & rhythm.

5. Identification of leg length discrepancy & its correction by the use of shoe raises.

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• The rehab program should also include treatment &/or advice on the management of problems associated with the hip disorders, for e.g., pain in the lumbar region or pain referred to the knee.

• The patient should be taught the safe negotiations of steps, stairs, slopes and uneven ground. it is essential to remember ‘the good leg leads going up steps and follows coming down’; i.e. the good leg is always higher, the bad leg always lower when ascending and descending stairs.

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• In case of bilateral hip replacement on the same day, it must be determined which leg is stronger or most reliable so that the patient can be encouraged to use this leg to lead the climb and follow on the descent of stairs.

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• Discharge from hospital is determined by the multidisciplinary team after discussion with patient. Discharge may be as early as 5 days after surgery.

• Following discharge, the patient continues to mobilize with the walking aids and will undertake a home exercise program aimed at strengthening the quadriceps, hamstrings and glutei on the affected side while improving general fitness & mobility of the rest of the body .

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• The patient should progress to full independence within approximately 6 weeks , although the timing of resumption of some activities differs from patient to patient according to surgeon’s judgement on the patient’s abilities.

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Complications of Surgery

• Deep Vein Thrombosis

• Pulmonary embolism

• Infection

• Anemia

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• Picture 1. Normal total hip arthroplasty. Anteroposterior radiograph of the left hip reveals cemented metal femoral component and metal and plastic acetabular component with screw fixation.

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The EndThe End