precipitating diseases for hip replacements
- SLE (lupus)
- AVN (avascular necrosis) (can be due to HIV meds)
- Ehler-Danlos syndrom
- bone tumor
breakdown of joint surfaces and subchondal bonecan be dure to loss of otion due to capsular or muscular restrictions. This leads to chanes of articlation bony surfaces. In later stages, osteophytes and cysts may form on the hip jt capsule or femoral head.This interupts proper joint mechanics, and muscle weakness develops - which muscles?
- glut med - it compresses the hip, suctioning it into the socket
- glut max
2 contributing factors to onset of OA
- labral disruption: the labrum gives neg pressure tho help suction the joint together. When we lose this, we lean away from that hip, use the hip less
- femoral-acetabular impingement: leads to compensatory neuromuscular patterns which will need to be addressed during rehab
recent discoveries, theories, and research say disruption of labrum --> _?_
may predispose the hip joint to cartilaginous degredation
purpose of acetabular labrum
- deepens socket and cotact surface area of the femoral head in the acetabulum
- increases stability by way of suction-seal
- once the labrum is torn, it takes a lot less force to distract the femur
factors in the hip's anterior glide syndrome
lack of adequate gluteal and iliopsoas activity and strength
basic progression once you have OA in the hip
hip instability --> acetabular labral tear --> need for imporved neuromuscular control, but instead compensatory patterns develop -- the brain and body prefer the path of least resistance, so you start favoring an antalgic position even if it's unstable or causing injury
risk factors for hip OA
- > 60 y/o
- developmental disorders (Legg-Calve-Perthes, congenital hip dislocation, slipped capital femoral epiphysis)
- dysplasia - any change in orientation of acetabulum and prox femur (coxa vara/valga)
- history of previous hip injury
pre-op symptoms / clinical presentation
- abductor "lurch" (trendelenburg gait)
- pain (ant hip/groin, medial thigh radiating to knee, post hip/tush, lat hip, knee - due to entrapment of adductors)
- loss of function - limited ADLs
the locations of pain to make one a candidate for hip repl
- ant hip/groin,
- medial thigh radiating to knee,
- post hip/tush,
- lat hip,
- knee - due to entrapment of obturator n. by adductors
Harris Hip Survey - used for what?
- measures success of outcome after THA
- asks q's about ADLs - sitting, walking, pain, dressing self...
- 100 points in all. 90-100 = excellent <70 = poor
can be used to asses pre-op function
in general, indications for hip surgery
- radiographic evidence of diseased joint
- chronic pain
- limited ADLs (amb, dressing, in/out car)
- severe deformity
PT tx for a pt who's got the symptoms for a THA?
- glutes, quads, core - is pt using these correctly?
- flexibility in TFL, iliopsoas, hammies, ER muscles
- mobilizations and modalities for pain
- lifestyle changes - learn limits, lose wt
a study on the effects of pre-op exercises found...?
the exercise group needed less time in therapy and had increased muscle strength/mass, but no diffs in WOMAC
contraindications to THA
- poor bone quality
- unstable medical conditions
- active infection
- morbid obesity
- insufficient musculature
- ankylosed joint
- rapidly progressing neurological disease
I'm going light with these cards. So...
be sure you reread his ppt.
post-op, of a posterior approach, what positions must pt avoid?
- hip flex > 90 degrees
- adduction past 0
- IR beyond neutral
- usually for 6-8 weeks
- BUT all that is dependant on the surgeon
- so, this limits sitting, dressing, reaching for items, turning, twisting, in/out of car...
lateral approach - where is the incision, what gets cut
- centered over greater trochanger
- ant fibers of glut med and min (careful to spare the sup glut n.)
position of hip for lateral approach
flexed and ER
anterior approach - where is the incision, what gets retracted, what ges cut?
- incision behind ASIS to greater trochanter (small incision)
- TFL, superficial sartorius, iliacus, nd reuts femoris are retracted
- piriformis is cut
position of hip for anterior approach
hip ext, abd, ER
advantags of a posterolat apporach
- less tissue dissection
- good femur exposure
- abd muscels not dissected
- less OR time
- (most common operation)
advantages of a lateral approach
- good acetabular exposure
- decreased risk of sciatic n. injury
advantages of anterior approach
- usually don't have to follow precautions post op except avoiding extension
- less muscle dissection
disadvantages of posterolat approach
- difficult to expose acetabulum
- increased dislocation rates
disavantages of lateral approach
- increased risk of sup. glut. n. injury
- difficult to expose femur
- increased HO (heterotopic ossification = bone forming in muscle)
disadvantage of anterior approach
- difficult to expose the femur
- steeper learning curve for surgeons
what is "good bone quality?" (makes you a good candidate for hip resurfacing)
no cysts, less osteophytes, no evidence of osteoporosis or osteopenia
basically what happens in hip resurfacing
- a large ball replaces the femoral head
- the acetabulum is debrided
- this is good for younger pts, and it's easy to transition from this to a THA
disadvantages of hip resurfacing
- greater success on men than women
- unknown longevity (old models - 10-12 yrs)
- some people have metal allergy
- risk of femoral neck fx
- nerve injuries
- orthopedic complication (dislocation, leg-length discrepancy)
what increases the risk of DVTs post op?
- prior history
- delayed amb.
risk levels off at 6 wks post-op
collapse of lung tissue affecting part or all of one lung
signs/symptoms of a DVT/PE?
calf pain, swelling, trouble breathing, atalectasis
risk factors for post-op infection
- sickle cell anemia
- current dialysis
- dental infections
preventative measures for post-op infections, and signs of infection
antibiotics, OR and peri-operative env cleanliness, surgical technique
swelling, read, heat, fever
how to treat a superficial or a deep infection
- sup: irrigation and debridement, antibiotics
- deep: remove prosthesis and put in an ABx spacer for 6 weeks, reimplant when pt is clean
nerves at risk for injury
- sup. glut
- lat femoral cutaneous n.
please Heather, reread the slides, I'm skipping anything that's familiar or general or unexciting
dislocation post-op -- common? contributing factors?
- fairly common - 3.9-14.4%
- factors: surgical approach, component mal-alignment, soft-tissue related factors, revisions have higher incidence than primary implants
- likelihood of dislocation tapers off after 10-13 weeks post-op
acute care, days 0-4, what to focus on
- initiate mobility: assisted transfers, assisted amb w AD
- bedside ther-ex: ankle pumps, quad/glut isometrics, heelslide, hip rotation
- edu/support: precautions, cryotherapy, positioning
post op day 2 activities
- initiate stairs
- coninue gait ad transfering training
- advance the ther-ex program
by discharge (POD 3-4) pt should be...
- indep transfers
- indep amb
- indep stairs
- indep HEP
- fully aware of hip precautions
3 phases of post op rehab - the timing and the plan
- Phase I: (0-2 weeks) HEALING - emphasize mobility, function, pain & edema control
- Phase II: (3-8 weeks) STRENGTH/ENDURANCE - begin and progress strength, gentle flexibility and mob of soft tissue, improve higher level function (stairs etc.)
- Phase III: (9-16 weeks) RETURN TO ACTIVITIES - increase sthregth/endurance, HEP for maintenance
out pt rehab (2 wks post op and beyond) goals
- imporve stregt of gluts/iliopsoas/surouning muscles
- wrk towards pt's goals
- indep w all ADLs
exercise for lumbopelvic dissociation
kneeling, go from straight pelvis to flexed (butt over knees)
glut retraining exercise
prone,relax hammies, flex glutes
clams strengthen the abductors if done right. How can a pt cheat? How fix that?
- pt will rotate runk and pelvis... so have pt put hand on hip to feel it and try to not let it rotate
- pt will use TFL ... but this'll look like flexion, so warn pt not to flex
- pt will side-flex lumbar spine ... have pt put hand on iliac crest and hold it down
3 weeks post op can pt use and upright bike?
only if you use raise the seat high, but best to postpone this exercise til later
6 weeks post-op ptis putting on socks and shoes w/o assistive device. Is this ok?
if pt is really strong and feels ok
4 wks post-op is a leg press appropriate?
- neuropraxia of lat fem cutaneous n.
- paresthesia/pain distribution on lat thight
- may be due to intra op injur or may appear during rehab
fix w masage, injections, surgery