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DEFINITION OF TERMS
ARTHROPLASTY
Excision arthroplasty
(Essential
Physical
Rehabilitation)
Replacement
Arthroplasty
Medicine
and
Partial replacement
Resurfacing
Cemented implants
Cement techniques
First-generation
femoral
cement
techniques: cement mixed by hand in
Arthroplasty
Uncemented implants
BEARING SURFACES
Highly
(XLPE)
cross-linked
polyethylene
Arthroplasty
Metal-on-metal
Direct Lateral
Anterolateral
Arthroplasty
Involvement
of
Hip Impact
on
Muscles
and
Other Postoperative
Soft Tissues Function
or
Gluteus maximus
Possible
earlier
divided in line with
recovery
of
a
its fibers with a
normal gait pattern
posterior approach
because
gluteus
medius
and
TFL left
Interval
between
intact
the
gluteus
Highest
risk
of
maximus
and
medius divided in a
dislocation
or
posterolateral
subluxation
of
approach
prosthetic hip
Short
external
rotators
and
piriformis released
and repaired
Gluteus maximus
tendon
possibly
released
from
femur; repaired at
conclusion
Posterior
capsule
incised
and
repaired
Gluteus
medius
and TFL left intact
Longitudinal
Weakness of the
division of the TFL
hip abductors
Release of up to
Possible
pelvic
one-half
of
the
obliquity
proximal insertion
Delayed recovery
of
the
gluteus
of symmetrical gait
medius
and
minimus;
reattached prior to
closure
Longitudinal
splitting
of
the
vastus lateralis
Capsulotomy and
repair
Incision
centered
Weakness of the
over the greater
hip abductors
Direct Anterior
Transtrochanteric
trochanter
and
lateral to the TFL
Anterior one-third
of
the
gluteus
medius
and
minimus
and
sometimes
the
vastus
lateralis
released;
reattached prior to
closure
External
rotators
usually
remain
intact
Anterior
capsulotomy
and
repair
Incision
made
anterior and distal
to the ASIS, slightly
anterior
to
the
greater trochanter,
and medial to the
TFL
No muscles incised
or detached, but
rectus femoris and
sartorius retracted
medially to access
the joint
Anterior
capsulotomy
and
repair
Osteotomy of the
greater trochanter
at the insertion of
the gluteus medius
and minimus
Anterior
capsulotomy
and
dislocation
Greater trochanter
reattached
and
wired in place prior
to closure
Delayed recovery
of gait symmetry
Lower incidence of
hip dislocation than
posterior approach
Weight bearing as
tolerated
immediately after
surgery
More
rapid
recovery
of
hip
muscle
strength
and normal gait
pattern compared
with anterolateral
approach
Extended period of
nonweight bearing
on the operated
extremity
Necessity
for
abduction
precautions
Possible pain due
to irritation of soft
tissues
from
internal
fixation
device
Arthroplasty
Arthroplasty
Arthroplasty
EPIDEMIOLOGY
OTHER TERMS
Hemiarthroplasty - Replacement
of only the femoral head
Bipolar hemiarthroplasty - A
specific form of hemiarthroplasty in
which a femoral prosthesis is used
with an articulating acetabular
component; the acetabular cartilage
is not replaced; the principle of this
procedure is to decrease the
frictional wear between the femoral
head prosthesis and the cartilage of
the acetabulum
Unicompartmental knee
replacement (unicompartmental
Race/Ethnicity:
incidence
of
Arthroplasty
ANATOMY/PHYSIOLOGY/KINESIOLOGY
HIP
Structure and Function
The pelvic girdle links the lower
extremity to the trunk and plays a
significant role in the function of
the hip as well as the spinal joints.
The proximal femur and the pelvis
comprise the hip joint. The unique
characteristics of the pelvis and
femur that affect hip function are
reviewed in this section.
Anatomical Characteristics
Boney Structures
The structure of the pelvis and
femur are designed for weight
bearing and transmitting forces
through the hip joint.
Pelvis
Each innominate bone of the pelvis
is formed by the union of the ilium,
ischium, and pubic bones and
therefore, is a structural unit. The
right and left innominate bones
articulate anteriorly with each
other at the pubic symphysis and
posteriorly with the sacrum at the
sacroiliac joints. Slight motion
occurs at these three joints to
attenuate forces as they are
transmitted through the pelvic
region, but the pelvis basically
Arthroplasty
Arthroplasty
Extension
Abduction
Adduction
Internal Rotation
External Rotation
Posterior
Lateral
Medial
Medial
Lateral
Motions of pelvis
When the lower extremity is stabilized
(fixated) distally, as when standing or
during the stance phase of gait, the
concave acetabulum moves on the
convex
femoral
head,
so
the
acetabulum slides in the same
direction as the pelvis. The pelvis is a
link in a closed chain; therefore, when
the pelvis moves, there is motion at
both hip joints as well as at the lumbar
spine.
Influence of the Hip Joint on Balance
and Posture Control
The joint capsule is richly supplied
with mechanoreceptors that respond
to variations in position, stress, and
movement for control of posture,
balance,
and
movement.
Reflex
muscle contractions of the entire
kinematic chain, known as balance
strategies, occur in a predictable
sequence when standing balance is
disturbed
and
regained.
Joint
pathologies, restricted motion, or
muscle weakness can impair balance
and postural control.
Functional Relationships in the Hip
Region
The hip functions in both nonweightbearing and weightbearing activities,
requiring the muscles to move the
femur or control the femur and pelvis
as outside forces are imposed on the
region.
Motions of the Femur and Muscle
Function Motions of the femur and
muscle actions are typically described
as occurring in the three primary
planes: flexion/ extension in the
sagittal plane, abduction/adduction in
the frontal plane, and internal/external
rotation in the transverse plane. Most
Gluteus
maximus
Adductor brevis
(posterior fibers)
Gracilis
Quadratus femoris
Pectineus
Obturator externus
External
(Lateral)
Obturator
internus
Gluteus
medius
Rotation
and externus
(posterior fibers)
Gemellus
superior
Gluteus
minimus
and inferior
(posterior fibers)
Quadratus femoris
Sartorius
Piriformis
Biceps femoris (long
head)
Gluteus maximus
Internal (Medial)
Arthroplasty
Rotation
No prime movers
Arthroplasty
Gluteus
medius
(anterior fibers)
Gluteus
minimus
(anterior fibers)
Tensor fasciae latae
Adductor longus and
brevis
Adductor
magnus
(posterior fibers)
Pectineus
The posterior superior iliac spines of
the pelvis move posteriorly and
inferiorly, thus closer to the posterior
aspect of the femur as the pelvis
rotates backward around the axis of
the hip joints. This results in hip
extension and lumbar spine flexion.
- Muscles causing this motion are the
hip extensors and trunk flexors.
- When hip extension is the desired
motion,
the
lumbar
extensors
contract to stabilize the pelvis.
- During standing when the line of
gravity of the trunk falls posterior to
the axis of the hip joints, the effect is
a posterior pelvic tilt moment.
Dynamic stability is provided by the
hip flexors and back extensors and
passive stability by the iliofemoral
ligament.
Pelvic Shifting
During standing, a forward translatory
shifting of the pelvis results in
extension of the hip and extension of
the lower lumbar spinal segments.
There is a compensatory posterior
shifting of the thorax on the upper
lumbar spine with increased flexion of
these spinal segments. This is often
seen with slouched or relaxed
postures.
Lateral Pelvic Tilt
Frontal plane pelvic motion results in
opposite motions at each hip joint.
Pelvic motion is defined by what is
occurring to the iliac crest of the pelvis
that is opposite the weight-bearing
extremity (that is, the side of the
pelvis that is moving). When the pelvis
elevates, it is called hip hiking; when it
externally,
opposite
-
Pelvic Rotation
Rotation occurs around one lower
extremity that is fixed on the ground.
The unsupported lower extremity
swings forward or backward along with
the pelvis. When the unsupported side
of the pelvis moves forward, it is
called forward rotation of the pelvis.
The trunk concurrently rotates in the
opposite direction, and the femur on
the stabilized side concurrently rotates
internally. When the unsupported side
of the pelvis moves backward, it is
called posterior rotation; the femur on
the stabilized side concurrently rotates
Arthroplasty
and
the
trunk
rotates
Pelvifemoral Motion
A
combined
movement
occurs
between the lumbar spine and pelvis
during maximum forward bending of
the trunk as when reaching toward the
floor or the toes.
This motion is also known as
lumbopelvic rhythm.
Although
there
is
considerable
variability in the participation of each
of the joints, the motion typically is
described as beginning with forward
bending of the head.
As the head and upper trunk initiate
flexion, the pelvis shifts posteriorly to
maintain the center of gravity over the
base of support.
The trunk continues to forward-bend,
controlled by the extensor muscles of
the spine, until at approximately 45.
At this point for an individual with
relatively
normal
flexibility,
the
posterior ligaments become taut, and
the facets of the zygapophyseal joints
approximate. Both of these factors
provide stability for the intervertebral
joints, and the muscles relax.
Once all of the vertebral segments are
at the end of the range and stabilized
by the posterior ligaments and facets,
the pelvis begins to rotate forward
(anterior pelvic tilt), controlled by the
gluteus maximus and hamstring
muscles.
The pelvis continues to rotate forward
until the full length of the muscles is
reached. Final range of motion (ROM)
in forward bending is dictated by the
flexibility of the various back extensor
KNEE
Arthroplasty
lateral
(fibular)
collateral
ligaments, respectively.
The convex bony partner is
composed of two asymmetrical
condyles on the distal end of the
femur. The medial condyle is longer
than the lateral condyle, which
contributes
to
the
locking
mechanism at the knee.
The concave bony partner is
composed of two tibial plateaus on
the proximal tibia with their
respective
fibrocartilaginous
menisci. The medial plateau is
larger than the lateral plateau.
The
menisci
improve
the
congruency of the articulating
surfaces. They are connected to the
tibial condyles and capsule by the
coronary ligaments, to each other
by the transverse ligament, and to
the patella via the patellomeniscal
ligaments. The medial meniscus is
firmly attached to the joint capsule
as well as to the medial collateral
ligament, anterior and posterior
cruciate
ligaments,
and
semimembranosus
muscle.
The
lateral meniscus attaches to the
posterior cruciate ligament and the
tendon of the popliteus muscle
through
capsular
connections.
Because of the relatively secure
attachment of the medial meniscus
compared to the lateral meniscus, it
has a greater chance of sustaining a
tear when there is a lateral blow to
the knee.
posteriorly
than
the
lateral
condyle). Concurrently, the hip
moves into extension. Tautness in
the iliofemoral ligament, which
occurs
with
hip
extension,
reinforces the medial rotation of
the femur. As the knee is unlocked,
the
femur
rotates
laterally.
Unlocking of the knee occurs
indirectly with hip flexion and
directly from action of the popliteus
muscle. An individual who lacks full
hip
extenson
(hip
flexion
contracture) cannot stand upright
and lock the knee, thus lacking this
passive stabilizing function.
Patellofemoral Joint
Characteristics
Arthroplasty
Arthroplasty
Compression forces
In full extension, because there is
minimal to no contact of the patella
with the trochlear groove, there is no
compression of the articular surfaces.
Furthermore, because the femur and
tibia are almost parallel, the line of
pull of the quadriceps muscle and
patellar tendon causes a very small
resultant
compressive
load.
The
resultant force of the quadriceps and
patellar tendon forces rises as the
knee flexes, but there is also greater
surface area of the patella in contact
with the groove to dissipate this force.
The joint reaction force on the articular
surface rises rapidly between 30 O and
60O. There is controversy as to the
extent of joint reaction forces in
greater degrees of flexion.
During squatting, the joint reaction
force continues to rise until 90and
then levels off or decreases
because the quadriceps tendon
begins making contact with the
trochlear groove and therefore
dissipates some of the force.
In an open-chain exercise with a
free weight on the distal leg, the
greatest joint reaction force occurs
at around 30O of flexion. This is
MUSCLE FUNCTION
The quadriceps femoris muscle group
is the only muscle crossing anterior to
the axis of the knee and is the prime
mover for knee extension. Other
muscles that can act to extend the
knee require the foot to be fixated,
creating a closed chain. In this
situation, the hamstrings and the
soleus muscles can cause or control
knee extension by pulling the tibia
posteriorly.
Closed-chain function.
During standing and the stance phase
of gait, the knee is an intermediate
joint in a closed chain. The quadriceps
muscle controls the amount of flexion
at the knee and also causes knee
extension through reverse muscle pull
on the femur. In the erect posture,
when the knee is locked, the
quadriceps need not function when
the gravity line falls anterior to the
axis of motion. In this case, tension in
the hamstring and gastrocnemius
tendons
supports
the
posterior
capsule.
Patella
The patella improves the moment arm
of the extensor force by increasing the
distance of the quadriceps tendon
from the knee joint axis. Its greatest
effect on the leverage of the
quadriceps is during extension of the
knee
from 60to 30and rapidly
diminishes from 15O to 0O of extension.
Torque. The peak torque of the
quadriceps muscle occurs between 70and
Arthroplasty
ETIOLOGY
Hematogenous
Experience of
the surgeon
Postoperative
Osteotomy
Renal disease
Cortisone induced
Alcoholism
Slipped capital femoral epiphysis
Arthritis
Tuberculosis
Rheumatoid
Juvenile rheumatoid
(Still's disease)
Absolute
Pyogenic
Ankylosing spondylitis
Avascular necrosis
dislocation Idiopathic
Postfracture
or
Bone tumor
Cassion disease
Degenerative joint disease
Osteoarthritis
Developmental dysplasia of the hip
Failed hip reconstruction
Cup arthroplasty
Femoral head prosthesis
Girdlestone procedure
Relative
Resurfacing arthroplasty
Total hip replacement
Fracture
or
dislocation
Acetabulum
Proximal femur Fusion or pseudarthrosis
of
hip
Gaucher's
disease
Hemoglobinopathies (sickle cell disease)
Hemophilia Hereditary disorders
Legg-Calve-Perthes disease (LCPD)
Osteomyelitis (remote, not active)
Arthroplasty
Complications of THR
Deep
vein
thrombosis
(DVT)/pulmonary embolism (PE)
without prophylactic bloodthinning, deep
vein thrombosis (DVT) is common after
THR.
Chemical
and
mechanical
thromboprophylaxis should be used
routinely.
Infection this is a major problem and
all measures are taken to avoid it,
including a clean air supply in theatre,
antibioticloaded
cement
and
perioperative antibiotics. If the prosthesis
becomes infected, a twostage revision
may be indicated in which the hip is
removed and the patient given antibiotics
for 6 weeks before a new prosthesis is
implanted.
Dislocation may occur if the soft
tissues are not balanced or the prosthesis
is
malpositioned
intraoperatively.
Precautions
including
avoidance
of
crossing legs, bending over and sitting in
low chairs, which are implemented by the
physiotherapists postoperatively.
Leg length discrepancy if the
acetabulum has been severely eroded or
the hip is an abnormal shape, leg length
differences are more common. Careful
preoperative planning helps avoid this. Up
to 15 mm difference is usually well
tolerated by the patient.
Primary Total hip arthroplasty
Indications
Total hip arthroplasty is indicated in
painful conditions of the hip that have
failed conservative management. These
are too numerous to list in this book but
Arthroplasty
Arthroplasty
Patellofemoral dysfunction
Mechanical stiffness
Contraindications
Problems,
include:
and
associated
symptoms,
Arthroplasty
Instability:
can
manifest
at
tibiofemoral or patellofemoral joint; after
total replacement most knees have slight
anterior laxity due to sacrifice of the
anterior
cruciate
ligament,
but
mediolateral and posterior stability should
be good in flexion and extension; history
and physical exam can discern this
instability; lateral radiographs may show
anterior subluxation of the femur on the
tibia;
patellofemoral
instability
is
manifested by pain, subluxation, and
even dislocation; Merchant or sunrise
radiographs aid diagnosis
Loosening: aseptic loosening is
gradual by history, with pain on weight
bearing and start-up, but not at rest
Periprosthetic fracture: may be
present in patients with pain of sudden
onset after trauma
PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY
Aging
Rheumatoid
arthritis of the
knee
Fall
osteoarthritis
of the knee
Gross limitation of
Arthroplasty
Trauma
Traumatic
arthritis of the
knee
Complete
fracture of
the
acetabulu
m
Knocked
Malunion
Non-union
DIAGNOSTIC TOOLS/TEST
TOTAL HIP ARTHROPLASTY
An evaluation with an orthopaedic
surgeon consists of several components.
Arthroplasty
Arthroplasty
Arthroplasty
DIFFERENTIAL DIAGNOSIS
PHARMACOLOGICAL MANAGEMENT
Opioid Analgesics
Types of Opioids
Natural opioids are among the
world's oldest known drugs and are
made from the dried "milk" of the
opium poppy plant. There are also
other types of opioids that are
made artificially in a laboratory.
These types are called synthetic or
semi-synthetic opioids.
How Opioids Work
Whether natural or synthetic, all
opioids work by binding to opioid
receptors in the brain, spinal cord,
and gastrointestinal tract. When
these drugs attach to certain opioid
receptors,
they
block
the
transmission of pain messages to
the brain.
Opioids can do this because they
look just like your body's natural
painkillers, called endorphins. This
similarity
in
structure
"fools"
receptors and allows the drug to
activate the nerve cells, flooding
the area with dopamine, which
produces the "opioid effect."
Advantages and Disadvantages of
Opioids
Opioids work rapidly to block pain
and also change the way your brain
perceives pain. The pain relief they
provide allows you to be more
active during the day and get more
rest at night.
Opioids are effective when given
through a variety or routes, such as
by mouth, through the skin, under
the tongue, and directly into the
bloodstream. They do not cause
bleeding in the stomach or other
parts of the body.
Arthroplasty
Drowsiness
Confusion
Nausea
Constipation
Itching
Patient-Controlled
Opioid Dependency
Opioids can provide excellent pain
relief and help to speed your
recovery from surgery or injury.
They are, however, a narcotic and
can be addictive. While addiction is
unusual, it is important to use
opioids only as directed by your
doctor. You should stop taking
these medications as soon as your
pain starts to improve.
Non-steroidal
Drugs
Anti-inflammatory
Non-steroidal
anti-inflammatory
drugs (NSAIDs) reduce swelling and
soreness and are often used alone
for mild to moderate pain. To
and
Disadvantages
of
Arthroplasty
Local Anesthetics
Arthroplasty
Many
anesthesiologists
now
use
ultrasound technology to help guide
placement of the needle or catheter
before medication is injected around the
nerves. An image on a monitor shows the
nerves, muscles, arteries, and veins in
the affected area. This allows the
anesthesiologist to make sure the
medication is injected into the right place.
Extremities
Regional anesthetics can also be used to
numb up a smaller area such as your arm
or leg.
Arthroplasty
http://orthoinfo.aaos.org/topic.cfm?
topic=A00650
Arthroplasty
Disadvantages
- Being rare
becomes
uncomfortable.
Technically is
more demanding
and needs an
experienced
surgeon
- Preserves the
- Difficulty in
patellar blood
everting the
supply
patella medially
- Prevents lateral - May require
patellar
tibial tubercle
subluxation
osteotomy
http://www.intechopen.com/books/arthrop
lasty-a-comprehensive-review/surgicalapproaches-for-total-knee-arthroplasty
Major
Advantages
Disadvantages/
Structures
Risks
At Risk
Anterior (Smithsuperficial
Lateral
Allows hip
Limits posterior
Petersen)
Sartorius (femoral femoral
dislocation without acetabular
nerve) and
cutaneous
risk to the femoral
visualization
tensor fasciae
nerve
head blood supply Extensive release
latae (superior Ascending
Useful for anterior
of the abductors
gluteal nerve)
branch of
column exposure
can result in
Deep
the lateral
(eg, pelvic
weakness and a
Rectus femoris
femoral
osteotomy or
high incidence of
(femoral nerve)
circumflex
fracture)
heterotopic
and gluteus
artery
Extensive access to
ossification
medius (superior
inner and outer
gluteal nerve)
tables of the ilium,
anterior femoral
head and neck,
and acetabulum
Two-incision
Same as anterior Lateral
Further study and
Technically difficult
anterior
approach
femoral
long-term followDoes not allow
(Berger)
cutaneous
up needed to
wide exposure of
Anterior incision
nerve
determine if it
the hip joint
for acetabular
expedites patient
insertion
recovery
Lateral incision
for femoral
component
Anterolateral
Tensor fasciae
Branch of
Low incidence of
Damage to the
(Watson-Jones) latae (femoral
the
postoperative
femoral shaft and
nerve) and
superior
dislocation
malpositioning of
gluteus medius
gluteal
Good exposure of
the femoral
(femoral nerve)
nerve that
hip joint and
component during
supplies
proximal femur
femoral canal
the tensor
without
preparation
fasciae
trochanteric
Damage to the
latae
osteotomy
abductors
Femoral
nerve
Lateral
None
Same as
Access to the
Postoperative limp
(Hardinge)
Modified Hardinge anterolater anterior and
(18% incidence in
approach divides al approach posterior hip joint
primary THA)
the gluteus
without osteotomy Heterotopic
medius at the
of the trochanter
ossification
junction of the
Low rate of
(incidence as high
anterior third and
postoperative
as 47% in primary
posterior two
dislocation
THA)
thirds
Improved access to
the proximal femur
for reaming
compared to
Arthroplasty
anterolateral and
anterior
approaches
Same as
Excellent exposure;
anterolater allows complete
al approach visualization of the
anterior and
posterior aspects
of the hip and a
full view of the
acetabulum
Ability to preserve
blood supply to the
femoral head
Improved
biomechanics of
the abductor
mechanism
through the
advancement of
the greater
trochanter through
distal
reattachment
Allows exposure of
the hip without
applying torque to
the femur,
decreasing fracture
risk (osteoporosis,
cortical defects)
Transtrochanteri No internervous
c lateral
plane, access to
(Charnley)
joint through
osteotomy of the
greater
trochanter
Level of the
osteotomy may
be varied based
on necessary
exposure
Small
wafer/trochanteri
c slide
Standard-size
osteotomy at the
vastus ridge
Extended
trochanteric
osteotomy 3 to
10 cm distal to
the trochanteric
ridge
Various techniques
for repair of the
trochanter have
been described,
including wire
knots and the
commonly used
Dall-Miles* cable
grip system
May be combined
with
anterolateral,
posterolateral, or
direct lateral
approaches
Posterolateral
None
Sciatic nerve Minimal anatomic
disruption
(abductors
preserved)
Excellent exposure
of socket and
femur
Quick recovery/no
limp
Higher patient
satisfaction
Less heterotopic
Arthroplasty
Increased
intraoperative
time and blood
loss because of
the time needed
to repair the
trochanteric
osteotomy site
Slower
rehabilitation
resulting from
weight-bearing
protection
postoperatively;
usually a period
of 6 weeks to
allow for
trochanteric
healing
Trochanteric
nonunion (rates
reported: 5% to
32%)
Broken wires,
trochanteric
bursitis, and
ectopic bone
formation
Slightly higher
dislocation rate
Mini-posterior
ossification
Extensile exposure
easy to obtain
Lower rate of
reported overall
complications
Same as standard Same as
Further study and
posterolateral
standard
long-term followapproach
posterolate up needed to
ral
determine if it
approach
expedites patient
recovery
Arthroplasty
Same as standard
posterolateral
approach
Increased
potential for
component
malpositioning
Tibiofemoral
joint
mobilization
techniques to increase knee flexion or
extension may or may not be appropriate,
depending on the design of the prosthetic
components. It is advisable to discuss the
use of these techniques with the surgeon
before initiating them.
Postpone unsupported or unassisted
weight-bearing activities until strength in
the quadriceps and hamstrings is
sufficient to stabilize the knee.
Weight bearing as
cemented
prosthesis,
uncemented or hybrid
tolerated
delayed
with
with
and
pulmonary
Patient presentation
Arthroplasty
Muscle-setting
exercises
of
the
quadriceps (preferably coupled with
neuromuscular electrical stimulation),
hamstrings,
adductors.
and
hip
extensors
and
Active
assisted
ROM
(A-AROM)
progressing to assisted ROM (AROM) of
the knee while seated and standing for
gravity-resisted knee extension and
flexion, respectively.
As weight bearing on the operated
lower extremity permits, wall slides in a
standing position, mini-squats, and partial
lunges to develop control of the knee
extensors and reduce the risk of an
extensor lag.
Regain knee ROM.
Heel-slides in a supine position or while
seated with the foot on the floor to
increase knee flexion.
Neuromuscular facilitation and
inhibition technique, such as the agonistcontraction technique , to decrease
muscle guarding, particularly in the
quadriceps, and increase knee flexion.
Gravity-assisted knee flexion by having
the patient sit and dangle the lower leg
over the side of a bed.
Gravity-assisted knee extension in the
supine position by periodically placing a
rolled towel under the ankle and leaving
the knee unsupported or in a seated
position with the heel on the floor and
pressing downward just above the knee
with both hands.
Gentle inferior and superior patellar
gliding techniques to prevent restricted
mobility.
P R E C A U T I O N : Avoid placing a
pillow under the knee while lying supine
Arthroplasty
Minimum pain
Full weight bearing
uncemented or hybrid
ROM 090
Joint effusion controlled
except
with
Reduce swelling
ROM 0110 or more
Full weight bearing
4/5 to 5/5 strength
Unrestricted ADL function
Adherence to home exercise program
Interventions
Patellar mobilization
LE stretching program
Closed-chain strengthening
Limited range PRE
Tibiofemoral joint mobilization, if
appropriate and needed
Proprioceptive training
Stabilization exercises
Gait training
Protected
aerobic
exercise
swimming, cycling or walking
activities
while
Patient presentation
Arthroplasty
Muscle
function:
70%
of
noninvolved extremity
No symptoms of pain or swelling
during previous phase
Pain assessment
Muscular strength
Patellar alignment/stability
Functional status
Goals
Interventions
Football, soccer
Gymnastics, tumbling
Water-skiing
Highly Recommended*
Stationary cycling
Arthroplasty
Early
Postoperative
Motion
Precautions
After
Total
Hip
Arthroplasty*
Posterior/Posterolateral Approaches
ROM
Avoid hip flexion 80to 90and adduction
and internal rotation beyond neutral.
ADL
Transfer to the sound side from bed to
chair or chair to bed.
Do not cross the legs.
Keep the knees slightly lower than the
hips when sitting.
Avoid sitting in low, soft chairs.
Arthroplasty
Arthroplasty
and
muscular
Nonimpact
aerobic
conditioning
program, such as progressive stationary
cycling, swimming, or water aerobics.
Reduce contractures while adhering
to motion precautions.
Gravity-assisted supine stretch to
neutral in the Thomas test position. Pull
the uninvolved knee to the chest while
relaxing the operated hip. (At least 10 of
hip extension beyond neutral is needed
for a normal gait pattern.)
Resting in a prone position for a
prolonged passive stretch of the hip flexor
muscles when rolling to prone-lying is
permissible and is also tolerable.
Integrate gained ROM into functional
activities.
P R E C A U T I O N : Check with the
surgeon before initiating a stretch of the
hip
flexors
to
neutral
or
into
hyperextension if the patient has
undergone an anterolateral approach.
Improve postural stability, balance,
and gait.
Emphasize use of a cane (in the hand
contralateral to the operated hip) and
Arthroplasty
progressive weight
operated limb.
bearing
on
the
Accelerated Rehabilitation
Preoperative activities.
Prior to surgery, educate the patient
about the surgical procedure and
postoperative
rehabilitation
program,
wound care, and the home exercise
program. Initiate gait training (weight
bearing as tolerated) using crutches and
a cane.
Immediate postoperative therapy.
Approximately 5 to 6 hours after surgery,
if the patient is medically stable, begin
the following activities.
Arthroplasty
Arthroplasty
REFFERENCES
http://orthoinfo.aaos.org/topic.cfm?
topic=A00389
http://orthoinfo.aaos.org/topic.cfm?
topic=a00377
Current Essentials: Orthopedics by
Harry B. Skinner, MD, PhD
Brunner and Suddarth's Textbook of
Med.-Surg. Nursing 12th edition
Arthroplasty