PHTY206 Lecture Notes - Lecture 25: Autologous Chondrocyte Implantation, Optical Fiber, Surface 3
Orthopaedic inpatient elective lower limb surgery
• OA/RA of the hip
o Primary total hip replacement (THR)
• Goal
▪ To attain a durable, painless, functional hip for those affected with
severely limiting OA, RA or AVN (avascular necrosis)
• Developed by Charnley in England in the 1950's
• Original prosthesis metal on metal - poor results due to friction and metal
fragments
• More commonly used prosthesis
▪ Femoral head = metal alloy
▪ Acetabular cup = high density polyethylene insert in a metal cup
• Operative approach
▪ Posterior
• Most commmonly used approach
• Advantage: easier for surgeon
• Disadvantage: discloation a possibility during sitting and excessive
hip flexion
• Dislocating position
• Flex >90, adduction past neutral, internal rotation past
neutral
• Combined flexion, adduction, internal rotation
▪ Antero-lateral
• Also known as Modified Hardinge Approach
• Becoming more common
• Advantage: decreased change of posterior dislocation as
posterior capsule not affected
• Disadvantage: more difficult for surgeon
• Dislocating position
• Forced extension
• Flex or ext with add and ER
• May be indicated for alcoholics or other patients who may be
unable to adhere to routine hip precautions post-op
• Complications
▪ Peri-operative complications
• Sciatic nerve (poster approach) damage can lead to short term
neuropraxia and subsequent 'foot drop'
• Poor positioning of acetabular component could increase chance
of dislocation
• Fractured acetabulum; fractured femoral sharft; excessive blood
loss
▪ Post-op
• DVT
• Dislocation
• Infection
• Loosening of components
• Post-op management
▪ Goals
• Independent mobility with appropriate aid
• Independent with home exercise programme
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• Independent mobility on stairs
▪ Post-op presentation
• Epidural, PCA, nerve block
• Drips, IDC
• Wound drains
• Abduction wedge, heel wedge
• LL compression device
▪ Day 1 exercises
• Commence circulo-respiratory exercises day 0
• Commence hip ROM and quads exercises day 1
• Active/assisted hip flexion and abduction on powder board
• Not - hip flexion limited to 90
• Inner range quads (IRQ)
• Bridging and bed mobility
• Note - SLR may be used as an assessment to test for LL strength
but is not a recommended strengthening exercise post THR due
to the high acetabular pressures created
▪ Day 1 mobility
• Day 1 - aim to mobilise
• Out of bed on unaffected side - care no to flex >90
• Rollator initially progressing to 4ww, 2 x SPS as able
▪ Sitting
• Allowed day 1-2, 30 min initially, dependent on pts symptoms
▪ Day 2 - discharge
• Exercises
• Progress ROM and strength functionally e.g. standing
hip/knee flex, abd, ext, mini squats etc.
• Mobility
• Progress mobility from rollator to 4 ww to sticks or crutches
• Stairs
• Advice/education on discharge
▪ Hip precautions - to be adhered to lifelong (strictly for first 3 months)
• Avoid combination of dislocating positions
• Do not site in low chairs
• Do not cross legs
• Do not lie on affected side
• Do not squat down to ground
• Do not bend from hips to pick things up
• No twisting on affected leg in standing
• No driving first 6/52 until cleared by drs
▪ Consideration for discharge planning
• Aim for discharge day 3-5
• OT review for ADLs before discharge. Home environment e.g.
bathroom rails, raised toilet seat etc
• Home exercise program handout
• Consider F/U physiotherapy - home physio or outpatients appt
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find more resources at oneclass.com
o Revision total hip replacement
▪ Failed or loose prosthesis is removed and replaced by new prosthesis
▪ Staged (Septic) vs 1 op (aseptic)
o Salvage procedures
▪ Excision arthroplasty - Girdlestone's
▪ Arthrodesis - fusion in a position of
• 15-20 flex, and
• Neutral abduction and rotation
o Birmingham hip resurfacing
▪ Resurfacing the bone with metal surfaces
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Flex or ext with add and er: may be indicated for alcoholics or other patients who may be unable to adhere to routine hip precautions post-op, complications, peri-operative complications. Sciatic nerve (poster approach) damage can lead to short term neuropraxia and subsequent "foot drop: poor positioning of acetabular component could increase chance of dislocation. Fractured acetabulum; fractured femoral sharft; excessive blood loss: post-op, dvt, dislocation. Independent mobility on stairs: post-op presentation, epidural, pca, nerve block, drips, idc, wound drains, abduction wedge, heel wedge. Ll compression device: day 1 exercises, commence circulo-respiratory exercises day 0, commence hip rom and quads exercises day 1, active/assisted hip flexion and abduction on powder board, not - hip flexion limited to 90. Home environment e. g. bathroom rails, raised toilet seat etc: home exercise program handout, consider f/u physiotherapy - home physio or outpatients appt, revision total hip replacement. Failed or loose prosthesis is removed and replaced by new prosthesis.
