ARTHROPLASTY (HIP AND KNEE)

1. ARTHROPLASTY (HIP AND KNEE)

2. Definition : An operation to regain or maintain motion in a chronically painful joint (degenerative joint disease) by means of replacing one or both joint surfaces. Replacement arthroplasty: Replacement of one (hemiarthroplasty) or both joint surfaces (total joint arthroplasty) or prosthetic joint replacement.

3. N.B :Arthrodesis: (not a type of arthroplasty) when a single joint is severely damaged and painful, or completely unstable and disabling, and when loss of its motion would not interfere significantly with the patient's function, it can be fused by producing bony union across it's surfaces in the optimum position of function. Indications of replacement: • Severe intolerable pain • Loss of function • Severe deformities Contraindications: •  Absolute > > > > children • Relative > > > > young adults Problems: •  Loosening • Wear and tear

4. Rehabilitation of Patients AfterTotal Joint Replacement A-Before Surgery: • The patient should be instructed in use and protection of the affected hip in respect to the specific surgical procedure. • The patient should be instructed in all postoperative exercises to be performed. These may include coughing and breathing exercises, ankle range of motion exercises, bed mobility exercises and lower limb strengthening and range of motion activities. Proper positioning of the joint should be stressed.

5. B-After the Surgery: • The exercises and activities learned preoperatively should be performed in a progressive manner in accordance with the patient's tolerance, the surgical procedure performed, and the surgeon's judgment. • Physical therapy should be given twice a day. A general plan of postoperative treatment progression for a patient who has received a total hip replacement follows:

6. Day 1: • Use a pillow or wedge to prevent adduction at all times. • Perform breathing exercises. • Perform active foot and ankle range-of-motion exercises. • Perform strengthening exercises for upper limbs and non operated limb. • Perform isometric exercises of major muscle groups on operated side. • Review proper methods of moving in bed. • Transfer to built-up chair cautiously. • Avoid any position of instability. • Move toward nonoperated side during bed activities and transfers. • Avoid painful movements • Avoid internal rotation.

7. Day 2: • Initiate partial weight bearing as tolerated • Begin active range of motion: • Avoid adduction. • Limited flexion to 30 degrees. • Avoid extension if anterior surgical approach was used. • Avoid resisted abduction for 3 weeks if trochanteric osteotomy was done Day 3: • Continue all previous exercises. • Begin resisted range of motion noting previous precautions. • Begin home instructions related to transfers, automobile transfers, and so forth.

8. Day 4: • Continue previous activities. • Progress hip flexion to 60 degrees on day 6 and to 90 degrees on day 10. Do not exceed 90 degrees of flexion. Upon return to home, the patient should be instructed to avoid specific activities and positions "These include: • Do not sit in low chairs. • Do not sleep on your side. • Do not cross your legs. • Do not flex your hips more than 90 degrees. • Do not force your hips to bend. • Do not drive. • Do not climb into the bath tub. • Do not squat. • Do not do exercises not given by the physical therapist

9. Rehabilitation of Patients After Total Knee Replacement Total knee replacement (TKR) or Total knee Arthroplasty (TKA). The rehabilitation of patients who have undergone TKA surgery takes place in three phases: Early motion, moderate protection, and return to activity. The goal of these phases is : • To promote a maximal degree of knee joint mobility while allowing sufficient bone in growth within the intra articular prosthesis to ensure sufficient knee joint stability.

10. I) Early Motion Phase: This phase begins immediately after surgery and emphasizes: • muscle reeducation • Initiation of knee joint motion, and • Reduction of postsurgical joint swelling. Through: • Quadriceps and Hamstrings co contraction exercises. • Electric muscle stimulation could be used. • Multiple angle isometrics (MAI) within the available pain-free range of motion. • Straight leg raising. • Continuous passive movement (CPM) to reduce swelling and increase range of motion.

11. 6) Ambulation: for cemented knee prosthesis, weight bearing is allowed to the level of patient's tolerance. 7) For cementless knee prosthesis, ambulation gradually progresses from non weight bearing to toe touch and then one quarter of body-weight bearing across the duration of rehabilitation phase. 8) For both prostheses, assistive device, such as crutches, canes, or walkers, are used during ambulation. 9) The early motion phase ends at the sixth week after TKA surgery.

12. II) Moderate Protection Phase: This phase, which encompasses postsurgical weeks 7to 12, continues the processes of muscle conditioning and joint mobilization and also emphasizes progressive ambulatory activities based on the stages of tissue healing. • Patients with cemented prosthesismay be: gradually weaned from dependence on assistive devices for ambulatory activities. • Advanced to bicycle ergometry • Aquatic therapeutic procedures.

13. Patients with a cementless knee prosthesis: (The rehabilitation program must parallel the time frame of fracture healing) • Progress to 50% weight bearing by the end of week 8. • Progress to 75% weight bearing by the end of week 10. • Progress to 100% weight bearing without the use of assistive device by the end of the phase in week 12.

14. III) Return to activity phase: This phase which begins in the 13th week after TKA and lasts until patient's knee function has been normalized or optimized, emphasizes maximizing full activity for the rehabilitating patient. • Muscle conditioning may advance through short-arc, isotonic, isokinetic activities to ensure sufficient dynamic stability of the knee complex. • Bicycling. • Swimming, aquatic therapy. • Fitness walking to increase the degree of knee joint motion and cardiovascular fitness. • Proprioception activities in a closed kinetic chain. • Work conditioning procedures to prepare the patients for successful return to activities of daily life.

15. ROM exercises