TOTAL HIP ARTHROPLASTY

BY
R.JEFFERY SAMUEL
BPT 3RD YEAR
ST JOHNS MEDICAL
COLLEGE
CONTENTS
• INTRODUCTION
• HISTORY
• TOTAL HIP ARTHROPLASTY
* TYPE AND CHOICE OF PROSTHESIS
* INDICATION
* CONTRA INDICATION
* COMPLICATIONS
* SURGICAL STEPS IN THR
* POST OP PT MANAGEMENT FOLLOWING THR
• CONCLUSION
INTRODUCTION :

ARTHROPLASTY essentially means replacement

of joints surgically ,this could be partial or total . When only
one part of joint is removed , it is called partial and is
known as hemi replacement arthroplasty . When complete
joint is replace it is called total joint replacement
HISTORY :

Till early 1930's, man tried various methods that

were essentially nonoperative to alleviate pain. Then came
the idea of replacing the worn out joints instead of restoring
the ailing joints. Thus, arthroplasty was born. From membrane
replacement, glass, metal, alloys, plastics, etc. were used to
substitute the joints. After various experimentation, research
we now have a very high quality of implants, technology,
infrastructure and expertise to give a near perfect joint.
TOTAL HIP
ARTHROPLASTY :
Total hip
arthroplasty involves
replacement of the
acetabular fossa and the
femoral head and neck .
TYPES AND CHOICE OF PROSTHESIS :
Types of Prosthesis
• Metallic prosthesis on one or both sides of the joints.
• High density polyethylene.
• Ceramic.
Choice of Prosthesis
• Both metals.
• Both ceramics.
• One metallic (Femoral) and one poly (Acetabular).
 Fixation could be cemented or uncemeted. The former is
used in older people and the latter in younger individuals.
 Hip arthroplasty can be performed using cement or
biologic fixation.
 In cement fixation there is mechanical interlock of
methylmethacrylate to the interstices of bone. Biological
fixation can be either a porous-coated metallic surface that
provides bone in-growths fixation or by a grit-blasted
metallic surface that provides bone ongrowth fixation.
 The choice of method of fixation remains controversial. In
hip arthroplasty the tendency is towards the use of
uncemented prosthesis in younger active patients because
cemented prosthesis have reported a higher loosening rate in
long-term followup.
 Aseptic loosening is the most common indication for
revision surgery. In cemented hip the most common reason
for revision is failure of the cemented acetabular component,
while in the uncemented ones the most common cause for
failure of the femoral component.
 Articular bearing in hip arthroplasty is mainly on "hard on
soft couple" which include metallic heads coupled with
polyethylene cup. The other hard on soft couple is ceramic
head with polyethylene cup. Titanium alloy heads should be
avoided because it is liable to scratching which will cause
rapid wear of the polyethylene surface.
INDICATIONS :

• Osteoarthritis.
• Rheumatoid arthritis.
• Secondary osteoarthritis.
• Avascular necrosis of the head of femur.
• Failed hemi replacement arthroplasty.
• Ankylosed hip.
• Tuberculosis hip.
CONTRA INDICATIONS :

• Infection is an absolute contraindication.

• Neuropathic joints.
• Poor medical risk.
• Poor anesthetic risk.
COMPLICATIONS :
• DVT.
• Fat embolism.
• Infection.
• Breakages of implants.
• Loosening of implants.
• Osteolysis.
• Periprosthetic fractures.
• Dislocation.
• Heterotrophic ossification.
• Vascular and nerve injuries.
Conservative management :
- Anti-inflammatories and analgesics are of some value (use is limited).
- EXERCISES :
We use exercises that strengthen and stretch the muscles and capsule of the
arthritic hip, incorporating motion and strength needed by the patient for daily
functioning. These exercises are for the arthritic hip. not after hip replacement.
1. Leg Rotations – Number of repetitions: repeat for each leg, 10 times a set.
Number of sets: 2 a day.
2. Leg Raises - Number of repetitions: 10-15.
Number of sets: 2 a day.
3. Knee Cross-Overs -Number of repetitions: 10-15.
Number of sets: 2 a day.
4. Strengthening Exercises - Number of repetitions: 5-10.
Number of sets: 2-3 a day.
5. Straight Leg Lifts - Number of repetitions: 10-15.
Number of sets: 2 a day.
6. Knee-to-Chest Lifts - Number of repetitions: 10.
Number of sets: 2- 3 a day.
7. Side Kicks - Number of repetitions: 10-15.
Number of sets: 2 a day.
8. Minimal Sit-Downs (Flexing the Knees Only 30 Degrees) - Number of
repetitions: 10-15.
Number of sets: 2 a day
PHYSIOTHERAPY MANAGEMENT FOLLOWING TOTAL
HIP ARTHROPLASTY :
Goals :
• Guard against dislocation of the implant.
• Gain functional strength.
• Strengthen hip and knee musculature.
• Prevent bedrest hazards (e.g., thrombophlebitis, pulmonary
embolism, decubiti, pneumonia).
• Teach independent transfers and ambulation with assistive devices.
• Obtain pain-free ROM within precaution limits.
Rehabilitation Considerations in Cemented and Cementless
Techniques
• Cemented total hip
Weight-bearing to tolerance (WBTT) with walker immediately
after surgery.
• Noncemented total hip
Touchdown weight bearing (TDWB) for 6 to 8 weeks with
walker: Some authors prefer partial weight bearing (PWB) of 60 to
80 Ibs.
Preoperative management :
• Instruct on precautions for hip dislocation
• Transfer instructions:
In and out of bed
Chair:
Depth-of-chair restrictions: avoid deep chairs. We also instruct patients to
look at the ceiling as they sit down to minimize trunk flexion.
Sitting: avoid crossing legs.
Rising from chair: scoot to edge of the chair, then rise. Use of elevated
commode seat: elevated seat is placed on commode at a slant, with higher part
at the back, to aid rising .
• Ambulation: instruct on use of anticipated assistive device
(walker).
• Exercises: demonstrate day-1 exercises.
Postoperative management :
• Out of bed in stroke chair twice a day with assistance 1 or 2 days postoperative.
Do NOT use a low chair.
• Begin ambulation with assistive device twice a day (walker) 1 or 2 days
postoperatively with assistance from therapist.
Cemented prosthesis: WBAT with walker for at least 6 weeks then use a cane in
the contralateral hand for 4 to 6 months. '
Cementless technique: TOWB with walker for 6 to 8 weeks
(some authors recommend 12 week ), then use a cane in
the contralateral hand for 4 to 6 months. A wheelchair may
be used for long distance with careful avoidance of excessive
hip flexion of more than 80 degrees while in the wheelchair.
Therapist must check to ensure that the foot rests are
long enough. Place a triangular cushion in the chair with
the highest point posterior, to avoid excessive hip flexion.
Day 1 :
- chest physiotherapy
- vigorous toe and ankle movements
- isometrics to quadriceps
Day 2 :
- sitting up by gradually raising the back rest
- bed transfers
- standing , walking with partial weight bearing (PWB) or toe down weight
bearing with a walker
Day 3 - 7 :
- isometrics to gluteus maximus ,medius and minimus
- assisted hip flexion (heel drag) and hip abduction
- initiate prone lying
- Thomas stretch
- relaxed passive movements
Week 2 :
- active hip flexion , knee extension (besdside sitting or chair sitting with back
rest )
Week 3 :
- PWB walking on crutches with free swinging of the operated leg .
Week 4 :
- pedo cycle or static cycle (possible free ROM)
- stair climbing going up with good leg first .coming down with operated leg
first .
- initiate leg rotation in supine and progress to against gravity and against
resistance .
Week 5-6 :
- gradually increase hip abduction and rotation in supine and bedside sitting .
Week 6-8 :
- achieving near normal strength , ROM , balance standing on the operated
leg alone
Transfers
Bed to chair:
Avoid leaning forward to get out of chair or off bed. Slide hips forward first then
come to standing. Do not cross legs when pivoting from supine to bedside
position.Nurse or therapist assists until safe, secure transfers.
Bathroom:
Use elevated toilet seat with assistance.
Continue assistance until able to perform safe, secure
transfers.
Transfer to Home
o Instruct patient to travel in the back seat of a 4-door sedan, sitting or reclining
lengthwise across the seat, leaning on 1 to 2 pillows under head and shoulders.
o Avoid sitting in conventional fashion (hip flexed more than 90 degrees) to avoid
posterior dislocation in the event of a sudden stop.
o Urge those without a 4-door sedan to sit on 2 pillows with the seat reclined
(minimize flexion of hip).
o Adhere to these principles for 6 weeks until soft tissue stabilization is achieved.
o May begin driving 6 weeks postoperatively.
o Review hip precautions and instructions with patient .
General Principles
1. Going up and down stairs: Up-step up with uninvolved leg, keeping crutches on
the top below until both feet are on the step above, then bring both crutches up on
the step. Down-place crutches on the step below, step down with the involved leg,
and then with the uninvolved leg.
2. Continue to use your crutches/walker until you return to see your doctor.
3. Avoid sitting for longer than 1 hour before standing and stretching.
4. You can return to driving 6 weeks after surgery only if you have good control
over the involved leg and can move your extremity from accelerator to brake with
little effort.
5. Place nightstand on the same side of the bed as the uninvolved leg. Avoid
twisting the trunk toward the involved side, which would be the same as turning
the leg inward.
6. Try to lie flat in bed at least 15 to 30 minutes per day to prevent tightness in
front part of hip.
7. lf you find you have increased swelling in the involved leg after going home, try
dropping foot up (remembering to lean back)-if swelling persists, contact your
doctor. Also contact your doctor if you develop calf tenderness. Remember that
as long as there is touch weight bearing only, the muscles are not acting to pump
blood up the leg, so the leg is likely to swell somewhat until full weight bearing is
established. This swelling usually disappear during the night.
DISCHARGE INSTRUCTIONS
o Continue previous exercises and ambulation activities.
o Continue to observe hip precautions.
o Install elevated toilet seat in home.
o Supply walker for home.
o Review rehabilitation specific to home situation (steps, stairwells, narrow
doorways, etc.).
o Ensure home physical therapy and/or home nursing care has been
arranged.
o Orient family to patient's needs, abilities, and limitations, and review hip
precautions with family members.
o Reliterate avoidance of driving for 6 weeks (most cars have very low
seats).
Precautions (Posterior Surgical Approach)
Do not lie on side that has undergone surgery until receiving clearance to do so
from your surgeon.
Avoid crossing legs or internally rotating involved limb.
Keep abduction pillow between legs when in bed.
Keep legs separated when sitting.
Avoid low chairs that cause significant flexion of hip; knees should always be lower
than hips.
Avoid low toilet (use elevated commode seat).
Avoid bending over to pick up objects (use a reacher); do not let hand pass knee.
Avoid sitting forward to pull up blankets (use a reacher).
Avoid leaning over to get out of chair; slide hips forward first, then come to
standing.
Avoid standing with toes turned in.
REFERENCES :
1. Textbook of Orthopedics by john ebenezar 4th edition .
2. Handbook of orthopedic rehabilitation by brentz brotzman
3. essentials of orthopedics and applied physiotherapy by jayant joshi