Monday, July 16, 2018

PT Pathologies: Total Hip Arthroplasty (Replacement)

Total Hip Arthroplasty (THA) is a surgical procedure in which the diseased parts of the hip joint are removed and replaced with prostheses (an artificial joint). A THA may be recommended due to progressive and severe osteoarthritis or rheumatoid arthritis (chronic inflammation) in the hip joint, developmental dysplasia of the hip, failed reconstruction of the hip or other hip conditions that produce incapacitating pain and disability.  Osteoarthritis is the most common cause of joint damage in the hip, and is a result of joint and bone deterioration including destruction of articular cartilage that results in bone to bone contact.  This may result in severe pain and stiffness in the affected areas.  Degenerate changes are usually apparent in both the acetabulum and the femoral head requiring THA.  Other contributing factors that may cause a breakdown of the hip joint include repetitive micro traumas, obesity, nutritional imbalances, falls, abnormal joint mechanics, avascular necrosis, fracture, and bone tumors.

A patient that requires a THA will show signs and symptoms of decreased range of motion, impaired mobility skills, and persistent pain that increases with motion and weight bearing.  Examples are hip pain that limits everyday activities such as walking or bending, hip pain that continues while resting, either day or night, and stiffness in the hip that limits the ability to move or lift the leg.  Usually the patient is over 55 years of age and has experienced consistent pain that limits the patient's functional mobility on a regular basis.  Diagnosis is confirmed through xrays computed tomography, and MRI procedures to view the integrity of the joint and to rule out a fracture or a tumor.  An xray may show changes in the size and shape of the joint, a buildup of bone spurs, a cyst or pitting.  Medical management includes choosing a surgical approach that meets the patient's needs and level of activity.  Depending on the patient's age and the extent of hip damage, surgery is usually the recommended course of treatment.  During a THA operation the surgeon removes diseased bone tissue and damaged cartilage from the hip joint.  The damaged ball (head of the femur) is removed and the socket (acetabulum) is prepared to hold the prosthesis.

After surgery pain medication may be injected into a muscle or delivered into the blood stream by an IV.  Anticoagulant therapy is used to help manage pain as well. The patient's post-operative care includes following hip precautions, use of an abduction pillow, hip protocol exercises, and physical therapy intervention.  Hip protocol exercises include ankle pumps, quad sets, glute sets, heel slides, and isometric abduction.

Physical therapy emphasizes patient education regarding hip precautions and weight bearing status, scar management and soft tissue mobilization.  The PT will teach the patient how to sit, pull on socks and shoes, wash their feet and legs, and how to use the stairs.  Physical therapy encourages early ambulation training (to avoid the risk of deep vein thrombosis), safe range of motion activities, and muscle strengthening exercises.  Outpatient therapy may be needed to assist the progression ambulation to a cane.  Exercise goals after surgery are to increase muscle strength, blood circulation, overall fitness and how to avoid injuring the new joint.  Examples of exercises that can help meet these goals are walking, stationary bike and swimming.  The benefits of physical therapy should result in the patient having diminished to no pain, increased strength and endurance and improved mobility within 6-8 weeks after surgery.  Other benefits are improvements in activities of daily living and improved quality of life.

In Summary:

  • Patients are typically over 55 years of age and have experienced consistent pain that is not relieved through conservative measures which serve to limit the patient's functional mobility.
  • Posterolateral approach allows the abductor muscles to remain intact, however there may be a higher incidence of post operative joint instability due to the interruption of the posterior capsule.
  • Cemented hip replacement usually allows for partial weight bearing initially, while noncemented hip replacement requires toe touch weight bearing for up to six weeks.

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