Total Hip Replacement

Description

Hip prosthesis components

A total hip replacement (THR) is a surgery in which damaged bone and cartilage are removed and replaced with prosthetic components. THR is one of the most cost-effective and consistently successful procedures in orthopedics.

• THR provides excellent outcomes for patients with advanced degenerative hip osteoarthritis, providing pain relief, functional restoration and improved quality of life[1]..[2]
• During THR, the femoral head is replaced by an on-axis prosthetic head, and the articular surface of the acetabulum is lined with a bowl-shaped synthetic articular surface.
• For femoral neck fractures (mostly displaced) [3], a partial hip replacement may also be performed, in which only the femur is replaced.

Clinically Relevant Anatomy

THR X-ray

The hip joint is a ball and socket joint. This design allows for multi-axis movement seen at the hip (see link).

The femoral head and the inside of the acetabulum are covered with a layer of hyaline cartilage. [4] Once this cartilage is worn away or damaged (often caused by arthritis), the underlying bone is exposed, causing painful stiffness and possible shortening of the affected leg. by replacing these The purpose of the surface is to reduce pain and stiffness in order to resume an active and pain-free life.

THR is mostly done selectively. [5][6][7][8]

Indications for Surgery

THA The most common indication for hip OA. Other indications include:[9]

• Trauma: femoral neck fractures (capsular displacement) in active and healthy patients can be considered on a case-by-case basis
• Osteonecrosis of the hip commonly known as avascular necrosis of the hip [10]
• Developmental dysplasia of the hip
• Hardware failure after internal fixation of hip fractures [1]

Complications

Leg length discrepancy after THR

Complications after THR can be roughly divided into systemic complications and procedure-specific complications. Complication rates have improved over time due to improvements in surgical and anesthesia techniques and better diagnosis and management of these complications.

The most common systemic complication is deep vein thrombosis. Infection is the most dreaded complication. Differences in leg length are a common cause of patient dissatisfaction [11]. For more information, see Complications of Total Hip Replacement.

Contraindications for Surgery

THA is contraindicated in the following clinical situations:

• Local: suppurative (infectious) arthritis
• Distant (i.e., extra-articular) active persistent infection or bacteremia.
• Severe cases of peripheral vascular disease [12]

  Orthopaedic Assessment

  An orthopedic surgeon’s evaluation consists of several parts:

  • Medical History: General health and questions about the extent of your hip pain and how it affects your ability to perform daily living.
  • Hip Examination
  • X-rays. To assess the extent of hip injury or deformity.
  • other tests. Sometimes other tests, such as an MRI scan, may be needed to determine the condition of the hip bones and soft tissues.

  Diagnosis of patients requiring THR is primarily based on symptoms. Painful loss of range of motion and functional impairment are primarily considered. [13]

  Prosthesis

  Stainless steel and UHMWPE THR

  When THR is performed, the ball is removed, the socket is reshaped, and the artificial implant is positioned in the bone. The implant can be secured in the bone by wedging the implant tightly into place or by gluing it in place. The type of fixation used depends on the patient’s bone health and the design of the implant. Modern THR technology has evolved into press-fit femoral and acetabular components, and many variations exist. [14] The basic components are:

  1. The bearing surfaces are the surfaces that form the articulation in the prosthetic joint. The femoral head and acetabular liner can be used in different combinations. These will give a different appearance on the radiograph depending on the configuration. Many options available such as metal to polyethylene Ceramic to Polyethylene Ceramic to Ceramic Metal to Metal[1]
  2. Femoral component or stem: This refers to the prosthesis that is placed in the femur. They can be described by the presence of a taper in length and a neckline. Attached to the femoral component is the neck and head, which in most prostheses can change size to form a stable joint [15].
  3. Prosthetic fixation: Femoral stem fixation can be cemented or non-cemented (biological) [15]. Popularization of fixation techniques: increasing trend towards cementless fixation; 93% of THA in the US were cementless in 2012 [16]

  Surgical Approaches

  Posterior hip approach

  Any number of methods can be used for the THA procedure. The three most common methods are:

  1. Posterior (PA): The most common surgical approach for THR. The main advantage of this approach is that the hip abductors are avoided. With the patient lying on his side, the surgical incision is made on the outside of the buttock. [17]
  2. Direct Anterior Approach (DA): This surgical procedure has been on the rise over the past decade. This approach is performed with the patient supine and the surgical incision is made down the front of the thigh (between the superficial tensor fascia lata and sartorius muscles, gluteus medius and rectus femoris on the deep side). The direct anterior approach has several potential advantages. The two that stood out the most were the low risk of dislocation and early postoperative recovery. [17]
  3. Immediately Lateral (Hardinge) or Anterolateral: Usually considered a balance between AP and PA. The person lies on their side, and the surgical incision is placed directly on the outside of the buttock. Pros: Balanced with versatile incisions that can be used to correct deformities And insert a specialized implant, postoperative dislocation rate is lower than the posterior approach. Disadvantage: Dissection of the superior gluteal nerve may result in nerve damage resulting in postoperative Trendelenburg gait characterized by compensatory movements Weakness of the hip abductor muscles. [17]

  MAKOplasty® THR is powered by an interactive robotic arm

  Additionally

  1. Robotic Arm-Assisted THR: Assisting THR surgery to aid in accurate positioning of implants, which correlates with improved THR function and longevity. Can be used with all current hip surgery methods (AP PA and Lateral).
  2. Minimally invasive surgery is becoming more popular worldwide due to faster recovery and reduced postoperative pain. Long-term follow-up and comparative studies are still needed in this field [18].

  Watch this 3-minute video to learn about the different approaches to hip replacement surgery and the benefits of each.

  [19]

  Physiotherapy Management

  Discuss hip precautions before surgery.

  1. PA avoidance: flexion beyond 90 degrees; extreme internal rotation; adduction beyond midline
  2. Anterolateral approach to avoid: extension; extreme external rotation; adduction beyond the midline of the body
  3. AP Avoid: bridging; dilation; extreme external rotation; adduction beyond midline of the body [16]

  Pre-operative

  A one-on-one preoperative physical therapy program was effective in reducing the number of postoperative PT visits and the time to prepare for discharge from PT. It plays an important role in improving the quality of life before surgery (people can wait months for surgery and experience Health-related quality of life deteriorates further during long waits. [20] See also Physical Activity Before and After Surgery

  Preoperative Evaluation and Treatment Session

  • Help develop a patient-specific rehabilitation plan to consider evaluating outcomes after surgery, such as whether the patient wishes to return to golf.
  • Benefits: shorter length of hospital stay [21]; lower anxiety levels [22]; increased self-confidence [23]; building trust between physiotherapist and patient.
  • A combination of oral explanations and written booklets is the best method of health education. [22] It is important to incorporate it into the preoperative physical therapy management of patients undergoing total hip arthroplasty (associated with better postoperative compliance). [twenty two]

  Pre op Assessment

  • Subjective history
  • Range of motion
  • Muscle power
  • Circulation
  • Mobility and function[23]

  Pre op Treatment

  • Education and Advice: Patient Information Booklet; Precautions and Contraindications; Recovery Process; Goals and Expectations; Functional/ADL Adaptation; Safety Principles
  • Encouraging smoking cessation, if applicable
  • Discharge planning
  • Teach: Bed exercises; transfer to and from bed (within precautions)
  • Gait re-education with mobility aids (crutches and walkers)
  • Stair climbing

  Post-operative

  Start on the day of surgery, as a shorter hospital stay can reduce pain and improve function.

  • Goals of postoperative rehabilitation: to address the patient’s functional needs (eg, to begin mobilization) and to improve mobility, mobility, and pain relief. [7]. This begins as an ancillary process, but the aim is to allow the patient to regain as much function as possible before discharge.
  • Patients may experience muscle atrophy and loss of strength, especially in the gluteus medius and quadriceps, due to underlying preoperative pathology. A consequence of the loss of strength is reduced independence in older adults. [5]
  • Surgery will correct the joint problem, but associated muscle weakness that was present before surgery will continue and require rehabilitation after surgery (studies show hip abductor muscle weakness after surgery is the main risk associated with joint instability and loosening of the prosthesis). [6] After total hip replacement, patients can experience dramatic improvement with a targeted strengthening program. [24] Motor imagery training has been found to be a useful adjunctive therapeutic tool as it improves specific and general adaptations related to the patient’s body Ability when added as a corollary of conventional physical therapy. [25]
  • There is currently no specific universal hip replacement protocol in use because a small portion of the rehabilitation process is surgeon specific. For example, in some accelerated recovery programs after surgery, patients are out of bed for the first 6 hours after surgery. Other settings may only start Get the patient out of bed on postoperative day 1 or 2. Accelerated recovery programs and early mobilization have been shown to give patients more confidence in postoperative mobility and activities of daily living and are more comfortable with early hospital discharge. [26]

    Evidence

    Physiotherapy: can improve strength and gait speed after total hip arthroplasty, help prevent complications such as subluxation and thromboembolic disease; increase the patient’s mobility, and provide necessary exercise and preventive measures regarding hospitalization education, and After hospital discharge [27]; maximizing patient function, which is associated with a greater likelihood of early discharge which in turn is associated with lower total cost of care [28]

    • Bed rest exercise after total hip arthroplasty is important for the effect of edematous cardiac function and for improving range of motion and muscle strength [29].
    • Early weight bearing and physical activity are beneficial to the quality of bone tissue [30], improving the fixation of the prosthesis and reducing the incidence of early loosening. Activity levels vary from patient to patient and should be adjusted as needed based on clinical reasoning. Certain specific sports carry a higher risk of injury for unskilled individuals and should be incorporated into the rehabilitation process under the supervision of a physical therapist.

    Proposed protocol in the absence of complications: The surgeon’s preference should be considered along with any other factors that may impede the execution of the protocol. Adjustments should be made to make it more patient specific. [23] [31]

    Day 1 Post-Surgery

    Bed mobility

    • Education and advice
    • Education of muscular relaxation
    • Revised precautions and contraindications (provided the patient had a preoperative conference with a physiotherapist, otherwise a full education as described in the preoperative section).
    • Bed exercises:
      • Circulation drills
      • Upper body exercise that stimulates heart function
      • Maintenance of the non-operated leg: Attention should be paid to range of motion to maintain controlled movement of the operated hip
      • Isometric quadriceps (progress to agree VMO) and gluteal contractions
      • Active assisted (progress to active) heel slide hip abduction/adduction
    • Bed mobilization using unilateral bridging on the unaffected leg
    • Get up and get up (see here)
    • Getting in and out of chairs with armrests (see here)
    • Sit up with a mobility aid (preferably one that provides more support, such as a walking frame or rollator)
    • Gait re-education with mobility aids as tolerated (weight bearing status determined by surgeon)
    • Sitting out in chair for maximum 1 hour
    • Postioning when transferred back to bed

    Day 2 Post-Surgery

    • Bed exercises as described above are gradually repeated and less and less helpful to the patient
    • Progression of distance mobility and/or mobility aids
    • Incorporate balance exercises if needed
    • Sitting in chair

    Day 3 Post-Surgery

    Bed exercises as described above are gradually repeated and less and less helpful to the patient

    • Progression of distance mobility and/or mobility aids
    • Climb stairs (at least 3 times or as required by family)
    • Sitting in chair
    • Revision of Precautions Contraindications and Functional Modifications
    • Give the patient 6 weeks of progressive resistance-strengthening home exercise; this can include stationary bicycles as long as the patient adheres to precautions (especially posterior procedures)

    After 3 days, the client is usually discharged home if the discharge criteria are met. Physiotherapists and nurses help shift to car maintenance hip preventive measures. Due to the lack of awareness of most patients about the activities that can be performed after discharge education before discharge from THR surgery Pain management exercise ADL and support requirements should be provided to the client. A recent randomized controlled trial showed that a video-assisted discharge program and educational manual provided to patients and their relatives after THR found improved functioning of daily living and patient satisfaction This video-assisted discharge program, along with physical therapy, reduced pain and kinesiphobia, improved hip function, and increased patient satisfaction. Further research is needed to evaluate the long-term outcomes of video-assisted discharge education in patients with THR. [32]

    Discharge Home Criteria:

    • Walking independently with assistive devices
    • independent transfers
    • independent ADLs
    • stairs with supervision
    • Appropriate home assistance (spousal home visiting nurse)[16]

    Home Planning

    Several modifications to make the home page easier to navigate. The following items help with daily activities:

    • Securely secured safety bars or grab bars in the shower or bathtub
    • Secure handrails along all stairways
    • A stable chair for your early recovery with a firm seat (to keep the knees lower than the hips), a strong back and two arms
    • A raised toilet seat
    • A stable shower stool or chair for bathing
    • A long-handled sponge and shower hose
    • a dressing stick a sock aid and a shoehorn with a long handle
    • Retriever for grabbing objects without excessive hip flexion
    • Sturdy pillows for chairs, sofas and cars allow clients to sit with their knees lower than their hips
    • Remove all loose carpet and electrical wiring from walking areas of the home[16]

    6 Weeks Post Surgery

    • Patients are usually followed up by a plastic surgeon
    • The surgeon determines whether to allow the patient to:
      • Full range of motion at the hip
      • Full weight without mobility aids
      • Driving

    After 6 Weeks

    • Get initial ROM stability and proprioception
    • Endurance
    • Flexibility
    • Balance
    • speed precision neural coordination
    • Functional exercises

    Return to sport

    Low-impact exercises are preferred

    • Golf: Little change in handicap after THA; handicaps show increase after TKA
    • High-Intensity Exercise Increases Revision Rates in Patients Under 55

    Outcome Measures

    • Harris Hip Score
    • Oxford Hip Score (OHS)
    • 6 Minute Walking Test
    • Timed Get Up & Go Test
    • Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
    • SF-36
    • Fear Avoidance Belief Score
    • Hip Disability and Osteoarthritis Outcome Score (HOOS)
    • International Hip Outcome Tool
    • Ibadan Knee/Hip Osteoarthritis Outcome Measurements

    Team Work

    Total hip arthroplasty (THA) is one of the most reliable, reproducible, successful and cost-effective of all orthopedic procedures. The program entails coordinating the care of various groups of healthcare providers, including nurses, physical therapists, advanced practitioners, and physicians Extended Medicine Physician and Plastic Surgeon.

    Clinicians, including surgeons, nurse practitioners, and physician assistants, should work together to educate patients and families about surgical expectations and aftercare guidance. [1]

    Virtual Clinic Visits

    Virtual follow-up of hip and knee replacement patients is an effective alternative to on-site clinical assessment, as confirmed by a recent survey that included 1749 patients who visited virtually between January 2017 and December 20184 .

    1. For postoperative 1-year follow-up and regular regular follow-up, only 7.22% of patients required further on-site evaluation.
    2. Being accepted by patients has high patient satisfaction, which can reduce the cost of medical services and patients. [33]