Total Hip Replacement – Precautions


Total Hip Replacement(T.H.R) is a surgical procedure of removing the diseased hip joint and replacing it with an artificial one.

Usually the patients considered for T.H.R are

  1. Young patient
  2. Osteoarthritis of hip joint
  3. Rheumatoid Arthritis
  4. Avascular Necrosis
  5. Septicemia

There is a progressive increase in chronic pain and difficulty in walking, stair climbing and rising froma chair.

Usually there are two types of prosthesis which are commonly used for the surgery: Cemented and Uncemented Prosthesis.

Difference of cemented and uncemented prosthesis:

Cemented prosthesis is usually used in older patients who are less active and have less bone moneral density.

Uncemented Prosthesis is used in younger and more active individuals.

The primary disadvantage of uncemented rposthesis is the extended recovery periof. Because it takes long time for natural bone to grow and attach to prosthesis, hence the person has to limit his activitties for upto 3 months to protect hip.

Your hospital stay my last for a week. If you go home you will need help for several weeks.

The following steps can make your home coming easier:

  • In kitchen as well as other rooms, place items of daily use within reach so you dont have to reach up or bend down.
  • Rearrange furniture you can walk easily with walker or stick.
  • Get a good chair that is firm and higher than average seat.
  • Remove rugs or area rugs that could make you slip.
  • Securely fasten electrical cords around perimeter of the room
  • Install a shower chair grab bar and raised toilet.
  • Use assistive devices such as long handle sponge and grabbing tool or reacher to avoid bending too far.

Once you get home, stay active.The key is not to overdo it while you expect some good and some bad days, you should notice gradual improvement over time.

WEIGHT BEARINGDiscuss with your physical therapist regarding the weight bearing of operated leg as the rehabilitation protocol will be different for cemented and uncemented prosthesis.

STANDING: Move your operated leg first and pushoff the armrest of chair to stand up.

SLEEPING POSITIONS: Sleep on your back with legs slightly apart on your side with abduction pillow.Be sure to use the pillow atleast 6 weeks or untill your doctor tells you to use. Sleeping on stomach is alright.

SITTING: For atleast 3 months donot cross your legs at knees. Make sure the seat height is good so as to avoid bending of hip beyond 90 degreesGet up and move around possibly every 1 hour.

SEX: Some sex positions can be safely resumed 4-6 weeks after surgery. Ask your doctor regarding the same.

CLIMBING: Stair climbing should be limited if possible untill the wound is healed.

Following pattern of stair climbing should be followed.

GOING UP :

  • the unaffected leg should step up first
  • then bring affected leg to same step
  • then bring the cane

GOING DOWN:

  •  put the cane first
  • next bring the affected leg down the step
  • finally step down with unaffected leg.

DRIVING: You can begin driving an automatic car 4 to 8 weeks after consulting your doctor and symptoms after surgery.

SITTING INTO CAR: Be sure the passenger seat is pushed all the back.Recline the seat as far as possible.with the walker in front of you slowly back up the car seat.Swing your legs into the car.Lean back if you need to avoid the hip more than 90 degrees.

GETTING OUT OF THE CAR: Push the seat all the way back.recline the seat and lift your legs out.lean back if you need to.place walker up in front of you and stand up on unaffected leg.

RETURN TO WORK: Depending on the type of activities you eprform it may take as long as 3 months to 6 months to return to work.

OTHER ACTIVITIES: Walk as much as you like once doctor gives you permission, but remember donot substitute walking to exercise.Swimming is recommended once suture are removed and wound is healed.Acceptable activities are dancing, golfing with spike less shoes and cart,bicycling on level road.Avoid activities that involve impact or stress on joints such as tennis, badminton or contact sports like baseball, football,squash, jumping or jogging, Lifting weights is not a problem but carrying heavy and awkward objects that cause to stagger is not advised especially if you must go up and down stairs or slopes.

Do’s and Dont’s

The do’s and dont’s vary depending on orthopaedic surgeons apporach.Your doctor and Physical therapist will provide you with a list of the same to remember with your new hip.The precautions will help you to prevent the new joint from dislocation and ensure proper healing.

 The Dont’s

  • Donot cross legs at knee for atleast 8 weeks
  • donot bring knee up higher han your hip
  • donot lean forward while sitting or as you sit down
  • donot try to pick up something on the floor while ou are sitting
  • donot turn your feet excessively inwards or outwards
  • donot reach down to pull your blanket when lying down
  • donot bend at waist beyond 90 degrees
  • donot use pain as a only guide for what you may or may not do

The Do’s

  • Keep skin dry and clean
  • Notify doctor if wound drains
  • Swelling is normal for first 3-6 months. Elevate leg slightly <30 degrees on pillow and put ice packs for 15-20 min
  • If you get calf pain , chest pain and shortness of breath notify doctor immediately
  • Do exercises prescribed daily.
  • A balanced diet is very important.
  • Maintain an active lifestyle after surgery.

DISCLAIMER: Kindly refer your doctor and Physical therapist for the instructions depending on your surgery procedure.

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Lower Crossed Syndrome


Lower-Crossed Syndrome (LCS) is also referred to as distal or pelvic crossed syndrome.According to Janda, there is a muscle imbalance in the lower segement of the body. Thus in Lower Crossed Syndrome there is:

TIGHTNESS: Thoracolumbar extensors on dorsal side and iliopsoas and rectus femoris,

WEAKNESS: Deep abdominals, gluteus maximus and gluteus medius

This pattern of imbalance creates joint dysfunction, particularly at the L4-L5 and L5-S1 segments, SI joint, and hip joint.

Specific postural changes include anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, lateral leg rotation, and knee hyperextension.

If the lordosis is deep and short, then imbalance is predominantly in the pelvic muscles.

if the lordosis is shallow and extends into the thoracic area, then imbalance predominates in the trunk muscles .

LOWER CROSSED SYNDROME TYPE-A vs TYPE-B

The two types are similar and involve the same main muscle imbalance characteristics.However

Type A: It extends into the thoracolumbar area, with a more cranial shift of the kyphosis, anterior pelvic tilt and genu recurvatum. It is typically due to shortness of hip flexors leading to a deeper and shorter lordosis .

Type B: It is primarily due to weakness and length of abdominal wall giving a shallower, longer lordosis.

Tennis elbow


Lateral epicondylitis, known colloquially as tennis elbow is a condition where the lateral surface i.e the outer surface of the elbow on lateral epicondyle becomes tender and swollen.

It is an over-use injury commonly seen in tennis players or even sometimes in computer users because of over use of common extensor tendon which originates from the lateral epicondyle.

SIGNS AND SYMPTOMS

  • Pain
  • Tenderness
  • Gripping movements are painful
  • Morning stiffness

PATHOPHYSIOLOGY

Cyriax proposed that there are macroscopic and microscopic tears between common extensor tendon and periosteum of lateral humeral epicondyle due to repetitive overuse.The non inflammatory chronic degenerative changes of the origin of extensor carpi radialis brevis muscle. This muscle has a small origin and does transmit large forces through its tendon during repetitive grasping,

SPECIAL TEST

COZEN TEST

1)     Examiner stabilizes the involved elbow while palpating along the lateral epicondyle. With closed fist, the patient pronates and radially deviates the forearm and extends the wrist against the examiner’s resistance

2)     Examiner stabilizes involved elbow with one hand and places the palm of the other hand on the dorsal aspect of the patients hand just distal to the proximal interphalangeal joint of the third digit

In both the tests the positive sign is patient complains of pain on the lateral epicondyle.

PHYSICAL THERAPY INTERVENTION

1) Ultrasound : Has been commonly used since years as a treatment for Tennis elbow, but very few evidence support this fact.

2) Icing: Icing has been found very effective to decrease the inflammation associated with the tenis elbow. Apply ice 2 -3 times a day for 10 min.

3) Mobilization with movement: Mulligan mobilization has found to be effective. Stabilize the humerus with elbow slightly bent and pronated. Give a lateral or a medial glide( depends on which glide is painfree) holding just below the elbow. Ask patient to either make fist and relax or extend and flex the wrist 5 times. Repeat it 3-4 times.

4) Bracing: Patient can buy a tennis elbow brace which should   be worn 1-2 cm below the lateral epicondyle .

5) Taping: The therapist can give a mobilization in either lateral or medial direction depending on painfree glide and put a tape to maintain it

6) Stretches: Patient should regularly perform stretches by holding the stretch for 10 counts.Perform the stretches 5 times for 3 times a day atleast.

7) Stregthening exercises: the Eccentric strengthening exercises are found to be effective as it works on the extensors of the wrist .

                     

8) Recently theraband academy has introduced theraflex bar exercises effective to strengthen the extensors.

http://www.youtube.com/watch?feature=endscreen&v=gsKGbqA9aNo&NR=1

9) Rest is also very important avoiding activities which may put strain on the tendon.

EQUIPMENT MODIFICATION

Using the wrong tennis racquet may have been a contributing factor to your injury. Guidelines for racquet selection fornon-tournament players are provided below.

  1. Racquet material – Graphite composites are currently considered the best in terms of torsion and vibration control.
  2. Head size – A midsize racquet (95-110 square inches) is preferred. The popular oversized racquets cause problems because they make the arm susceptible to injury due to the increased torque effect of shots hit off-center.
  3. String tension – stay at the lower end of the manufacturer’s recommendation. While higher string tensions provide improved ball control, it also increases the torque and vibration experienced by the arm.
  4. Stringing material – synthetic nylon (re-string every 6 months).
  5. Grip size – A grip too large or too small lessens control and promotes excessive wrist movement. To measure an appropriate grip size for your hand see image below.

DISCLAIMER: Kindly check with your physical therapist before attempting any of the exercises.

Stroke Rehabilitation: ADVANCES


Check out some interesting advanced rehabilitation techniques for the stroke patients.

1) ZERO-G

Zero G is an advanced overground gait and balance training system. It allows patient to safely practice intensive physical therapy early in their rehabilitation. The technology allows therapist to safely train patient through wide range of training activities such as

  • Overground walking
  • Dynamic balance and stability
  • Stair climbing
  • Side stepping
  • Transfer
  • Getting off the floor
  • Postural tasks
  • Treadmill training
  • Using assistive devices.

The training session is highly customized with respect to body weight support, walking speed and fall distance,Therapist can set a “Safe walking speed” for each patient and the machine uses an advanced tracking algorithm to help patient stay at that speed. This allows therapist to control the momentum of the patient,

BENEFITS

Training with Zero G may help to

  1. Increase overground walking speed
  2. Improve balance
  3. Enhance endurance
  4. Reduce lower extremity impairment

Benefit to therapist: Realtime feedback and stores number of falls prevented and maximum body-weight support within each session.

CONDITIONS

  • Stroke
  • Traumatic brain injury
  • Incomplete spinal cord injury
  • Cerebral palsy
  • Multiple sclerosis
  • Amputation
  • Orthopaedic injuries

Clinical evidence suggests improvement with the training in acute stroke patients.

CHANGE IN WALKING SPEED PRE AND POST TRAINING

2) BIONESS- FUNCTIONAL ELECTRICAL STIMULATION:

The L300 Plus System stimulates the appropriate nerves and muscles of the upper and lower leg and helps reeducate brain signals, to help restore function in weak or paralyzed muscles.

The difference between the L300 Foot Drop System and the L300 Plus System is the addition of the thigh cuff for a more natural walking pattern and to correct thigh weakness. The leg cuff, combined with the thigh cuff, produce an electrical current to activate and contract specific leg muscles to help control leg and foot movement. This makes it easier to walk with increased speed and improved balance.

This device may be used to reduce impairments and to increase daily functional activities in patients with neurological diseases or injuries. It thus helps to restore activities such as standing,walking, stair climbing.

Assist with reduction in secondary problems of paresis such as

  • poor blood circulation
  • limited range of motion
  • muscle spasm muscle
  • disuse atrophy

All three systems can help certain CNS patients regain natural use and movement, some even to the point of reeducating the brain to relearn natural movements for the following diagnoses: Stroke, Multiple Sclerosis, Traumatic Brain Injury and Spinal Cord Injury.

Check out a Video Coverage:

http://www.youtube.com/watch?v=AiyQz5_7MLw&feature=related

Frozen Shoulder: An Introduction


Frozen shoulder or Periarthritis of shoulder or Adhesive capsulitis is one of the most commonly seen cases, presenting with remitting shoulder pain and stiffness.

Codman in 1934 described some classic diagnostic criteria of this condition

  • Global restriction of shoulder movement
  • Idiopathic etiology
  • Usually painful at onset
  • Normal X-ray
  • Limited external rotation and abduction

CLASSIFICATION

PRIMARY/IDIOPATHIC FROZEN SHOULDER:  is a distinctive pathological condition in which there is global restriction of shoulder range due to loss of compliance or elasticity of the capsule. Usually the age group affected is 40-50 years of age with or without history of diabetes mellitus.

SECONDARY FROZEN SHOULDER: is typically present after an injury or surgery, usually associated with conditions like shoulder impingement or rotator cuff tear.

NATURAL HISTORY

The frozen shoulder history typically passes through three stages:

FREEZING PHASE (0-3 months) this is associated with pain and loss of range of motion.

FROZEN PHASE(3-9 months) with pain relatively eases but there is extreme loss of range of motion and marked stiffness.

THAWING PHASE (9-18 months) : usually this stage is painless and stiffness starts to gradually resolve at this stage.

PATHOLOGY

The macroscopic appearance is the thickening of the anterior capsule, particularly the coracohumeral ligament and middle glenohumeral ligament. Contractures of the capsular ligament restricts the movement of glenohumeral joint.

Coracohumeral ligament: external rotation in neutral

Medial glenohumeral ligament: external rotation in midelevation

Anteroinferior glenohumeral ligament: external rotation in abduction

Inferior capsule: abduction in neutral rotation

Posteroinferior capsule: internal rotation

Posterosuperior capsule: internal rotation in abduction

Villonodular synovitis within the rotator interval with thickeneing and contracture of coracohumeral ligament is primary pathology.

SPECIAL TESTS to Diagnose Frozen shoulder

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

TREATMENT OPTIONS

1) Physiotherapy                               

2) Distension injections

3) Locally acting steroid injection

4) Manipulation under anaesthesia

5) Open/ arthroscopic capsular release

Primary idiopathic frozen shoulder is extremely disabling condition, which does pass through a typical 3 stage progression. Early intervention during early phases of the the condition can improve the outcome of the condition.

Total Knee Replacement-An Introduction


Total Knee Replacement is a surgical procedure in which the knee joint, which comprises the lower end of femur and upper end of tibia are replaced by a  prosthesis.

Usually it is done in cases of chronic knee pain due to degeneration, injury etc  and which is  not being managed conservatively with help of medications or physical therapy.

Causes chronic knee pain and disability are

Osteoarthritis: This is the age related wear and tear of the joint. The cartilage that cushions the bones of the knees softens and wears away.

Rheumatoid Arthritis :This is a disease in which synovial membrane of the joint becomes inflamed and thickened eventually leading to cartilage loss, pain and stiffness.

Post traumatic arthritis: This can follow a serious knee injury.

The surgery is recommended when

  • Severe knee pain or stiffness that is limiting the everyday activity.
  • Moderate to severe knee pain in resting day or night.
  • Chronic knee inflammation.
  • Knee deformity.
  • Failure to substantially improve with conservative management.

POSSIBLE COMPLICATIONS

  1. Wound infection
  2. Blood clots
  3. Implant problems
  4. Continued pain
  5. Neurovascular injury

TYPES OF IMPLANTS USED

The implants are not one size fits all. Prosthesis implants vary greatly by design, fixation and material.

TOTAL KNEE IMPLANT COMPONENTS

THE FEMORAL COMPONENT: Made up of metal and curves around the lower end of femur.Also it has a groove which fits in the patella.

THE TIBIAL COMPONENT: It is a flat metal platform with a polyethelyne plastic insert or spacer.

THE PATELLAR IMPLANT: It  is a dome shaped polyethylene knee cap.

TYPES OF PROSTHESIS

a) FIXED BEARING IMPLANTS

This is the most common implant. Its is called fixed because the cushion of tibial component is fixed firmly to metal platform base.It provides good range of motion.

b) MOBILE BEARING IMPLANTS

If you are young and more active and or overweight the doctor may recommend a rotating platform or mobile bearing knee replacement, the implants are designed for longer performance.

The difference between fixed and mobile bearing implant is the bearing surface is though both use the same 3 components, in mobile bearing the polyethylene insert in tibial component can short distances inside the metal tibial tray. This rotation allows greater rotation to medial and lateral sides of their knee, rotate but this does require a strong ligament support otherwise chances of dislocation are there,

c) MEDIAL PIVOTAL IMPLANT

It replicates rotating, twisting, bending , flexion and stability of natural knee.The locking and unlocking mechanism is quite perfectly mimicked by this knee. But compared to above two knees this implant is less forgiving of imbalance in soft tissues

d) POSTERIOR CRUCIATE LIGAMENT RETAINING OR SUBSTITUTING IMPLANT

The PCL is one of the most important ligament to support and stabilize the movement of knee and preventing femur to roll back on top of tibia hen flexed.

PCL retaining: In this design, rearwards movement of tibia continues to be resisted by intact PCL creating stability.t= The prosthesis have notches to accommodate ligament.

PCL substituting: They have raised surface on tibial component cushion with raised sloping cam or post which compensates for missin PCL to give stability.

e) UNICOMPARTMENTAL IMPLANTS

If only one side of knee joint is damaged smaller implants can be used to resurface other side.

f) GENDER SPECIFIC INPLANTS:

Some orthopaedic have recently introduced gender specific implants, considering the geometrical difference between both sexes.

TYPES OF KNEE IMPLANT FIXATION

Cemented prosthesis utilize special kind of bone cement that holds components. This is most commonly used,

Cementless it becomes fixed with bone growth into surface of implant, but recovery takes little longer.

COMING SOON!!!!
Exercise therapy and Do’s and Don’t’s after a total knee replacement.