Glossary. WZWA Wheeled zimmer walking aid. ZF Zimmer frame. E/C Elbow crutches. A/C Axillary crutches. MUA Manipulation under anaesthetic

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1 WZWA Wheeled zimmer walking aid ZF Zimmer frame E/C Elbow crutches A/C Axillary crutches MUA Manipulation under anaesthetic ORIF Open reduction internal fixation DHS Dynamic hip screw IM Nail Intramedullary nail THJR/THR Total hip joint replacement TKJR/TKR Total knee joint replacement # NOF Fractured neck of femur TAQ s Toe s, Ankle s, Quad s exercises IRQ Inner range quads TRQ Thru range quads SQ Static quads SLR Straight leg raise PCA Patient controlled analgesia NWB Non-weight bearing PWB Partial weight bearing TWB Touch weight bearing FWB Full weight bearing POP Plaster of Paris Glossary

2 FFD Fixed flexion deformity AFO Ankle foot orthosis Quads Lag Able to extend knee but falls into a degree in flexion on SLR or IRQ Quads Lack Pt unable to fully extend knee and remains in this degree of flexion during SLR or IRQ FFB Friction free board. Useful reading! David J. Dandy Essential Orthopaedics and Trauma (616.7 DAN) T. Duckworth Orthopaedics and Fractures (616.7 DUC) McRae and Kinninmonth Orthopaedics and Trauma (616.7 MACR)

3 Analgesia Dihydrocodeine Paracetamol Morphine Tramadol Voltarol Anti Emetic Cyclizine Metoclopramide DVT Anticoagulent Aspirin Tinzaparin Warfarin

4 Subjective Examination The subjective examination can mostly be taken from the patients notes and usually briefer than one in an out patient setting. This is due to the fact that the patient has already been referred for a joint replacement. The main aim of a pre-op assessment is to find out the length of time the patient has had this complaint, present mobility status and ROM (active and passive). This gives an indication of muscle shortening, altered gait or need of a walking aid and any capsular pattern. During this the physiotherapist should also ask about any previous joint replacements and the success of it. PC Constant pain and loss of function. HPC How long they have had present complaint, How long they have used a walking aid, PMH Hereditary factors Previous operations Diabetes Any other joint replacements DH Analgesia and any other medication SH Hobbies Stairs and how many, bed and bath on same level. Who they live with

5 Active and passive ROM Objective Examination of the HIP R L Flexion Extension Abduction External rotation Internal rotation Muscle Power (Grade I-V) R L Hip Flexors Hip Extensors Abductors Adductors Quadriceps Hamstrings Alignment Test Leg length discrepancy The test is performed with the patient lying supine, with hips in line and as flat as possible. Measurement is taken from the ASIS to the medial malleolus on both sides. A difference signifies a leg length discrepancy.

6 Special tests Thomas Test This test is to rule out of confirm a hip flexion contracture. The test is performed with the patient lying supine on the plinth. One knee brought to chest and the other straight. Make sure the lower region of the lumbar spine remains flat on the plinth. Ely s Test To assess for tightness of the rectus femoris. It is performed with the patient lying supine with the knees hanging over the edge of the plinth. The unaffected leg is brought to the chest stabilizing the pelvis and back. Extension of the test knee is a sign of tight rectus femoris. Trendelenburg s Test To test pelvic stability maintained by the hip abductor muscles. The patient stands on the test leg and raises the other off the floor. The test is abnormal if the pelvis drops on the non-weight-bearing side. Capsular Pattern of the HIP Medial Rotation Extension, Abduction, Lateral rotation.

7 Contraindications Twisting operated leg. The hip is put at risk if swivelled when turning, particularly internal rotation. Bend the operated leg past 90, bending to pick something off the floor when seated or leaning forward from the waist. Moving operated leg past mid line. Avoid kneeling for the first four months. Getting in and out of bed When getting out of bed 1. Sit up and step legs towards edge of bed, operated leg must lead, as this reduces the risk of operated leg passing mid line. For patients with a posterior incision they must keep the knee of the operated leg straight and their trunk and operated leg in line at all times. 2. Sitting on the edge of the bed with unoperated foot flat on the floor and the other out in front with knee straight. 3. Place hands on the bed at either side and push up to stand drawing the operated leg back. When the patient is standing and well balanced, they should they take hold of their frame or crutches. GETTING BACK INTO BED IS THE REVERSE PROCEDURE OPERATED LEG LEADING (this may vary)

8 Guidelines for Total Hip Replacement Active/assisted, hip/knee extension only. No re-education boards. These are only guidelines and therefore may alter if conditions changed. Post-op regime for revision of total hip replacement will require modification and patient may require to be non-weight bearing. Pre-op Issue hips booklet and discuss Explain role of the physiotherapist Assessment i.e. ROM, muscle power, gait Pre op advice Teach deep breathing and circulatory exercises Measure for height of ZWA Post-op care, PCAS, oxygen, IV drips PoD 1 Chest care i.e. deep breathing exercises Circulatory exercises TAQ s Commence active/ assisted hip/knee flexion/extension exercises either With/without the re-education board. IRQ exercises Measure active and passive ROM

9 PoD 2 Exercises as day one plus abduction exercises with re-education board Depending on check x-ray or on doctors instruction, transfer out of bed and Mobilise with ZWA usually PWD/FWB Chair transfers and up to sit Leg usually elevated PoD 3 Continue as day two but increase mobility PoD 4 Progress from ZWA to elbow crutches PoD 5 Continue, modify and increase exercises PoD 6 Encourage mobility with elbow crutches, stair practice with elbow crutches and rail or with elbow crutches only PoD 7 Patient can progress to two walking sticks or continue with elbow crutches Stair practice if necessary on D/C Outpatient follow-up only if required. Non-standard procedure

10 Guidelines for Total Knee Replacement PoD 1 & PoD 2, patient may wear Buchanan splint (Monklands Hospital) until wound checked and if satisfactory, then patient can commence knee flexion exercises. Patient allowed to mobilise with splint in-situ. This can be discontinued once wound checked and patient can SLR. At other sites, the post op regime will vary and splints may not be used. However, almost always, the check x-ray will be done before mobilising the patient. These are only guidelines and therefore may alter if conditions changed. Post-op regime for revision of total knee replacement will require modification and patient may require to be non-weight bearing. It can be very easy to become focused on the degree of knee flexion. This is easier to achieve than knee extension, which is very important for gait. Remember to work on extension too! A few examples are long sitting or sup lye with a rolled up towel under the ankle. This allows gravity to act on the knee, letting it stretch into extension. This can be uncomfortable for the patient so use only for short periods throughout the day. Another way to increase extension is to position the leg as above, with the ankle elevated on a rolled up towel and passively stretch the knee into extension or perform SQ s in this position.

11 Pre-op Issue knee booklet and discuss Explain role of the physiotherapist Assessment i.e. ROM, muscle power, gait Pre op advice Teach deep breathing and circulatory exercises Measure for height of ZWA Post-op care, PCAS, oxygen, IV drips PoD 1 Chest care i.e. deep breathing exercises Circulatory exercises TAQ s and gluts Commence active/ assisted hip/knee flexion/extension exercises either with/without the re-education board. IRQ exercises if able SLR if able Depending on check x-ray or on doctors instruction, transfer out of bed and mobilise with ZWA, usually PWB/FWB Chair transfer and up to sit, leg usually elevated

12 PoD 2 Exercises as PoD 1, encourage active work and SLR If patient not mobilised on PoD 1, patient usually mobilised PoD 2 PoD 3 Continue as PoD 2, increase mobility If appropriate progress from ZWA to E/C If drain is removed and dressing reduced commence use of cryocuff or ice pack, compression bandage (TED stockings) must be applied when cryocuff/ice pack removed. PoD 4 If not already progressed changed from ZWA to E/C or 2x walking sticks PoD 5 Continue to evaluate and modify treeatment. PoD 6 Continue modify and increase exercises i.e. modified PNF PoD 7 Encourage mobility with elbow crutches/sticks, stair practice with elbow crutches/sticks and rail or with elbow crutches/sticks only.

13 Types of hip replacements A: Thompson prosthesis secured B: Austin-Moore prosthesis. with cement. with no cement. The Thompson and the Austin-Moore hemiarthroplasties are the commonest types of hip replacements used in the UK. The total hip replacement replaces the damaged head of femur with a stainless steel ball mounted on a stem and relines the acetabulum with a special plastic polyethylene socket. The components are usually attached to the bone with a type of cement called Methyl Methacrylate, shown in figure A. Figure B shows a prosthesis applied with no cement, the type of prosthesis used is to the discretion of the surgeon.