hip replacement

[nadja66]

why does a patient have a minor range of motion and reduced strength after the surgery?

reasons i know so far:

- swelling can reduce the range of motion
- adverse-effects reflex can reduce the strength
- pain due to the sugery can reduce the skills

what other reasons are there??
and how can i reduce the swelling that shows post postoperative?

thanx for your help

greets..

[Canuck Physio]

Additionally,

a few days bed rest can result in significant muscular atrophy, some of the muscles surrounding the hip/pelvis are cut through during the OP, neuromuscular recruitment is diminished due to bed rest and inability to recruit motor units post-injury/pre-op phase. Amongst others...

[nadja66]

thanx for your answer canuck..

is there realla an atrophy after a day lying in bed?or is it just the inability to recruit the motor units?
and how can i treat this? is it enough if i just get the patient to activate his muscles again?

[Canuck Physio]

Yes, as little as 6 hours of bed rest begins the process, however the the real significance is the effect of atrophy over the long term with possible concomitant problems such as: cachexia, sacropenia.

Additionally please read:
Pavy-Le Traon, A. (2007) From space to Earth: advances in human physiology from 20 years of bed rest studies (1986–2006). European Journal of Applied Physiology

SpringerLink - Journal Article

Alkner, B. A. (2004) Efficacy of a gravity-independent resistance exercise device as a countermeasure to muscle atrophy during 29-day bed rest. Acta Physiologica Scandinavica 181(3)

Prolonged bed rest decreases skeletal muscle and whole body protein synthesis -- Ferrando et al. 270 (4): E627 -- AJP - Endocrinology and Metabolism

Calf muscle area and strength changes after five weeks of horizontal bed rest -- LeBlanc et al. 16 (6): 624 -- American Journal of Sports Medicine

Also, please consider time post-incident. Most patients I saw while I was on Orthopaedic ward would have 2-7 days before operation, and depending on co-morbidities another 2-7 to begin mobilising.

However for your patient, previous activity/strength levels are equally important.

I would consider rapidly progressive isometric, to functional isometric, to weight bearing based on consultant report asap.

Additionally to back up the 6 hours:

Related Literature Skeletal muscle atrophy begins within 6 hours of bed rest (Booth, 1977; Booth & Seider, 1979).

[emad]

My view , the mobility ,rehabilitation better goes slowly to avoid protective reflexes ,pain . One of the reasons for range limitation the joint itself can not get more than 90 degrees flexion .

cheers
Emad

[nadja66]

thanx a lot for your comments and links..
i do think that the pre operative status of the patient has a really big influence on the healing process afterwards..

[morwenna]

Originally Posted by emad

One of the reasons for range limitation the joint itself can not get more than 90 degrees flexion .

I don't really understand that sentence. Do you mean to say that all joints will not flex to more than 90??

I am doing post op checks for patients one year or more after their surgery, and some will flex to 120 plus quite easily. Some don't though.

Some have restricted movement from soft tissue tightness, and sometimes there is impingement at the end of available range. Often that is dependent on the orientation of the implants, or maybe heterotrophic bone.

Some of our surgeons advise their patients that they will never be able to flex "much more than 90".

... which brings me to the questions of "Hip Precautions".

Is everyone advising on the usual hip precautions these days? ... there is evidence that a stable hip is stable, and instability often is a result of inadequate placement of the implants. How long do you tell patients not to flex beyond 90 or adduct past mid-line?

It is really quite limiting for a patient if they are strictly to observe those rules for ever!

Here's another thing: In the UK we'd tell our patients that supine with a pillow between their legs was safest sleep position. If they really could not sleep supine we'd advise them to lie on their OPERATED side, with a pillow between their knees. Obviosuly this would be uncomfortable for most people until the immediate post-op swelling/pain had subsided.

Here in Calgary they are advised to lie on their GOOD side with pillows supporting their operated leg. This, I always thought, is the least safe position as the leg can "fall into flex/add". Indeed I found one of my Home Care patients had subluxed her hip sleeping in this position. I told her to stop doing it!! (and reduce flexion to max of 70 until seen again by the surgeon)

I'd be interested to know other people's experiences/views?

[nadja66]

hmm..at the place where i work we also tell the patients that they can sleep on the good side with a pillow between the leg. to lie on the operated leg mostly really hurts them and is not possible during the first week..
but of course if they lie on the good side the chance that the leg goes in to adduction is much bigger..
most patients by us anyway prefer to sleep supine, even if they didnt befor surgery..

[morwenna]

Originally Posted by nadja66

hmm..at the place where i work we also tell the patients that they can sleep on the good side with a pillow between the leg. to lie on the operated leg mostly really hurts them and is not possible during the first week..
but of course if they lie on the good side the chance that the leg goes in to adduction is much bigger..
most patients by us anyway prefer to sleep supine, even if they didnt befor surgery..

Heh .... well, I used to find in the UK that patients just about got used to sleeping supine by about six weeks ... ie the time we told them they no longer had to!

[emad]

Hi Mawr :

I meant it preaucation .Unfortunately ,I have seen implants long time ago during my undergraduate study ,so that I can not remember how much range does it allow ,however it may be different from producation to another , just preacuation for dislocation . As for timing of keeping not flexing beoyend 90 degrees ,usually I tell them that but have not thought of long term .I do think mobility is central here .
Just interesting to me ,in your practice do they recommend hip protector fallowing hip replacment for prevention of hip fracture ?

cheers
Emad

[morwenna]

Originally Posted by emad

.
Just interesting to me ,in your practice do they recommend hip protector fallowing hip replacment for prevention of hip fracture ?

No. We recommend our patients try not to fall over though!

The hip would not fracture following a total hip replacement anyway, though I have seen periprosthetic fractures (femoral shaft), usually later down the line.

[emad]

Well , I began a hip-fracture prevention program however seems the prevention program is complex needs cooperation from all society and health professionals .
There is eveidence that people who experienced hip fracture are more liable to have hip fracture on sound side and be ridden patient or sidentry .Of course, I am talking about elder people .

cheers
Emad

[morwenna]

Well our patients are virtually all having cold joint replacement surgery for OA so most are not especially at risk of falls.

People who have fallen and undergone a hemiarthroplasty (or occasionally a THA) to fix a fractured hip are a different case of course.