Rehabilitation after endoprosthetics - features of recovery

Endoprostheses are artificially produced devices designed to replace certain internal human organs and fully perform their function. Thus, hip joint prostheses allow patients who have undergone surgery to perform the entire range of movements that people without pathologies in this area perform. In addition, prosthetics relieve pain and discomfort, making it possible to return to a full active life.

This type of intervention can be indicated in many cases: for diseases of the musculoskeletal system or after a hip fracture, if its motor function has been partially or completely lost.

Despite all the results that are achieved with the help of the operation, it is not always prescribed. The fact is that it has many contraindications and risk factors.

Recovery at home

If you decide that the recovery period after hip or knee replacement will take place at home, you need to prepare your apartment.
In the bathroom, handrails are installed for support during bathing, a bench is installed, and an anti-slip mat is placed. When taking hygiene procedures, relatives need to accompany the ward. Teach him to get in and out of the bathtub, holding the handrail tightly with his hands.

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Wires, carpets, and other obstacles are removed from the path of the household. Increase the height of a kitchen chair with a folded blanket or purchase a bar stool. Raise the bed, placing the second mattress. It is placed in the room in such a way that it is convenient to approach and lie down.

A bedside table or small table is placed next to the bed. It contains essential items:

• glasses;
• cellular telephone;
• phone charger;
• a bottle of water;
• flashlight;
• table lamp.

The lighting in the apartment is made optimal: so that the light does not dazzle and is not dim. Otherwise, a person will not be able to see the obstacle on the way and get around it. Discuss with your doctor what exercise equipment should be used to develop joints. Devices can not only be purchased. There are companies that provide devices for rent.

The recovery period of a joint after prosthetics is easier and faster in people with normal weight. Therefore, it is worth fighting extra pounds, eating healthy foods, and sticking to a diet. It is useful to introduce foods rich in calcium, protein, collagen into the diet: milk, fish, meat, jellied meat, fruit jelly.

Shoes for a relative with a prosthetic joint are chosen to be comfortable, preferably orthopedic, without laces. Purchase crutches or a walker with four legs for walking. They must have tips made of non-slip materials. Normally, a person starts walking with a cane 2 months after installation of the prosthesis.

Elderly people need more time to adapt to the joint.

Patients begin to walk without a cane after six months. The mode of walking in the fresh air is: several times a day for 30 minutes. A limb with a prosthesis begins to be used as a support when walking after 2 months.

You should avoid physical activity and do not carry heavy objects. If redness and swelling in the joint area or fever appear, you should immediately consult your doctor.

Relative contraindications

Relative contraindications are factors that do not prevent the installation of a prosthesis, but are a reason to conduct more detailed studies and consider the possibility of surgery on an individual basis.

Such indications usually include the following cases:

• oncological diseases;
• chronic somatic pathologies (sometimes);
• mild liver failure;
• hormonal osteopathy;
• some technical difficulties in installing the prosthesis;
• obesity of the 3rd degree.

Modern developments in the field of medicine and orthopedics make it possible to perform unique operations even in the presence of these factors. Over time, many features are no longer considered contraindications.

Exercises after hip replacement

In a rehabilitative exercise program, daily workouts involve different muscle groups. Loads are increased gradually, taking into account the general health and age of the person. Tasks must be performed strictly according to the instructions to prevent dislocation of the artificial joint.

In the first postoperative week, gentle activity is useful: breathing exercises, Thomas testing technique. At the later stage of treatment of the hip joint, classes are carried out in various states: lying down, sitting, with a transition to verticalization of the body with additional support.

Exercise No. 1

1. Lie on your back.
2. Tighten your buttocks and bring them together, as if holding a pencil between them.
3. Stay in this state for 6 seconds.
4. Relax for 5 seconds.
5. Repeat the task.

Exercise No. 2

1. Sit up in bed.
2. Pull in your stomach.
3. Straighten your shin.
4. Bend and pull the toe towards you.
5. Stay in this state.
6. Slowly lower your shin.

To stretch muscles and develop a new joint, each task should be performed 6-8 times. The lesson consists of a series of similar training tasks.

RDN, posture and walking

The role of RDN in standing

Check for specific compensation used by the patient to compensate for height differences.

• If the leg remains uncompensated, the anterior and posterior iliac spines on the side of the shortened leg may be lower, which can lead to pelvic tilt and/or scoliosis.
• Increased muscle activity in several muscle groups.

The role of RDN in walking

• Gait asymmetry along the entire kinetic chain.
• A vertical displacement of the center of mass leads to an increase in energy consumption. Compensatory mechanisms include calcaneal eversion, knee extension, toe walking, circumduction, hip or knee flexion, and stepping.
• Reduced stance phase time and step length on the side of the shorter leg.
• Reducing walking speed, increasing cadence (step frequency).

The role of RDN in running

The biomechanics of running are different from the biomechanics of walking. When running, the vertical vibration is greater and there is no double support, so the weight is not distributed equally between the legs. When running, the stance phase is only 30%, while when walking it is 60%. This leads to an increase in the load on the lower limb (the load becomes three times greater than when walking). Data on the effects of running are conflicting, but it is believed that the effect of RDN is also tripled.

Exercises after knee replacement

During the recovery period, doctors recommend performing a standard set of tasks: flexion and extension of the knee joints, pulling the operated leg up. At an early stage, exercises should be performed lying on your back. At a later stage - standing, using a chair or table for support.

Exercise No. 1

1. Sit on a chair.
2. Place your feet on the floor.
3. Bend and straighten the limb at the knee, making sliding movements with the heel on the floor.

Exercise No. 2

1. Sit on the edge of a chair, place your heels on the floor.
2. Straighten your leg and pull your foot towards you.
3. Keep your back straight.
4. Lean forward until you feel a stretch on the back of your thigh muscles.
5. Hold your body in this position for 5 seconds.
6. Straighten up, return to your original state.

Exercise #3

1. Stand next to a chair or table, holding onto it with your hands.
2. Shift your body weight from one side to the other.
3. Lift one leg off the floor and lift it, holding for 4 seconds.
4. Place it on the floor.
5. Distribute body weight evenly.
6. Repeat the task, maintaining balance alternately on the healthy and sore leg.

A person with an implant will have to limit his sports hobbies throughout the rest of his life. Football, hockey, and weightlifting are contraindicated for him. Swimming, cycling, skiing and race walking are allowed.

Epidemiology

RDN occurs in approximately 70-90% of the population. Passive structural changes - pelvic torsion, mild lumbar scoliosis, facet joint deformity, changes in muscle length - appear to be able to compensate for ARDD up to 20 mm. After the ~20 mm point, passive structural changes give way to active muscle compensatory mechanisms.

Some authors have attempted to define a significant level of RDN through quantitative assessment, others through significant discrepancies in functional outcomes. Prevalence rates for leg length discrepancies often lack important information about demographics, examiner experience, patient recruitment methods, and methods used to identify leg length discrepancies, yet they are frequently cited and used by other authors.

Rehabilitation at home and boarding house

After hip and leg replacement, the recovery period is best spent in a specialized center or private boarding house. Patients will be closely monitored by medical personnel.

All types of movements and increased physical activity are performed according to the recommendations of doctors. Treatments are carried out by qualified specialists, after consultation with a surgeon and kinesiotherapist. In medical centers and boarding houses for the elderly, unlike at home, there are special devices, apparatus, and simulators for improving motor skills. Mobility aids are provided: walkers, crutches, canes.

The advantage is that the services are provided in one place. At home, you will either have to invite massage therapists and physical education instructors to your home, paying for their services, or go to the clinic every day.

As a rule, one of the family members remains at home with the ward. It is difficult for him to combine different functions and provide versatile support. The boarding house uses an interdisciplinary approach, healing techniques are varied in a timely manner based on the results of weekly observations.

Classification of leg length discrepancies

There are two types of RDN non-compliance:

• Anatomical (ARDN) difference

This is a physical (bone) shortening of one lower limb between the trochanter of the femur and the ankle joint. Congenital conditions include mild developmental disabilities found at birth or during childhood, while acquired conditions include trauma, fractures, orthopedic degenerative diseases, and surgical cases such as joint replacements. A systematic review assessing the prevalence of ARDN using radiographic measurements found that 90% of the normal population had some type of lower limb length dispersion, and 20% showed a difference of >9 mm (Khamis, 2017).

• Functional (FRDN) difference

This is an asymmetry of the lower extremities without any shortening of their bony components. FERD can be caused by changes in lower extremity mechanics, such as due to joint contracture, static or dynamic mechanical axis misalignment, muscle weakness or shortening. It is not possible to detect these defective mechanics using a non-functional assessment such as radiographic examination. FERD can develop due to abnormal movement of the hip, knee, ankle, or foot in any of the three planes of motion.

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It is clear that people with a long history of RDN are able to cope with greater RDN values ​​than those who have received artificial or induced RDN. This is reasonable because, given enough time, most people could reduce the energy and mechanical costs of RDN. In addition, young adults are generally able to adapt to greater RDN than older adults (given that walking patterns have been shown to vary significantly between old and young adults and that older adults have greater difficulty learning new motor tasks). A person's activity level also appears to play a role. People who are on their feet or exercising most of the day appear to be more sensitive to RDN than those who are less active.

Types of prostheses and manufacturers of artificial joints and prosthetic options:

In the Russian market today, many manufacturers of endoprostheses from the USA, Switzerland, Germany, Great Britain, France, and Russia compete, which offer a huge number of different models and systems of endoprosthetics.

All these companies and their products are quite competitive with each other and, by and large, differ only in service.

The hip joint endoprosthesis consists of an acetabular component (cup), a femoral component (leg), a head and a liner (polyethylene, ceramic).

The knee joint endoprosthesis consists of a femoral component, a tibial component and a polyethylene liner.

The components of endoprostheses are made from various high-tech materials (titanium, steel, ceramics, polyethylene).

In principle, all joint endoprostheses are divided according to the type of fixation of the prosthesis in the bone into prostheses with cementless and cemented fixation.

Today, in most cases of primary coxarthrosis, cementless hip replacement is performed; cement fixation is used only in cases of severe osteoporosis, during revision surgeries.

As for knee replacement, in most cases only cement fixation of the endoprosthesis is performed.

Postoperative treatment:

Postoperative inpatient treatment:

Stay in the hospital – 5-7 days. After the operation, the patient is in a single ward under constant 24-hour dynamic monitoring of the resuscitator on duty.

The patient is undergoing: - Intensive therapy. — Infusion therapy; — Blood transfusions; — Plasma transfusions. — Anticoagulant therapy (Clexane, Fraxiparine, Pradaxa). — Systemic antibiotic therapy.

Physiotherapeutic treatment: exercise therapy and learning to walk with the help of crutches from the 2nd day after surgery.

Local wound treatment (removal of drainage on days 1-2, postoperative dressings).

Why might endoprosthetics be required?

It is quite natural that in order to perform hip replacement with an artificial prosthesis, there must be significant indications. They are based on such destruction of the components of the joint, in which a person either experiences excruciating pain or is unable to perform basic movements of the affected limb. In other words, the joint ceases to fulfill its physiological purpose and becomes an unnecessary part of the body, as it sharply disrupts the quality of life. In such cases, only endoprosthetics can be the only solution to their situation.

Among the diseases that can provoke destructive changes in joint structures, the most common are:

· Deforming osteoarthritis of the hip joint (coxarthrosis), occurring simultaneously on both sides in grades 2 and 3 of the disease;

· Coxarthrosis of the 3rd degree with deformation of one joint;

· Unilateral deforming arthrosis of the hip joint of 2-3 degrees in combination with ankylosis (complete immobility) of the knee or ankle joint of the affected limb;

· Damage to one hip joint by grade 2-3 coxarthrosis in combination with ankylosis of the same joint on the opposite side;

· One- and two-sided ankylosis of the hip joints in ankylosing spondylitis and rheumatoid arthritis;

· Destruction of the femoral head (aseptic necrosis) caused by injury or circulatory disorders;

· Traumatic injuries of the head and neck of the femur in the form of a fracture or false joint in persons over 70 years of age;

· Malignant tumors in the ankle joint requiring surgical treatment. After tumor resection, simultaneous endoprosthetics is performed.

It is advisable to replace the hip joint with an artificial prosthesis only if its structure and functions are so impaired that motor activity of the limb and walking become almost impossible. In this case, the actual possibilities of implementation and the benefits of the operation in each specific case must be taken into account!

Cemented and cementless endoprosthetics

A very pressing issue for both specialists and their patients is the choice of method for fixing the endoprosthesis. In this regard, things are not so simple for several reasons. After all, metal and ceramic materials must be firmly connected to the bones. Only if this condition is met is it possible to perform the function of support and walking with the affected limb.

Having selected the correct type of endoprosthesis and its size, the choice of method for connecting it to tissues is made during surgery, guided by the following tactical decisions:

· Fixation of the endoprosthesis using cement - a special biological glue, which, after hardening, will firmly connect the osseous tissues with the structures of the endoprosthesis;

· Cementless fixation. Such products have a special design and are designed in such a way that there are many small protrusions, depressions, irregularities and holes on their surface. Over time, bone tissue grows into them, and the prosthetic bone becomes a single complex with the endoprosthesis;

· Hybrid or mixed fixation. Involves a combination of cement and cementless methods. In this case, the stem is fixed in the femur with cement, and the cup is screwed into the acetabulum.

Many years of observation by specialists of patients after such interventions allowed us to draw the following practical conclusions:

· When cement cools, it creates a very high temperature. This leads to accelerated destruction of the surrounding bone tissue, which can cause failure of the prosthesis and its failure into the pelvic cavity;

· Cement fixation speeds up rehabilitation and shortens the recovery time of patients, but its use is limited in patients with osteoporosis and the elderly;

· Cementless endoprosthetics is associated with prolongation of the terms of full rehabilitation. Patients must maintain a limited motor regimen for much longer due to the high risk of impaired stability of the prosthesis fixation;

· Endoprosthetics using combined methods of fixing different parts of the product is considered the most optimal. This rule is the gold standard of treatment tactics for patients of all age groups.

Preoperative preparation and surgery:

What type of endoprosthesis is suitable for the patient is planned only by the operating doctor during the preoperative examination.

Preoperative examination includes a list of standard tests and consultation with a therapist before surgery. A prerequisite before prosthetics is the sanitation of foci of chronic infection (dentistry, ENT, etc.).

To perform this type of operation, an operating room of the 1st degree of cleanliness is required, which is not provided in all hospitals. The duration of the operation is from 1 to 2 hours. Most often, joint replacement (joint replacement) is performed under combined anesthesia (epidural or spinal with intravenous support), in 10% of cases endotracheal anesthesia is required. The operation is accompanied by blood loss from 100 ml to 1 liter, and requires intraoperative or postoperative blood transfusion in 10% of patients.