i bc27f85be50b71b1 (65 page)

208 AClJTE CARE HANDOOOK FOR PHYSICAL THERAPISTS

Figure 3·19. Total hip arthroplasty resection (Girdlestone).

Physical Therapy Intervention after Resection Arthroplasty

Physical therapy after a resection arthroplasty withollt reimplantation or a two-staged reimplantation is dependent on the extent of joint or bone destruction caused by the infection and the removal

of the prosthetic components, cement, and debridement of soft tissue. Weight-bearing restrictions may depend on use of cement spacers and vary from non weight bearing to weight bearing as tolerated, as established by the surgeon. Physical therapy sessions focus on functional mobility, safety, assistive device evaluation,

and maintenance of muscle strength and endurance in anticipation

for reimplantation of the joint.

• Patients who have an infection and joint resection arthroplasty

may be compromised by general malaise and decreased endurance

secondary to the infection, and, possibly, from increased blood loss

during surgery. This may lead to decreased pain tolerance. The

physical therapist should take these factors into account when

mobilizing the patient. Functional mobility training should begin

when the patient is stable, and physical therapy sessions should be

modified for patient tolerance.

• THA precautions often do not pertain after removal of the prosthesis. The physical therapist should verify any other precautions, such as trochanteric precautions (see Table 3-6) and weight-bearing status,

MUSCULOSKELETAL SYSTEM

209

with the surgeon. Without movement precautions, most isometric,

active, and active-assisted exercise may be appropriate. Progress the

patient as tolerated to maximize function, strength, and endurance in

preparation for eventual reimplantarion of the prosthesis.

• For knee resection surgery, strengthening exercises for the quadriceps muscle can be initiated as long as the extensor mechanism is intact. Isometrics, active-assisted, and active-straight leg raises can

be initiated according to patient comfort.

• Edema should be controlled with ice and elevation. Positioning

of the limb is important to decrease discomfort from muscle spasm

and the potential for deformities caused by muscle contractures

around the hip and knee.

Clinical Tip

• A hip Girdlestone procedure may leave a patient with a

significant leg-length discrepancy. A patient'S shoes should

be adapted with a lift to correct gait and increase weight

bearing on the affected extremity.

•

With decreased leg length, the musculature surrounding

the hip shortens. External (e.g., Buck) traction can be used

to maintain muscle length and may be used while the

patient is in bed. Shortened muscles may spasm. Isometric

exercises should be encouraged to gain control of these

muscles to reduce spasm.

• ROM should be minimal with knee resection so as to

maintain integriry of bone surfaces if reimplantation is

planned. A brace or knee immobilizer should be worn during functional activities to maintain knee extension but

can be removed in bed. The unaffected limb can assist

with lifting the affected limb with transfers out of bed.

• With a patient that is non weight bearing, a shoe on the

unaffected side and a slipper sock on the affected side can

assist with roe clearance when advancing the affected leg

during the swing phase of gait. Conversely, with a patient

who has a significant leg-length discrepancy, a slipper sock

on the unaffected side and a shoe on the affected side can

assist with ambulation until a shoe lift is obtained.

2 1 0

ACUTE. CARE HANDBOOK FOR PHYSICAL THERAPISTS

Surgeries of the Spine

The vertebral column fotms the central axial suppOrt of the body and

consists of bony segments and fibrocartilaginous discs connected by

ligamentous structures and supportive musculature. Degenerative,

traumatic, or congenital changes can cause compensation in the vertebral bodies, intervertebral discs, facets, and interverrebral foramen.

Any changes in these struc[Ures can result in dysfunction that, in turn,

causes pain. Some common dysfunctions of the spine and associated

structures are ligamentous sprain, muscle strain, herniated nucleus

pulposus, rupture of the intervertebral disc, spinal stenosis with nerve

root compression, spondylolisthesis, and degenerative disease of the

disc, vertebral body, or facet joints. Any dysfunction can present itself

in the cervical, thoracic, and lumbar spine.

Back pain is the major indication for spinal surgery. Pain can be

disabling ro a patient, limiting the ability to work or complete ADLs.

Any acute injury, such as muscle spasm, herniated nucleus pulposlls,

and chronic low back pain exacerbations, should be managed conservatively before surgical treatment is recommended. Many injuries will heal with treatments, such as bed rest, anti-inflammatory medication,

lifestyle modification, education in proper body mechanics, and outpatient physical therapy.56 Surgery may be indicated when rhese measures fail to relieve a patient'S symptoms or if there is a decline in the neurologic status of the patient.

Advances have been made in all areas of spinal surgery; however,

there is still no cure for low back pain. Low back pain and leg pain

can arise from degenerative disc disease and herniation or rupture of

the intervertebral disc. Surgical procedures can be performed to

relieve the symptoms associated with degenerative disc disease when

conservative measures have failed. Open disc surgery and microdiscecromy remove disc fragments and herniated disc material that compress the adjacent nerve root. Microdisceclomy is a minimally invasive procedure that uses a microscope to view the surgical area,

allowing for decreased surgical exposure '6 Most microdiscectomy

surgery can be done on an outpatient basis, and early return to activity can be accomplished. Symptom relief is high both inirially postoperatively and on a long-term basis.57 If additional exposure of the nerve root is needed, associated procedures, such as a laminectomy or

foraminoromy, may be performed in conjunction with discectomy or

spinal fusion. Refer ro Table 3-8 for descriptions and indications for

these procedures.

MUSCULOSKt::LI:.'AL SYSTEM

21 t

Table 3-8. Common Spinal Surgeries and Their Indications·

Surgery

Indication

Procedure

Discectomy or

Herniated nucleus

Removal of the herniation or

microdiscecromy

pulposus (HNP)

entire intervertebral disc.

Laminecromy

Spinal stenosis or

Removal of bone at the internerve root comlaminar space.

pression

Foraminotomy

Spinal stenosis,

Removal of the spinous pro

HNP, or multiple

cess and the entire laminae

nerve roOt comro [he level of the pedicle.

pression

Usually done in conjunction with a fusion to maintain spinal stability.

Carpectomy

Multilevel stenosis,

Removal of the vertebral

spondylolisthesis

body. The disc above and

with nerve root

below the segment is

compression

removed, and a strut graft

with instrumentation is

used to fuse the anterior

column.

Spinal fusion