What is Comprehensive Care for Joint Replacement Model
Model that moves away from fee-for-service payment systems and toward improving patient outcomes.
Value-based purchasing —> bundle payments
Mandatory for hospitals in areas covered and expanded to include OP replacement procedures
What does the CJR Model encourage hospitals to do
Coordinate care and collaborate with groups across the healthcare continuum.
Quicker patient gets better = better outcome = more pay
Hospitals are given a target price that includes cost of inpatient or OP procedure and all related care through 90 days post discharge!!!!
CJR implications for rehab
- PTs need data to demonstrate value in the CJR model — need to accurately identify and track patients s/p total joint
- Recommended outcomes = PROMS (global function measure), HOOS/KOOS (more specific to joint)
- PTs should be familiar with and promote EBP
- CJR = opportunity for care redesign including post-op protocols / clinical pathways — increased need for PTs in home health leads to decreased cost compared to SNF/Rehab.
Why are total joint surgeries increasing so much
- Expanding aging population
- Obesity
- Trauma
- Higher participation in high impact sports (more trauma = more injuries = more OA down the road)
THA options
- Metal on polyethylene
- Ceramic on polyethylene
- Ceramic on ceramic
- Large head metal on metal
- Ceramic on metal
Talk about ceramic on ceramic
- Wear and scratch resistance
- Decreased revision rates, osteolysis, aseptic loosening, and dislocation
- Less abrasion risk because has least amount of particles that are released with rubbing.
Types of impants
- Short stem total hip arthroplasty
- Hip resurfacing — less invasive, better outcomes after
- Total hip arthroplasty
How does Hip Resurfacing work?
- Femoral head is preserved
- No femoral stem
- Capped head — goes over the top of femoral head to make it smooth and articulate well with acetabulum.
Hip resurfacing candidate?
- Male, <60 years old
- Normal functioning kidneys
- Active lifestyle
- BMI < 30 — CAN’T BE OBESE BECAUSE TOO MANY FORCES THROUGH THE THING
Big picture younger and more active people
Post op hip resurfacing pros?
- Higher ROM
- Decreased chance of dislocation — because they have their own femoral dislocation
- Significant gains in ROM by 6 months and 1 year
- Pre-op flexion predicts post-op flexion and therefore can participate in higher level activities sooner
- Systematic review on post op review showed improvements in = gait, hip ROM, pain, ADLs. But not much in hip strength
What are 2 traditional THA approaches
- Anterolateral (anterior 1/3 of glute med and min released and repaired, ERs left intact)
- Posterolateral (short ERs and piriformis released and repaired, glute med and TFL left intact)
Both have an incision length of 15-25 cm
What is main reason for precautions and explaining to patients?
AVOID DISLOCATION OF NEW HIP
Minimally invasive surgery THA approach?
- Length of 1-2 incisions < 10cm
- Posterior approach = incision between interval between the glute medius and the piriformis muscles; short ERs may/may not be released and repaired
- Anterior approach = all muscles left INTACT — sartorius and rectus femoris retracted medially and TFL retracted laterally.
PRECAUTIONS
- Traditional Anterolateral THA — avoid hip flexion past 90, hip extension, abduction, and ER past neutral
- Traditional Posterolateral THA — avoid hip flexion past 90, no adduction past neutral, no IR past neutral
- Minimally invasive Surgery THA approaches — precautions may or may not happen, check with surgeon
- Hip Resurfacing — usually no precautions but check with surgeon.
Max protection phase for THA
0-4 weeks
- Prevent vascular/pulmonary complications
- Prevent dislocation/subluxation
- Achieve independent functional mobility
- Maintain functional level of strength in non-operated extremities
- Regain active mobility and control of the operated extremity
Mod protection phase for THA
4-12 weeks
- Regain strength and muscular endurance esp. with hip abduction and extension
- Improve cardiopulmonary endurance
- Restore ROM while adhering to precautions
- Improve postural stability, balance, and gait
Min protection phase for THA
12+ weeks
- Continued training for restoration of strength, muscular, and CardioPulm endurance, balance, and symmetrical gait
- Gradual resumption or modification of functional/recreational activities
Open chain exercises vs. Closed chain exercises
Open chain way to start with these patients — concentric and isometric first because easier
Closed chain is more functional but def harder so want to work up to it. There are more compressive forces so not ideal when you are trying to protect the joint
Designing a rehab program for arthroplasty
- Maximize strength
- Maximize flexibility
- Limit abnormal forces across the hip or knee — increasing forces as patient tolerates it
- Prevent hip/knee dislocation
- Prevent excessive wear
program variation over a training period to maximize gains and prevent overtraining
What’s going to be weak post op THA
Hip abductors
Hip extensors
Glute med
ERs
These are gonna be weak because of the nature of the surgery maybe and/or they were probably weak before the surgery was even recommended
what is going to be tight post op THA
Hip flexors
Hamstrings
TFL/glute med
QL
ERs
Wanna work to normalize the joint mechanics as much as we can whether its flexibility or strength or both
Hip motion requirements
Full squat
- Flex = 130 deg
- ER = 5-36 deg
- ABD = 10-30 deg
Cross-Legged
- Flex = 90-100 deg
- ER = 35-60 deg
- ABD = 40-45 deg
Structural vs. Functional THA leg length discrepancy
Structural = a true leg length difference
Functional = most are due to…
1. Pelvic obliquities (mm imbalances)
2. Muscle contractures
3. Tight capsular structures
4. Other joint abnormalities
*usually resolves by 12 months s/p THA
Muscular-balance length and strength that causes leg length discrepancy
- abd/add contractures
- QL tightness
- Hamstring tightness
- Hip flexor tightness and TFL
