Total Joint Repair Complications
Inpatient Physical Therapy Inservice
Total Joint Arthroplasty Problems
Post-operative complications can cause inpatient physical therapists to attempt therapy on a patient multiple times or even prevent a patient’s discharge, which causes increased load on the physical therapists and PTAs, physical therapy administration, nursing, orthopedic department, and other aspects of the hospital.
Causes of failed discharge
- Orthostatic intolerance1
- Insufficient muscle strength
- Poor sensation
Orthostatic Hypotension & Intolerance
Orthostatic Hypotension (OH)
Orthostatic hypotension refers to the clinical decrease in blood pressure associated with changes in position.
| Type | Definition |
|---|---|
| Classic | Decrease in SBP of >20mmHg or DBP ≥10mmHg after 3 minutes of standing or head-up tilt (HUT) ≥60° on a tilt table2 |
| Initial | Temporary BP decrease of >40mmHg SBP or >20mmHg DBP within 15 seconds of standing2. |
Orthostatic Intolerance (OI)
Orthostatic intolerance is a presentation of symptoms associated with a sitting or standing position including:
Patient Presentation
On average, most orthostatic events occur within the first 12 hours after the surgical procedure, but can occur up to 48 hours after surgery1.
Etiology
The causes of post-op orthostatic hypotension include:
Pathophysiology
Although there the pathophysiologic mechanism of orthostatic intolerance is not fully understood, there is a widely accepted theorized mechanism of orthostatic intolerance.
- Standing up leads to a decrease in blood pressure rostrally and an increase in BP caudally.
- The blood shifts below the diaphragm to the venous capacitance system3.
- The fluid shift causes a decrease in venous return, ventricular filling, cardiac output, and blood pressure3.
- This gravity-induced BP change is sensed by arterial baroreceptors in the aortic arch and carotid sinus3.
- The body dysfunctionally has a diminished vasopressor response and absent baroreflex to these pressure changes1.
- Due to the diminished autonomic response, the rostral blood pressure decreases.
- Decreased rostral blood pressure results in cerebral hypoperfusion1.
- Cerebral hypoperfusion can result in the syndrome of symptoms known as orthostatic intolerance1.
Pre-op Risk factors
Patients in these groups had statistically significantly higher rates of OI:
Predictors
When the above differences were examined using a multivariable analysis, only 4 items were found to significantly impact the odds of having orthostatic intolerance:
Pharmacological management
There are pharmacologic measures that reduce orthostatic hypotension. The problem is that pharmacologic interventions that improve OH cause other cardiac side effects, primarily supine hypertension and ventricular hypertrophy4. In addition, since physical therapists cannot prescribe medications this is irrelevant to the profession.
Hydration
A systematic review by Figueroa3 found that drinking 16-oz of cold water can improve OH and related symptoms by expanding the plasma volume3. Within a few minutes, the cold water produces a pressor effect, which results in improve orthostatic hypotension by increasing standing SBP by >20 mmHg for ~2 hours and reducing symptoms of orthostatic intolerance3.
Caffeine / Caffeine withdrawl
According to a systematic review by Gibbon and Frith, caffeine had inconsistent effects on orthostatic hypotension, but no serious adverse events were reported5.
Sitting up
Night positioning
Elevating the head of the bed at night by 10-20° could decrease nocturnal hypertension and diuresis3.
Day Positioning
During the day, adequate orthostatic stress, ie, upright activity, should be maintained. If patients are repeatedly tilted up, their orthostatic hypotension is gradually attenuated, presumably by increasing venomotor tone.3
Exercise
Physical countermaneuvers can be performed to reduce venous capacitance, resulting in increased total peripheral resistance which assists venous return to the heart3.
Patient Education
Considered the “single most iimportant factor” in orthostatic hypotension management by Figueroa3.
Items to consider:
- The mechanisms that maintain postural normotension and how to recognize the onset of orthostatic symptoms3.
- There is no specific treatment of the underlying cause and that drug treatment alone is not adequate3.
- Nonpharmacologic approaches and be aware that other drugs they start may worsen symptoms3.
Educate the patient on environmental stressors
- Prolonged or motionless standing
- Alcohol ingestion (causing vasodilation)
- Carbohydrate-heavy meals (causing postprandial orthostatic hypotension related to an increase in the splanchnic-mesenteric venous capacitance),
- Nocturnal diuresis causing early morning orthostatic hypotension
- Physical activity sufficient to cause muscle vasodilation
- Heat exposure (eg, hot weather or a hot bath or shower) producing skin vessel vasodilation
- Sudden postural changes
- Prolonged recumbency
Inpatient approach
- Perform motor and sensory evaluations first
- Move patient to sitting EOB as soon as possible
- Continue with subjective and objective
- (+) Hypotension
- Have the patient drink water
- Perform exercises sitting EOB
Dropfoot
Drop foot refers to a sign of motor weakness caused by common fibular nerve palsy.
Etiology
During surgery, the nerve can be damaged through:
- Direct trauma6
- Thermal injury6
- Retractor placement6
- Hardware dislocation6
- Perforation6
- Postoperative Hematoma6
- Postoperative pseudotumor6
Up to 50% of the cases are idiopathic6
THA
Injury to Common fibular division of the Sciatic nerve6.
TKA
During a TKA, either the common fibular division of the sciatic nerve or the Common fibular nerve itself is damaged at some point during the operation.
Epidemiology
Common fibular nerve vs Tibial Nerve
- Injuries to the sciatic nerve during total joint arthroplasty can affect the Common fibular division and/or the tibial division of the sciatic nerve6.
- Injuries to the tibial division are less severe and less common6.
Patient Presentation
Sensory symptoms
Sensory on dorsal aspect of the foot:
- Decreased sensation
- Numbness
- Tingling
Motor Symptoms
Loss of function in
- Tibialis anterior
- Extensor digitorum longus
- Extensor hallucis longus
- Fibularis longus
- Fibularis brevis
- Fibularis tertius
Resulting in
- Dorsiflexion weakness/paralysis (footdrop)
- Eversion weakness/paralysis
Onsert
Symptoms should be present by shortly after the operation in the recovery room or at the ward7.
Management
Patient education
If the foot drop is caused by the surgery, you shoudl educat the patient that they need to advocate for themselves to home health physical therapy and outpatient physical therapy, that this issue was caused during the surgery and should be part of the physical therapy management.
Positioning
Passively positioning the ankle in dorsiflexion and eversion is important to prevent contractures8.
Stretching
Stretching the Triceps surae and the associated achilles tendon is important to prevent contractures8.
Anemia
Definition
Hemoglobin (HB) level is below the normative value:
Secondary complications
- acute kidney injury (AKI)9
- Delirium due to decreased oxygen transport9
- Delirium often occurs postoperatively with an incidence of up to 74%9
- Orthostatic intolerance1
Management
There is very little physical therapists can perform in the short term to prevent acute iatrogenic anemia.
At the same time, acute anemia will have little effect on whether a physical therapist can perform their evaluation and discharge, except for orthostatic hypotension. Thus the best way to manage acute iatrogenic anemia, is to treat the symptoms of OI as outlined above1.