BERNICE HOWELL, RN

Joint surgery: Paving tiie way to

Hip and knee replacenfients can relieve pain, allowing people to live more active lives. Your nursing care can help these patients avoid postop complications.

oint replacements are among the most common and successful orthopedic surgeries, giving more people the opportunity to remain active well into their golden years.^

The American Academy of Orthopaedic Surgeons estimates there are more than 193,000 total hip replacements (THRs) and 365,000 total knee replacements (TKRs) performed every yearnumbers that have more than doubled since 1990.^ Most patients who undergo total joint replacement, or arthroplasty, experience a dramatic reduction in pain and a significant improvement in their ability to function in daily life.^ The growing number of joint replacement surgeries means an increasing number of patients who'll require the expert postop care aimed at preventing complications and additional surgery. That's where you come in, and why you need to be well-informed.

Arthritic patients can be helped

The main reason for joint replacement surgery is osteoarthriHs, which affects 30 million Americans, most of them older adults." In normal, healthy joints, smooth, articular cartilage covers the ends of bones, and there's ample space for easy joint motion. Osteoarthritis wears away the cartilage,, resulting in de-

BERNICE HOWELL is an RN for Allegheny Orthopedic Associates at Allegheny General Hospital in Pittsburgh, The author has no financial relationships to disclose. STAFF EDITOR: Linda M. Roman

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a smooth recovery
formity and abnormal articulation, accompanied by pain and limited motion.^ Younger patients benefit from joint replacement surgery, too, including those with traumatic injury or debilitating illnesses such as rheumatoid arthritis. Another indication for the surgery is osteonecrosis, a disease resulting from the temporary or permanent loss of blood supply to the hip joint.^ An orthopedic surgeon evaluates a candidate for joint replacement surgery by taking a detailed history and performing a physical examination to assess the motion, strength, stability, and position of the diseased joint. X-rays are essential to establishing the diagnt>sis and determining whether surgical inten'^ention is necessary. Once surgery is scheduled, the patient may require further evaluation by a primary care physician or other specialists to detect conditions that could interfere with surgery or recovery. For example, it's important to rule out the possibility of a urinary tract infection or dental disease. If undetected and left imtreated, either of these conditions could result in disastrous consequences, as infection could spread through the bloodstream to the new artificial joint. During THR, the orthopedic surgeon will clean the acetabular socket by removing damaged cartilage and bone, then position and secure the artificial joint surfaces to restore the alignment and function of the patient's hip. Many different designs and materials are used in artificial hip joints. The ball componentan artificial femoral head and stemis made of metal or ceramic, and the metal socket component has a plastic, ceramic, or metal cup liner.^'' During TKR, the femur and the tibia may be replaced by prostheses made of metal alloys, high-grade plastics, and polymeric materials.'^ Most of the other structures of tiie knee, such as the connecting ligaments, remain intact." The surgeon smootlis the rough edges of bones, and trims or removes damaged portions. If damage is restricted to tlie medial or lateral surface of the knee joint, he may consider a procediu'e called unicompartmental artliroplasty, which essentially involves only half a prosthesis. It's a simpler procedure that allows for a greater degree of knee flexion following surgery.^' For either THR or TKR, the surgeon may use polymetliylmethacrylate, a fastsetting bone cement, to secure the artificial joints. Non-cemented prostheses, first introduced m the 1980s, are generally placed in younger, active patients with stronger bones. Tlie prosthesis may be coated with textured metal or a special bone-like substance, which allows bone to grow into the prosthesis.^

Care involves limiting complications

Postop nursing care includes many of the standard protocols as well as those specific to joint replacement. Nursing priorities are to prevent complications, manage pain, and teach patients how to care for themselves after

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discharge. (See the patient information handout on page 35.) With total joint replacement surgery comes the risk of deep vein thrombosis (DVT), pulmonary embolism (PE), nerve injury, dislocation of the artificial joint, and ir\fection. The risk of complicahons is greater for patients who are obese or have peripheral vascular disease or diabetes. These conditions can delay woimd healing. Excess weight also places increased stress on the components and adjacent bones." Your diligent assessment and nursing care are essential to the prevention and early identification of postop complications. In addition to standard postop interventions, such as teaching patients to cough and deep breathe, and use an incentive spirometer, your interventions will focus on the following potential problems:^ DVT and PE. To prevent DVT and its tifethreatening consequence, PE, the Seventh American College of Chest Physicians (ACCP) Conference on Antitlirombotic and Thrombolytic Therapy recommends that patients who undergo elective hip or knee replacement surgery receive one of the following: a vitamin K antagonist such as warfarin (Coumadin), the antithrombotic drug fondaparinux (Arixtra), or low molecular weight heparinenoxaparin (Lovenox) or dalteparin (Fragm^in), for example." Depending on wliich agent and dose are chosen, the regimen may begin before surgery or six to 24 hours postop."^ DVT prophylaxis may continue for several weeks, as studies show that 90'^ of the fatal PEs in THR patients occur within four weeks of surgery."^" Teach patients to be alert for the signs of DVT and PE and to seek help if they develop shortness of breatli, chest pain, an unexplained cough, bloody sputum, or leg pain, tenderness, warmth, swelling, or discoloration. (More information on DVT will appear in the February 2007 issue of RH.)

STAT Facts
Deep vein thrombosis and infection are among the risks of joint replacement surgery. Distocation occurs less frequently in total knee replacements than in totol hip replacements. A new artificiol joint should lost 15 years or longer, depending on the patient's activity level.

Immobility is a risk factor for DVT, so early postop ambulation is important. Bed rest is recommended the day of surgery, but most patients are assisted out of bed and, if tolerated, started on physical therapy on the first postop day. Effective pain control is crucial to early ambulation. Patients may get an epidural, patient-controlled analgesia (PCA), or oral medications, as ordered. Teach your patient how to properly use his PCA and to employ relaxation techniques like focused breathing. A patient whose pain level is tolerable will be more active and willing to engage in physical therapy.^ Don't underestimate the potential benefits of mobility. Early ambulation not only reduces tlie risk of DVT, it prevents other postop pulmonary and neurovascular problems as well.^ Peroneal nerve injury. This complication may occur after TKR as a result of nerve compression during the procedure, the use of traction, or ischemia. Complete peroneal nerve palsy can cause weakness of the foot musculature and may result in foot drop. As part of your postop care, keep the wound dressing loose and ensure that the knee remains flexed.** Foot dropalso caused by lying in bed too longis prevented or treated with a splint or an ankle and foot orthosis to assist with ambulation.^ To detect problems like peroneal nerve injury, perform a neurovascular assessment every two hours for the first 24 hours after surgery, then every eight hours until discharge. Notify the surgeon immediately of any new neurovascular deficits.** Dislocation of the artifidat joint. Following THR, dislocation most often happens during the first postop month." To avoid internal and external rotation of the hip joint, keep the patient's feet straight and slightly apart while he's sitting or lying down. Tell the patient not to cross his legs or ankles, and place an abductor pillow between his legs while in bed. Teach him to continue these practices even after he's been disdiarged. The patient also shouldn't flex his hip more than 90 degrees, so advise him to use an elevated commode seat in the hospital as well as at home, refrain from sitting in low chairs, and use an assistive reaching device instead of leaning forward to pick things up. Hip precautions usually remain in effect for four to 12 weeks.'" Be aware that the THR prosthesis may result in tmequal leg lengths. If this happens, the surgeon may reconmiend, after a follow-up exam six to 12 weeks postsurgery, that the patient be fitted with a shoe lift.'" Dislocation occurs less frequently in TKR than in THR. Use ice packs on postop knees for 48 hours. Place

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a pillow under the patient's leg from the calf joint isn't likely to be the same as that of a to the heel, avoiding the popliteal space normal joint. However, it should function directly behind the knee. well enough to allow them to participate in For two years the activities of daily living.'' Adequate Later, teach the patient not to sit for long after joint knee motion, in particular, is critical to the periods with the knee bent and to avoid repiocement, resumption of normal, daily activities such deep knee bends and kneeling. Regardless patients should as walking, negotiating stairs, and getting of the type of surgery the patient had, reinup from a seated position, which demands force your teaching with written instructake antibiotics knee flexion of 90 degrees or more."' tions that he can use once he leaves the before baving hospital. After surgery, a TKR patient may need to any dental Infection. This complication occurs in use a continuous passive motion machine, procedures. less than 2% of joint replacement patients, which will slowly and gently Ilex and exbut its consequencesincluding further tend the knee, to improve the knee joint's surgery and removal of the diseased implant :an be range of motion. Knee stiffness usually resolves within severe.^'' You'll monitor for wound infection immedisix to eight weeks postop. ately postop, but after discharge, it's essential that If limited motion persists beyond that time, addipatients notify their physician if they have fever, fluid tional treatment measures may be necessary, including buildup in the operative site, inflammation, or persissurgical manipulation under anesthesia, arthroscopic tent pain that's not relieved by rest." lysis of adhesions, or arthrotomy with extensive soft tissue release.'" If the infection becomes chronic, tlie patient may have to undergo a two-stage surgical revision. The surPatients resume most activities of daily living at six geon will need to remove the implant and debride the to eight weeks postop. They may hesitate to ask, so soft tissue by irrigating the wound. Then he'll implant you'll need to offer guidance on when they can resume temporar)' antibiotic-laden cement beads or a prosthesexual activityusually in four to eight weeksand sis that delivers medication directly to the area and prohow they can do so without dislocating their new vides stability to the joint.'^ When the infection is elimijoints. For tips on how to approach this subject, and nated, the surgeon will implant another permanent information on safe positions, see "New meaning for prosthesis in six to eight weeks.** safe sex" in the January 2003 issue of RN, available online at www.mweb.com. Teach patients that the presence of any infection increases the risk that the infection will migrate to the If a patient's plans include travel and his prosthetic site of the implant. Both the American Dental Associaimplant is made of metal, let him know that the prostion and the Academy of Orthopaedic Surgeons recomthesis may set off metal detection devices at airport mend that for two years following joint replacement security checkpoints. Some surgeons provide patients surgery, patients take prophylactic antibiotics prior to with a card or note to this effect, which patients can undergoing dental procedures. Such procedures may then present at airports or other facilities where secuinclude teeth cleaning, extraction, dental implant, rity is an issue. endodontic surgery, placement of orthodontic bands, or injection of local anesthetic into the gums."

Smaller incisions, shorter stays

Educate patients before discharge

Patients undergoing joint replacement are usually hospitalized for about three to five days. After discharge, they may go to an inpatient rehabilitation facility, or directly home with arrangements for visits from a physical therapist. With today's shorter hospital stays, patients are often discharged before achieving functional milestones like managing stairs. Remind patients that their surgery won't be successful without proper postop rehabilitation to regain function of the joint and strengthen muscles. Advise patients that the motion of their artificial

No discussion of joint replacements would be complete without mention of the newer "minimally invasive" procedures. Are they worthy of all the publicity? And how do they differ from standard joint replacement? Minimally invasive surgery has been promoted as the newest advancement in joint replacement procedures, allowing surgeons to perform joint replacement using smaller incisions. Traditional THR involves a 10-inch to 12-inch incision, while a single minimally invasive liip incision may measure only 3 to 6 inches. Likewise, a TKR that usually involves an 8-inch to 10-inch incision can be accomplished with a 4-inch to 6-inch incision. '"''"'

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Still cinother minimally invasive procedure for THR involves a two-incision technique. Using X-rays to guide him, the surgeon makes a 2-inch to 3-inch incision in the groin for placement of the socket, and a 1-inch to 2-inch incision in the buttock for placement of the stem. While the larger opening created during traditional hip surgery allows ample space for the surgeon to work and provides complete visualization of the joint, it also causes disruption of the soft tissue, meaning more substantial blood loss and a longer period of postop rehabilitation.'*''' A smaller incision causes less disruption of the soft tissue, and therefore less blood loss, a shorter hospital stay, and shorter postop rehabilitation. But the surgery may take up to two or three times as long to perform as traditional hip replacement surgery, increasing the risks associated with anesthesia.'"^ The smaller incision means there's less direct visualization and less room for the surgeon to work. And because a greater amount of retraction is required to open the incision, damage may occur to the skin or musculature.'" In response, special instruments have been created for these types of surgical procedures. Such instruments include lighted retractors, low-profile reamers, and offset acetabular/femoral instruments, which can mudi more easily accommodate a smaller incision."* The results of studies to assess postop recovery and
1. American Association of Hip and Knee Surgeons. "Minimally invasive and smail incision joint replacement surgery: What surgeons should consider." 2004. www.aahks.org/pdf/MiS_phys _adv_stmt.pdf (26 Oct. 2006). 2. Kurtz, S.. Mowat, F., et ai. (2005). Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Jo/nfSurg^m, a7[7). 1487, 3. American Academy of Orthopaedic Surgeons, "Total hip replacement," 2006. http://orthoinfo.aaos.org/fact/thr_report -ctm?Tnread_lD=504&topcategory=Joint%20Replacemem (26 Oct. 2006). 4. Hohler, S. E. (2004). Minimally invasive total hip arthroplasty. AORNJ. 79{6). 1244. 5. Arthritis Foundation, "Osteonecrosis." 2006. www.arthritis.org /condit(ons/DiseaseOenter/osteonecrosis,asp (26 Oct. 2006). 6. Lucas, B. (2004), Nursing management issues in hip and knee replacement surgery- Br J Nurs, 73(13). 782. 7. American Academy of Orthopaedic Surgeons. "Knee implants." 2001, http://orthoinfo.aaos.org/fact/thr_report.cfm VThreadJD =279&topcategorv-Joint%20Replacement (26 Oct. 2006). 8. Best, J. T. (2005). Revision total hip and total knee arthroplasty. Orthop Nurs. 24{3). 174. 9. Geerts, W, H., Pineo, G. F.,etal. "Prevention of venous thromboembolism: The seventh ACCP conference on antithrombotic and thrombolytic therapy," 2004. www.chestjoumal.org/cgl /content/full/126/3_Suppl/338S (27 Oct 2006). 10. Bitar. A. A., Kaplan, R. J.. et al. (2005). Rehabilitation of

rehabilitation following minimally invasive joint replacement procedures have been promising, with hospital discharge noted as early as the day of surgery for both THR and TKR.''' But it's wise to keep in mind that the long-term effects have yet to be confirmed.'^ Whatever the surgical technique, in the absence of comphcations, a new artificial joint is expected to last 15 years or longer, depending on the patient's activity level. Over time, however, the fixation may wear out or loosen from the bone, and surgical revision may be necessary. To ensure that the new artificial joint continues to function properly, long-term follow-up is recommended.''' Advise your patients to go for periodic X-rays, which may reveal evidence of osteolysisbone lossa sign of implant loosening that may occur months or years before the patient becomes symptomatic. With your care and teaching, joint replacement patients can achieve the best possible outcomes. Many of them will enjoy pain-free movement for years to come. RN

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REFERENCES orthopedic and rheumatologic disorders. 3. Total hip arthroplasty rehabilitation. Arch Phys Med Rehabil, 86(3 Supp11). S56. 11. Phillips. C , Barrett, J. A., el al. (2003). Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am. 85A^^). 20. 12. Malek, M. M., Fanelli. G. C . et al. (2001). Knee surgery: Complications, pitfalls and salvage. New York: Springer-Verlag. 13. Harwin, S. P. (2002). The diagnosis and management of infected total knee replacement. Seminars in Arthroplasty. ^3^^). 9. 14. American Academy of Orthopaedic Surgeons. "Minimally invasive hip replacement." 2004. http://orthoinfo.aaos.org/fact/thr .report.cfm?Thread_ID^471&topcategory=Joint%20Repiac6 ment (26 Oct. 2006). 15. American Academy of Orthopaedic Surgeons. "Minimally invasive total knee replacement." 2005. http://orthoinfo.aaos.org /fact/thr_report. cfm?Ttiread JD^472&topcategory=Joint%20Rep lacement (26 Oct. 2006). 16. Waldman, B, J. "Advancements in minimally invasive total hip arthroplasty." 2003. www.orthosupersite.com/print.asp7rlD =2306 (14 Nov. 2006). 17. Berger. R. A., Jacobs, J. J., et al. (2004). Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relai Res, Dec(429), 239. 18. Teeny, S. M.. York. S. C . et al, (2003). Long-term fotlow-up care recommendations after total hip and knee arthroplasty. J Artiiroplasty. ;8(8), 954.

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RN/AHC Media LLC Home Study Program

Continuing Education Test #1097

"Joint surgery: Paving the way to a smooth recovery"
OBJECTIVES After reading the article you should be E^le to:

m
1. Identify postop complications of total joint replacement. 2. Discuss nursing and medical management for a patient receiving a total joint replacement. 3. Develop a teaching plan for a patient receiving a total joint replacement. Circle the one best answer for each question below. Transfer your answers to the card that follows page 32. Save this sheet to compare your answers with the explanations you'll receive, Or, take the test online at www.rnweb.com.
1. The American Academy of Orthopaedic Surgeons estimates that there are more than how many total knee replacements (TKRs) performed every year? a. 127.000. b. 193.000. C. 271,000. d. 365.000. 7. All of the following are signs of a PE that the nurse should teach the patient to report EXCEPT: a. Clear spulum. b. Shortness of breath. c. Chest pain. d. Unexplained cough. 8. Physical therapy following total joint replacement is typically started the; a. Evening of surgery. b. First postop day. c. Second postop day. d. Third postop day. 9. How long are patients undergoing joint replacement surgery usually hospitalized? a. Two to four days. b. Three to five days. c. Four to six days. d. Five 10 seven days. 10. Which of the following measures should the nurse implement following THR to prevent dislocation of the artificial joint? a Keep hip flexed at 180 degrees. b. Keep feet ciose together while sitting or lying down, c. Keep the patient's feet straight while sitting or lying down. d. Encourage the patient to avoid using a pillow between their legs. 11. How long after joint replacement surgery should patients take prophylactic antibiotics prior to undergoing dental procedures? a. Six months, b. One year. c. 18 months. d. Two years, 12. Postop nursing care following TKR includes: a. Using heat packs for the first 48 hours postop. b. Instructing patient to use deep knee bends to strengthen knee. c. Placing a pillow under the patient's leg from the calf to the heel. d. Putting a piliow in the popliteal space. 13. How many weeks must a patient watt for a new implant once a postop infection following joint replacement surgery is resolved? a. One to two. b. Two to four. c. Four to six. d. Six to eight, 14. Which of the following is the main reason for joint replacement surgery? a. Osleoarthntis, b. Osleonecrosis. c. Osteoporosis. d. Rheumatoid arthritis. 15. How is minimally invasive THR surgery different from traditional THR? Minimally invasive THR surgery; a. Involves a lO-mch to 12-inch incision. b. Takes a shorter period ot time to perform. c. Causes no damage to the skin or musculature. d. Involves less blood loss. 16. A new artificial joint is expected to last how many years? a. Seven years. b. Nine years. c. 12 years. d. 15 years. 17. Postop care of the patient undergoing a THR includes all EXCEPT; a. The drain yi^ll be removed the tfiird postoperative day. b. Elastic hose may be wom. c. Ambulation and walking may begin the day after surgery. d. Prophylactic antibiotics may be ordered, 18. Postop teaching for a patient undergoing totat joint replacement includes: a. Notifying the physician it the patient's temperature exceeds 99 F [37.2 C), b. Applying warm moist heat for 15 20 minutes at a time, a few times a day, c. Swelling is normal for the first three to SIX months after surgery. d. Resuming sexual activity in one week.

Postop nursing care to prevent peroneal nerve injury for a patient with TKR includes; a. Keeping the wound dressing tight, b. Keeping the affected leg straight. c. Performing neurovascular assessments every four hours for (he first 24 hours. d. Using a splint or ankle and foot orthosis.

During TKR, which of the following may be replaced by a prosthesis? a. Acetabulum. b. Rbula. c. Tibia. d. Talus. 4. All of the following are complications of joint replacement surgery EXCEPT: a. Deep vetn Ihrombosis (DVTj. b. Nerve injury, c. Pleura! effusion. d. Pulmonary embolism (PE). 5. To prevent DVT and PE, total joint replacement patients should receive which of the following? a. Acetaminophen. b. Fondaparinux (Arixtra).

c. Vitamin K.
d. Urokinase (Abbokinase). 6. Studies show that 90% of fatal PEs in total hip replacement {THR) occur within how many week(s) following surgery? a. One week. b. Two weeks. c. Three weeks. d. Four weeks.

This continuing education offering is co-provided by AHC Media LLC and M . Provider approved by the Caiifornia Board ot Registered Nursing, Provider # 14749, for 1 Contact Hour. This activity is approved for 1 nursing contact hour using a 60-minute conlact hour. This activity has been approved by the American Association ol Criticai-Care Nurses for 1 nursing contad hour (Category A aedit). Credit will be granted for this unit through January 2009. It was prepared by Marilyn Herbert-Ashton, RN, BC. MS.

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