THR and TKR

Presenter Moderator
Navreet Kaur
Saini Mr. L. Gopichandran
M Sc Nsg Student Lecturer
AIIMS AIIMS
 STATISTICS
Ostheoarthritis is one of the ten
most disabling diseases in developed
countries (WHO, 2010b).
Worldwide estimates are that 10%
of men and 18% of women aged over
60 years have symptomatic
osteoarthritis, including moderate
and severe forms.
TKR/ 1,00,000 pop (2009)
THR / 1,00,000 Pop (2009)
Goals of Joint Replacement
Surgery

Relieve pain!!!

Restore function, mobility

PREOPERATIVE ASSESSMENT OF
PATIENTS UNDERGOING TJR
Posture And Gait
Bone integrity and Joint function-
• Range of motion
• Palpation
• Muscle strength
• Skin changes
• Neurovascular Status
TOTAL HIP
REPLACEMENT
Anatomy—Hip
Total Hip replacement
• Total Hip replacement is the
replacement of a severely
damaged hip with an artificial
joint.
HISTORY OF THR
The earliest recorded attempts at hip replacement
(Gluck T, 1891), which were carried out in Germany,
used ivory to replace the femoral head (the ball on the
femur).

On September 28, 1940 at Columbia Hospital in

Columbia,South carolina Dr. Austin T. Moore (1899–
1963), an American surgeon, reported and performed
the first metallic hip replacement surgery.

The original prosthesis he designed was a proximal

femoral replacement, with a large fixed head, made of
the Cobalt-Chrome alloy Vitallium. It was about a foot
in length and it bolted to the resected end of the
femoral shaft (hemiarthroplasty)
In 1960 a Burmese orthopaedic
surgeon, Dr. San Baw (29 June 1922
– 7 December 1984), pioneered the
use of ivory hip prostheses to
replace ununited fractures of the
neck of femur when he first used an
ivory prosthesis to replace the
fractured hip bone of an 83 year old
Burmese Buddhist nun, Daw Punya
HISTORY OF THR
Low friction arthroplasty- was lubricated with synovial
fluid. The small femoral head (7/8" (22.2 mm)) was
chosen for it would have lower friction against the
acetabular component and thus wear out the
acetabulum more slowly. Unfortunately, the smaller
head dislocated more easily.
Alternative designs with larger heads such as the
Mueller prosthesis were proposed. Stability was
improved, but acetabular wear and subsequent failure
rates were increased with these designs. The Teflon
acetabular components of Charnley's early designs
failed within a year or two of implantation.
HISTORY OF THR
This prompted a search for a more suitable material.
A German salesman showed a polyethylene gear sample
to Charnley's machinist, sparking the idea to use this
material for the acetabular component.

The Ultra High Molecular Weight Polyethylene or

UHMWPE acetabular component was introduced in
1962. Charnley's other major contribution was to use
polymethylmethacrylate (PMMA) bone cement to attach
the two components to the bone. For over two
decades, the Charnley Low Friction Arthroplasty, and
derivative designs were the most used systems in the
world. It formed the basis for all modern hip implants.
NEW V/S OLD
Initial hip designs were made of a
one-piece femoral component and
a one-piece acetabular component.
Current designs have a femoral
stem and separate head piece.
Metal implants are in practice
compared to ivory in old times.
Indications
Arthritis(degenerative joint disease,
rheumatoid arthritis )
Femoral neck fractures
Failure of previous reconstructive
surgeries(failed prosthesis,
osteotomy)
Problems resulting from congenital
hip disease
THR: Indications
TYPES OF HIP
REPLACEMENT
Total hip replacement (THR) or total hip arthroplasty (THA)
- Replacement of the femoral head and the acetabular
articular surface

Hemiarthroplasty - Replacement of only the femoral head

Bipolar hemiarthroplasty - A specific form of

hemiarthroplasty in which a femoral prosthesis is used with
an articulating acetabular component; the acetabular
cartilage is not replaced; the principle of this procedure is to
decrease the frictional wear between the femoral head
prosthesis and the cartilage of the acetabulum.
BIPOLAR
HEMIARTHROPLASTY
THA Implants
THR IMPLANTS
Implant Choice
Cemented:
• Elderly (>65)
• Low demand
• Better early fixation
• late loosening
IMPLANT CHOICE
 Cemented joint
replacement
(cemented joint
arthroplasty) - A
procedure in which
bone cement or
polymethylmethacryl
ate (PMMA) is used
to fix the prosthesis
in place in the joint
 Cementless:
• Younger
• More active
• Protected weight-bearing
first 6 weeks
• Better long-term
fixation
IMPLANT CHOICE
 Ingrowth, or cementless,
joint replacement (ingrowth,
or cementless, arthroplasty)
- A procedure that does not
involve bone cement to fix
the prosthesis in place; an
anatomic or press fit with
bone ingrowth into the
surface of the prosthesis
leads to a stable fixation;
this procedure is based on a
fracture-healing model.
Technique: Total Hip
Replacement
Femoral neck resection
Acetabular reaming
Insertion of acetabular component
Reaming/broaching of femoral
component
Insertion of femoral component
Femoral head impaction
Final implant
THR
Nursing
Interventions
Pre Operative Management
Assessment

Hydration status (skin and mucous membrane,vital signs,urine

output and lab values)

Current medication history

Possible infection (h/o cold,dental problems,UTIs or other

infections within 2 wks before surgery)

Nursing diagnosis
Acute pain related to orthopedic problem,swelling or inflammation

Risk for ineffective regimen management related to insufficient

knowledge or lack of available support and resources,

Impaired physical mobility related to pain,swelling and possible

presence of an immobilization device.

Risk for situational low self esteem,disturbed body image or

functional impairement related to impact of musculoskeletal disorder.

Post Operative management
Pain related to Total Hip
Replacement
Assess patient for pain using a standard
pain intensity scale
Ask patient to describe discomfort
Aknowledge existance of pain;inform
patient about available analgesics or
muscle relaxants.
Use pain modifying techniques:
Use analgesics
Change position within prescribed limits
Modify environment
Notify surgeon about persistent
pain
Evaluate and record discomfort
and effectiveness of pain
modifying techniques
Impaired physical mobility related to
positioning,weight bearing and activity
restriction after surgery.

Maintain proper position of the hip

joint(abduction,neutral
rotation,limited flexion)
Keep pressure off heel
Instruct and assist in position changes
and transfer.
Instruct and supervise isometric
quadriceps and gluteal setting
exercises.
In consultation with physical therapist
instruct and supervise progressive safe
ambulation within limitations of weight
bearing prescription.
Offer encouragement and support
exercise regimen.
Instruct and supervise safe use of
ambulatory aids.
Hemorrhage,neurovascular
compromise,dislocation of prosthesis,DVT
and infection related to surgery.
Hemorrhage
Monitor vital signs, observing for shock.
Note character and amount of drainage
Notify surgeon if patient develops shock
or excessive bleeding and prepare for
administration of fluids,blood component
therapy and medications.
Monitor hemoglobin and hematocrit
values.
Neurovascular dysfunction
Assess affected extrimity for colour and
temperature.
Assess toes for capillary refill response.
Assess extrimity for edema and
swelling.report patients complains of leg
tightness.
Elevate extrimity(keep leg lower than hip
when in chair).
Assess for deep,throbbing pain
Assess for pain on passive flexion
of foot
Assess for change in sensation and
numbness.
Assess ability to move foot and
toes.
Assess pedal pulses in both feet.
Notify surgeon if altered
neurovascular status is noted.
Dislocation of prosthesis
Position patient as prescribed.
Use abducter splint or pillow to maintain
position and to support extremity
Support legs and place pillows between
legs when patient is turning and side
lying;turn to the unaffected side.
Avoid acute flexion of hip(head of bed
at 60 degrees or less)
Dislocation of prosthesis
 Avoid crossing legs.
 Assess for
dislocation of
prosthesis(extremity
shortness,internally
or externally
rotated,severe hip
pain,pt.unable to
move extrimity).
 Notify surgeon if
possible dislocation.
Deep vein thrombosis
Use elastic compression stockings or
sequential compression device as
prescribed.
Remove stockings for 20 min twice a day
and provide skin care.
Assess popliteal,dorsalis pedis and
posterior tibial pulses.
Assess skin temperature of legs
Assess for Homans sign every 8 hrly
Avoid pressure on popliteal blood
vessels from equipments or pillows.
Change position and increse activity
as prescribed.
Supervisee ankle exercises hourly.
Monitor body temperature
Encourage fluids.
Infection
Monitor vital signs
Use aseptic techniques for dressing
change and emptying of portable
drainage.
Assess wound appearance and character
of drainage.
Assess complaints of pain.
Administer prophylactic antibiotics if
prescribed and observe for side effects.
Risk for ineffective health
maintenance related to THR.
Assess home environment for
discharge planning.
Encourage patient to express
concerns about care at home;explore
together possible solution of the
problem.
Assess availability of physical
assistance for health care activities.
Teach caregiver home health care
regimen.
Instruct patient on post hospital care:
Activity limitation(hip precautions,weight
bearing limits)
Exercise instructions
Safe use of ambulatory aids
Wound care
Measures to promote healing
Medications, if any
Potential problems
Continuing health care supervision and
management
Avoiding hip dislocation after
replacement surgery
Methods for avoiding displacement include
the following:
Keep the knees apart at all times
Put a pillow between the legs when sleeping
Never cross the legs when seated
Avoid bending forward when seated in a
chair.
Avoid bending forward to pick up an object
on the floor.
Use a high seated chair and a raised toilet
seat.
Do not flex the hip to put on clothing such
as pants, stockings,socks or shoes.
Positions to avoid after THR
Do not cross
the Affected
leg at the
centre of the
body

Hip should not

be bent more
than 90 degree

Affected leg
should not be
turn inward
while lying down
Complications
 ACUTE  CHRONIC
 Infection  Heel pressure
 DVT ulcer
 Thromboembolis  Heterotrophic
m ossification
 Excessive wound  Avascular
drainage necrosis
 Dislocation of
prosthesis
TKR
Anatomy—Knee
Total Knee Replacement (TKR).

A total knee replacement (TKR) or

total knee arthroplasty is a Surgery
that resurfaces an arthritic knee
joint with an artificial metal or
plastic replacement parts called the
'prostheses'
Total Knee replacement surgery is
considered for patients who have
severe pain functional disability
related to joint surfaces
destroyed by:
Arthritis
Bleeding into the joint(hemophilia)
TYPES OF PROSTHESIS
Fixed Bearing: A fixed-bearing prosthesis is the most common
knee replacement implant in use today. The components are as
described above but the polyethylene cushion of the tibial
component is fixed to the metal platform base.

Mobile Bearing: The difference between a fixed-bearing implant

and a mobile bearing implant is in the bearing surface. They allow
patients a few degrees of greater rotation to the medial and
lateral sides of their knee.

Medial Pivot (also known as Rotating Platform): In a rotating

platform, the polyethylene insert can rotate slightly around a
conical post, thereby copying the activity of the natural knee
joint.
Type of prosthesis
Metal and acrylic prosthesis designed to
provide the pt. with a functional,painless,
stable joint may be used.
If pts ligaments are weakened,a fully
constrained or semiconstrained prosthesis may
be used to provide joint stability.
A nonconstrained prosthesis depending on the
patient’s ligaments for joint stability may be
used.
Knee Replacement—Implants

Patellar
component
Knee Replacement—Bone Cuts
Knee Replacement—Implants
Knee Replacement—Implants
TYPES OF TKR
 Total knee
replacement (TKR)
or total knee
arthroplasty (TKA) -
Replacement of the
articular surfaces
of the femoral
condyles, tibial
plateau, and
patella.
 Unicompartmental
knee replacement
(unicompartmental
arthroplasty) -
Replacement only
of the medial or
lateral tibiofemoral
compartment of the
knee.
NURSING
INTERVENTIONS…
Pre Operative Management
Assessment

Hydration status (skin and mucous membrane,vital signs,urine

output and lab values)

Current medication history

Possible infection (h/o cold,dental problems,UTIs or other

infections within 2 wks before surgery)

Nursing diagnosis
Acute pain related to orthopedic problem,swelling or inflammation

Risk for ineffective regimen management related to insufficient

knowledge or lack of available support and resources,

Impaired physical mobility related to pain,swelling and possible presence

of an immobilization device.

Risk for situational low self esteem,disturbed body image or functional

impairement related to impact of musculoskeletal disorder.

Post Operative management
Continuous passive
motion(CPM) device
Pts leg is put in this device,which increases
circulation and range of motion of knee joint

Rate and amount of extension and flexion are

prescribed. Usually 10 degrees of extension
and 50 degrees of flexion are prescribed
initially increasing to 90 degrees of flexion
with full extension by discharge.
Encourage the patient to use the
device most of the time
If satisfactory flexion is not achieved,
gental manipulation of knee joint under
GA may be necessary about 2 wks
after surgery.
Post operatively, the knee is dressed
with a compression bandage.
Ice may be applied to control
edema and bleeding.
Assess the neurovascular status
of the leg
Encourage active flexion of the
foot every hour when the patient
is awake.
COMPLICATIONS TKR
 ACUTE  CHRONIC
 Infection  Dislocation of
 Implant failure thrombosis
 Limited range of  Dislocation of
motion prosthesis
 Peroneal nerve  Osteolysis
parlysis
Dislocation/Instability
Infection
Wear of Articular Bearing Surface
Osteolysis
Peri-Prosthetic Fracture
Implant Failure
Major Osseous Defects
Major Osseous Defects
A wound suction drain removes fluid
accumulation in the joint.Drainage ranges
from200 to 400 ml during the first 24
hours after surgery and diminishes to
less than 25ml by 48 hours
The colour ,type and amount of drainage
are documented and any excessive
drainage or change in the characteristics
of drainage are promptly reported to
the physician.
Assist the patient to get out of
the bed on the evening or the day
after surgery.
Protect the knee with
immobilizer(splint,cast or brace)
and is elevated when the patient
sits in the chair.
After discharge
Patient may continue to use the
CPM device at home and may
undergo physical therapy on an
outpatient basis.
Late complication:
infection,loosening and wear of
prosthetic components.
REHABILITATION
AFTER TJR
PATIENT EDUCATION
Considerations:
Pain management
Wound care
Mobility
Self care
Potential problems
Discuss with patients the methods to
reduce pain:
Periodic rest
Distractions and relaxation
techniques
Medication therapy:
action,administration,schedule,side
effects
Instruct the patient to:
Keep incision clean and dry
Take care of wounds and change the
dressing
Recognize signs of wound infection like
pain, swelling,drainage,fever etc
Explain that sutures or staples will
be removed 10-15 days after
surgery
Teach patient about:
Safe use of assistive devices.
Wt. bearing limits
How to change positions frequently
Limitations on hip flexion and adduction
How to stand without flexing hip acutely
Avoidance of low seated chairs.
Sleeping with pillow between legs
to prevent adduction.
Gradual increase in activities and
participation in prescribed
exercise regimen
PROSTHESIS AFTER TKR
Assess home environment for
physical barriers
Encourage patient to accept
assistance with ADLs during early
convalescence until mobility and
strength improves
Assess patient for developing of
potential problems and instruct pt.to
report signs of potential problems :
Dislocation of prosthesis: increased
pain, shortening of leg, inability to
move leg, popping sensation in hip,
abnormal rotation.
DVT:calf pain.swelling,pulmonary
embolism
Wound infection:swelling,purulent
drainage,pain,fever
Pulmonary emboli:sudden
dyspnea,tachypnea,pleuritc chest pain

Discuss with patient the need to

continue regular health care and
screening
Common queries after TJR
What activities are permitted following total joint
replacement surgery?
On recovery, one may return to most activities,
including walking, climbing a flight of stairs,
gardening, and golf. Some of the best activities
to help with motion and strengthening are
swimming and cycling.
What activities should I avoid after total joint
replacement surgery?
One should avoid impact activities, such as running
and jogging, and vigorous racquet sports like
squash or tennis.
Common queries after TJR
When can I return to work after total knee
replacement surgery?
When you can return to work after total knee
replacement surgery depends on your
profession. If your work is sedentary, you
may return to work as early as two to four
weeks after the operation. If your work is
more rigorous, you may require more time,
sometimes up to twelve weeks before you can
return to full duty.
Common queries after TJR
When can I travel after total joint replacement
surgery?
The patient is allowed to travel post-op as soon
as they feel comfortable. It is recommended that
they get up to stretch or walk at least once in an
hour, every hour, when taking long trips. This is
important to help prevent blood from clotting.
Long flights (or long car rides, for that matter)
may increase the risk of a blood clot. Often, in
some cases, the use of a blood thinner such as
aspirin may be indicated after consultation with a
physician.
Common queries after TJR
Will an implant set off a metal detector say, at an airport?
Since knee implants are made of metal, there’s a chance
they could set off metal detectors; whether it actually does
so depends, of course, on the type of implant that has been
put in and the sensitivity of the security checkpoint
equipment. It is customary to provide the patient who has
undergone a TKR with a special card or certificate to keep
with oneself, explaining that they have a knee implant.
When can I start driving after total joint replacement
surgery?
Driving is not recommended for at least eight weeks after
the operation, especially if one is on a course of strong
painkillers like narcotics.
Common queries after TJR
How long will my new joint last and can a second
replacement be done?
A joint implant’s longevity will vary from patient
to patient. All implants have a limited life
expectancy, and how long they last would depend
on an individual’s age, weight, activity level and
medical condition. By and large, over 90% of knee
replacements will be functioning well even 10 to
15 years after the operation. With continued
improvements in knee replacement technology, a
new knee may soon last well beyond this time
period.
Exercises AfterTKR
REASEARCH INPUT
A Specific Inpatient Aquatic Physiotherapy Program Improves
Strength After Total Hip or Knee Replacement Surgery:
A Randomized Controlled Trial
Ann E. Rahmann, BPhty, Sandra G. Brauer, PhD, Jennifer C. Nitz, PhD

Objective: To evaluate the effect of inpatient aquatic

physiotherapy in addition to usual ward physiotherapy
on the recovery of strength, function, and gait speed
after total hip or Knee replacement surgery.
Interventions: Participants were randomly assigned to
receive supplementary inpatient physiotherapy,
beginning on day 4: aquatic physiotherapy, nonspecific
water exercise, or additional ward physiotherapy.
Main Outcome Measures: Strength, gait speed, and
functional ability at day 14.
Results: At day 14, hip abductor strength was significantly
greater after aquatic physiotherapy intervention than
additional ward treatment (P.001) or water exercise (P.011).
No other outcome measures were significantly different at
any time point in the trial, but relative differences favored
the aquatic physiotherapy intervention at day 14. No adverse
events occurred with early aquatic intervention.

Conclusions: A specific inpatient aquatic physiotherapy

program has a positive effect on early recovery of hip
strength after joint replacement surgery. Further studies
are required to confirm these findings. Our researchOur
research indicates that aquatic physiotherapy can be safely
considered in this early postoperative phase.
Patient Education Before Hip or
Knee Arthroplasty Lowers Length of Stay
Richard S. Yoon, BS, Kate W. Nellans, MD, MPH, Jeffrey A.et al...

From April 2006 to May 2007, 261 patients

undergoing primary unilateral total hip arthroplasty or
total knee arthroplasty were offered voluntary
participation in a one-on-one preoperative educational
program. Length of stay (LOS) and inpatient data were
monitored and recorded, prospectively. Education
participants enjoyed a significantly shorter LOS than
nonparticipants for both total hip arthroplasty (3.1 ±
0.8 days vs 3.9 ± 1.4 days; P = .0001) and total knee
arthroplasty (3.1 ± 0.9 days vs 4.1 ± 1.9 days; P =
.001).
A Targeted Home- and Center-Based Exercise Program
for People After Total Hip Replacement: A Randomized Clinical
Trial
Mary P. Galea, PhD, Pazit Levinger, PhD, Noel Lythgo, PhD, Chris Cimoli, et al…

Objective: To examine the physical function, gait, and quality

of life of patients after total hip replacement (THR)
randomly assigned to either a targeted home- or center-
based exercise program.
Design: Randomized controlled trial.
Setting: Rehabilitation research center in Australia.
Participants: Twenty-three patients with unilateral THR were
randomly assigned to a supervised center-based exercise
group (n11) or an unsupervised home-based exercise group
(n12).
Intervention: The center-based group completed an 8-
week targeted exercise program while under the direct
supervision of a physiotherapist. After initial
instruction, the home-based group completed the 8-
week targeted exercise program at home without
further supervision.
Main Outcome Measures: Quality of life, physical
function,and spatiotemporal measures of gait.
Results: No significant interaction (group by time) or main
of grouping were found. Within each group, quality life,and
stair climbing improved significantly (P.05) as did
Timed Up & Go test and 6-minute walk test performances
(P.05). Walking speed increased by 16cm/s (P.01), cadence
by 8 steps/min (P.05), step length by 4.7cm (P.05),
and double-support time reduced by a factor of 16%. Step
length symmetry showed significant improvement (P.05)
over time. Step length differential between the affected and
unaffected limbs reduced from 4.0 to 2.7cm.
Conclusions: The targeted strengthening program was
effective for both the home- and center-based
groups. No group differences were found in the
majority of the outcome measures.This finding is
important because it shows that THR patients can
achieve significant improvements through a targeted
strengthening program delivered at a center or at
home
Bed exercises following total hip replacement:
a randomised controlled trial
Toby O. Smith a,∗, Charles J.V. Mannb

Objectives :To determine whether the addition of bed exercises after

primary total hip replacement (THR) improves functional outcomes and
quality of life, in adult patients, during the first six postoperative
weeks.

Design :Single-blind randomised controlled trial.

Setting :Inpatient and outpatient orthopaedic departments at a National

Health Service hospital.
Participants :Sixty primary elective THR patients.

Intervention :Patients were assigned at random to receive either a

standard gait re-education programme and bed exercises, or the
standard gait re-education programme without bed exercises after THR.
The bed exercises consisted of active ankle dorsiflexion/plantarflexion,
active knee flexion, and static quadriceps and gluteal exercises
Results: There was no statistically significant difference in ILOA scores
between the two groups on the third postoperative day [gait reeducation
and bed exercise group median 40.5, interquartile range (IQR) 17.5 to 44.5;
gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70].
Although there was a small difference between the median ILOA scores
atWeek 6 between the two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to
12.5; P = 0.05), this difference was not statistically or clinically significant.
There was no difference between the groups in duration of hospital admission,
SF-12 scores or postoperative complications at Week 6.

Conclusion :This study suggests that during the first six postoperative weeks,
the addition of bed exercises to a standard gait re-education
programme following THR does not significantly improve patient function or
quality of life.
Summary
THR
Indications
Technique
Complications
Nursing management
TKR
Indications
Implants
Complications
Nursing management
Conclusion
PREVENTION IS BETTER THAN
CURE.
Nurses should educate patients about
measures to prevent arthritis.
IF IT HAPPENS-  
PROPER HEALTH EDUCATION
SHOULD BE GIVEN AFTER TJR.
References
Medical Surgical Nursing (Brunner
and Suddarth 10th edition )
www.emedicine.com
www.wikipedia.com
www.google images
http://emedicine.medscape.com/artic
le/320061-overview#aw2aab6b9
THANK
THANK YOU………
YOU…….

HAVE A NICE DAY……………