Orthopaedics
care of patients
Correspondence
Jennie.Walker@nottingham.ac.uk
Jennie Walker is clinical
educator, Academic Division
of Orthopaedic and Accident
Surgery, Queen’s Medical Centre,
Nottingham
Date of acceptance
October 24 2010
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
www.nursingolderpeople.co.uk
After knee replacement,
patients can engage in activities
such as golf, ballroom dancing
and driving
14 February 2012 | Volume 24 | Number 1
undergoing joint
replacement
Recovery from hip and knee arthroplasty can be prolonged
and painful. Jennie Walker describes the support that
nurses need to offer individuals before and after surgery
Abstract
Hip and knee replacements are common orthopaedic
procedures that can greatly improve patients’
quality of life and provide relief from the pain
caused by various musculoskeletal diseases. This
article considers pre-operative preparation of the
patient undergoing joint arthroplasty and significant
post-operative clinical considerations.
The nurse has an important role in the
preparation, care and support of the patient
throughout the surgical journey. Holistic
assessment and effective pre and post-operative
planning facilitate patient-focused care and
optimal recovery.
Keywords
Hip replacement, knee replacement, musculoskeletal
system and disorders, orthopaedics, surgical nursing
Arthroplasty is the replacement of a joint
with a prosthesis. It is one of the most common
reconstructive operations in orthopaedics (Huo et al
2008). In 2010, 76,759 hip replacement procedures
and 81,979 knee replacement procedures were
recorded on the National Joint Registry (NJR) (2011).
Arthroplasty can be performed when irreversible
damage has occurred to a joint that causes pain,
dysfunction and reduced health-related quality of
life. Damage can be caused by primary arthrosis
(disease of the joint) (Table 1, page 16), or secondary
causes such as other disease processes, trauma and
musculoskeletal injury.
The earliest recorded attempt at joint
replacement was in 1891 in Germany by
Themistocles Glück who used ivory to replace
the femoral head (Gomez and Morcuende 2005),
and an ivory cup for a tibial hemiarthroplasty in
1894 (Wong et al 2011). Austin Moore inserted the
first metal hip prosthesis in 1940, however, the
first effective total hip replacement was performed
by John Charnley in the 1960s (Wroblewski et al
2006). Knee replacement was first performed in
1954 by Shiers and has also been through many
developments to reach its current form.
Pathophysiology
Arthrosis describes degeneration of the joint
caused by primary disease, for example,
osteoarthritis, or secondary processes such as
those listed in Box 1 (page 16). Initial pathology
can cause bone remodelling with formation of
osteophytes (bony spurs) at joint margins and
damage to the articular cartilage. This is termed
secondary osteoarthritis and can result in pain
and dysfunction of the affected joint in a similar
manner to primary osteoarthritis.
Intracapsular fractures of the neck of the femur
are prone to developing avascular necrosis (AVN)
because of the disruption of the blood supply
(McRae and Esser 2002). Necrosis of the femoral
head results in collapse of the structure with
NURSING OLDER PEOPLE
Image Source
 Orthopaedics
Table 1 Primary causes of arthrosis
Osteoarthritis ■■ Non-inflammatory disorder of the synovial joints.
■■ Localised loss of hyaline cartilage, remodelling of underlying
bone and osteophyte formation (bony spurs) at the joint
margins with consequential remodelling of the joint shape.
Ankylosing ■■ Chronic inflammatory rheumatic disease (seronegative
spondylitis spondyloarthropathy).
■■ Progressive stiffness and fusion (ankylosis) of the joints.
Rheumatoid ■■ Chronic inflammatory rheumatic disease.
arthritis ■■ Destruction of articular cartilage and bony erosions.
consequential pain and loss of joint function. In
such cases arthroplasty may be required to preserve
functional use of the joint. AVN in the knee can
occur without previous history of injury and may
be referred to as spontaneous osteonecrosis of the
knee (SONK). While there are initial strategies to
treat AVN, a knee replacement may be required if
these are not successful.
AVN can also be caused by non-traumatic
diseases such as Gaucher’s disease, sickle cell
disease or use of corticosteroids (Chillag 2004).
Diagnosis
Arthrosis commonly causes reduced range of
movements and is accompanied by pain and
difficulty carrying out daily activities such as
mobilising, dressing or cutting toenails. The pain
associated with arthrosis is typically worse with joint
use and is less at the start of the day or after rest,
although severe arthrosis can cause pain even when
the person is at rest. Diagnosis of osteoarthritis is
largely based on history and clinical examination,
although X-ray, computed tomography or a
magnetic resonance imaging scan may be required
to confirm the diagnosis or to diagnose fractures or
AVN. X-rays of osteoarthritic joints typically show
signs of joint space narrowing, sclerosis and cysts,
which Doherty et al (2006) suggest are small areas
of osteonecrosis caused by increased pressure in
the bone.
Box 1 Secondary causes of arthrosis
■■ Avascular necrosis (hip or knee).
■■ Developmental hip dysplasia.
■■ Infection, for example, tuberculosis, osteomyelitis.
■■ Ligamentous instability.
■■ Legg-Calvé-Perthes disease.
■■ Paget’s disease of bone.
■■ Previous trauma or injury.
■■ Slipped femoral epiphysis.
(Walker 2010)
16 February 2012 | Volume 24 | Number 1
Pre-operative assessment
General health and fitness can decline because of
reduced mobility and increasing disability, resulting
in muscle weakness and loss of function by the
time patients are admitted to hospital for surgery
(McMeeken and Galea 2007). Pre-operative preparation
should begin when the patient is placed on the
surgical waiting list. While it is often difficult for
patients to exercise, it is important that appropriate
information and advice is provided to assist with
maintaining or improving health before surgery.
Nurses in primary care are ideally placed to
assess the physical, psychological and social
preparation of patients before admission to hospital
(Lucas 2008).
Discharge planning Pre-operative involvement of
the multidisciplinary team aids effective assessment
and planning for identified needs. Inadequate
planning can result in delayed discharges because
of lack of equipment or services. Provisional
discharge planning should begin at pre-operative
assessment, taking into consideration the patient’s
age, comorbidities, home circumstances and
availability of carers after discharge (British
Orthopaedic Association (BOA) 2006). Patients’
discharge needs should be assessed well in advance
of surgery, taking into account their environment,
social support and social roles.
The patient and family can be given information
and advice on, for example, stocking up the
cupboard/freezer, or moving furniture to make
things easier for the patient after discharge.
Patients will need to check whether the height of
chairs and location of toilets will cause difficulties
because of their compromised strength, which will
make getting up from low chairs or climbing stairs
more difficult.
Social support is of great benefit in the post-
operative period, often providing help with tasks
such as shopping and laundry, although this
cannot be relied on and many people do not have
such support. The social support or care a patient
provides to others also needs to be considered so
that appropriate support can be arranged for others
until the patient is able to resume normal activities.
Risks Pre-operative assessment clinics facilitate
effective assessment of patients in relation to
risks associated with surgery and help reduce
cancellations (BOA 2006). Nurse-led pre-operative
assessment clinics offer patients and families the
chance to discuss surgery and raise any concerns.
Routine investigations such as blood tests
including group and save or cross-matching, urine
NURSING OLDER PEOPLE
sample and relevant microbiological assessment
such as meticillin-resistant Staphylococcus aureus
screening should be carried out during the pre-
operative assessment.
It is important that infections are treated before
joint replacement surgery because the implant
may become infected as a result of haematogenous
seeding (Montanaro et al 2007). Baseline observations
such as blood pressure, pulse, respiratory rate and
oxygen saturations should be documented to allow
post-operative comparison. Comorbidities such as
diabetes, cardiac arrhythmias and hypertension
should be assessed and appropriately managed
before surgery. It is important that infection or other
issues are managed before surgery to ensure patient
safety. If this is not possible in the time frame given,
surgery may need to be postponed to maximise
patient fitness.
Education and information Pre-operative outcome
expectations can affect post-operative outcomes
(Lucas 2008), especially as patients may not
appreciate that complete recovery can take up to
one year. Pre-operative education is a fundamental
part of pre-operative assessment clinics. Providing
patients with verbal and written information on post-
operative exercises and post-operative pain relief
allows time for patients to familiarise themselves
with the information, practise skills and ask
questions before surgery.
Information given at this time helps to reduce
pre-operative anxiety and prepare patients for their
forthcoming procedure (McDonald et al 2004, Walker
2007). Having the opportunity to practise using
crutches or performing exercises before surgery can
increase confidence in using them post-operatively.
Surgery
Many patients are admitted to hospital on the day of
surgery, although it is important to ensure adequate
time is planned for pre-operative and pre-anaesthetic
procedures to be carried out (BOA 2006). The side
of the patient’s body to be operated on should be
marked indelibly by the surgeon or surgical team
and consent should be appropriately documented in
the medical notes. It is important that patients are
fasted in accordance with local policy before transfer
to theatre, and are aware of the types of drips, drains
and analgesia they may have in place when they
return to the ward.
Joint replacement can be either a hemi (partial) or
total arthroplasty, and both incur surgical insult to
the soft tissue, ligaments and surrounding muscles.
This not only causes post-operative pain, but makes
mobilisation difficult in the early stages.
NURSING OLDER PEOPLE February 2012 | Volume 24 | Number 1 17
Patients’ discharge needs should be assessed
well in advance, taking into account their
environment, social support and social roles
A partial hip replacement (hemi-arthroplasty)
involves removal of the femoral head and
replacement with a prosthesis. This procedure is
commonly performed after intracapsular fractures
or AVN of the femoral head. Total hip replacement
(Figure 1, page 18) involves the insertion of a femoral
prosthesis and resurfacing of the acetabulum with
a concave lining. This lining allows the prosthesis
to move smoothly in the acetabulum and is more
common in osteoarthritis. Similarly knee arthroplasty
may involve total knee replacement (Figure 2, page
19) in which the distal femur and proximal tibia are
cut to shape before inserting the metal components
into the bone, or a replacement of the medial, lateral
or patellofemoral region as required.
Hip and knee replacements may be cemented
using polymethyl methacrylate, uncemented or
use ‘hybrid’ methods to secure the prosthesis.
In uncemented prostheses, bony ingrowth is
encouraged by a porous coating on the implant.
In patients aged 70 or over cemented prostheses
were associated with the lowest revision rates,
and the highest rates with metal on metal types of
replacements (NJR 2011).
A range of prostheses are available for each joint,
which vary in design, suitability for pathology and
cost (Table 2, page 19). Revision arthroplasty may
be required when there is failure of the prosthetic
device which causes joint pain and dysfunction.
Implant failure can be caused by particles generated
by wear of the joint. Polyethylene wear debris
can cause synovitis, osteolysis and loosening of
the implant (Wong et al 2011). Revision surgery
is often longer and more complex than primary
replacement because the old cement and prosthetic
components have to be removed before implanting
new mechanisms. Larger prostheses are required
for revision to ensure good purchase, although this
makes further replacements difficult and increases
risk of periprosthetic fracture.
The NJR provides a record of all prostheses and
data about the number of joint replacements carried
out by each trust and by which surgeons. Details can
be found at www.njrcentre.org.uk
Post-operative care
After surgery, regular observations should be carried
out such as blood pressure, pulse, respiratory
rate, oxygen saturations and temperature. It is also
 Orthopaedics
Figure 1 Radiologist studying an X-ray of a total hip replacement
important to monitor for signs of dehydration, shock
or increased levels of pain. Early warning systems
enable any abnormal parameters to be identified and
prompt action taken (Higgins et al 2008). The wound
should be inspected regularly to check for signs of
haemorrhage or infection.
Regular neurovascular observations of the limb
that was operated on to assess colour, warmth,
sensation, movement and pedal pulses can promptly
identify circulatory or neurological impairment after
surgery. Continuing assessment of fluid balance must
also be documented including intravenous (IV) and
oral intake, urine output and any drainage in surgical
drains. The extensive nature of the surgery and the
older age and multiple comorbidities of many patients
undergoing arthroplasty mean that it is important
that nursing staff carry out observations regularly,
until the patient is considered stable.
Pain relief Pain assessment and checks of patient-
controlled analgesia (PCA), epidurals and blocks
should be carried out regularly to monitor the use
and effectiveness of analgesia in the early post-
operative period. The PCA should be checked to
ensure effective delivery of the medication and,
where appropriate, patient requests for analgesia
and the number of doses administered should
be noted. The patient’s level of consciousness
should be assessed to ensure he or she is
alert and orientated, as opposed to sedated or
18 February 2012 | Volume 24 | Number 1
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unresponsive. Findings and any actions taken
should be documented on the pain assessment
chart. Patients who have effective pain relief are
able to mobilise earlier with greater ease, which
reduces the risk of post-operative complications
such as deep vein thrombosis (DVT) and respiratory
infection. Conversely, prolonged post-operative
pain may result in higher mortality and morbidity
rates, increased length of hospital stay and greater
healthcare expenses (Eid and Bucknall 2008).
Physiotherapy Physiotherapists advise patients on
specific exercises to do and assess them for use
of mobility aids. Initially patients will be partially
weight bearing and will therefore need to use a
frame or crutches. Patients should be encouraged
to do foot exercises such as the rotation, flexion
and extension of the ankle to promote venous
return and help prevent pooling of blood in the calf
muscles (Temple 2004). Because nurses spend more
time with patients than other health professionals,
it is important that they are aware of appropriate
and simple post-operative exercises that patients
can perform.
Nurses should be confident in the instruction and
support of patients performing these exercises at
regular intervals throughout the day.
It is important that patients are informed about
activities which should be avoided after surgery.
In hip replacements the femoral head is taken out
NURSING OLDER PEOPLE
of the socket and replaced with an implant. In the
initial post-operative period the soft tissues cannot
support the structure and maintain it in place,
therefore movements that may increase the risk of
dislocating the prosthesis should be discouraged.
Risk can be reduced by avoiding excessive range of:
■■ Adduction and abduction (moving toward and
away from the midline).
■■ External rotation of the hip.
■■ Flexion of the hip beyond 90 degrees.
Occupational therapy assessment can assist with
appropriate equipment and adaptations such as
chair raisers and raised toilet seats to help prevent
excessive hip flexion and reduce the risk of
dislocation. Other home adaptations may be required
in the initial period while the patient is rehabilitating.
After knee replacement, activities such as
jumping, jogging or running, contact sports or high
impact aerobics should be avoided, however, less
strenuous activities such as golf, ballroom dancing
and driving are not problematic.
Complications
Venous thromboembolism (VTE) is a common
complication (BOA 2006) and occurs in more than
40 per cent of patients undergoing orthopaedic
procedures (National Institute for Health and Clinical
Excellence (NICE) 2008). There is also the risk of fat
embolism after arthroplasty, although this is much
less common than VTE.
The risk of VTE increases significantly after
surgery because of the advancing age and immobility
of many patients. Obesity (a body mass index
Figure 2 Knee replacement
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NURSING OLDER PEOPLE February 2012 | Volume 24 | Number 1 19
Table 2 Type of replacement
Metal on metal ■■ Increased risk of revision, although more data required
implant to confirm finding.
Ceramic on ceramic ■■ Ceramic is resistant to wear and scratch resistant.
lining ■■ No long-term data available.
Polyethylene on ■■ No long-term data available.
metal lining
greater than 30), active heart/respiratory failure, or
a personal or family history of VTE are considerable
risk factors for VTE after surgery. Local guidance
about anti-embolic therapy should be followed for
patients undergoing arthroplasty of the hip or knee;
this may include a combination of anticoagulant
therapy such as low molecular weight heparin
(LMWH), anti-embolic stockings and possibly the
use of intermittent pneumatic compression or foot
impulse systems (NICE 2008). Some areas are moving
away from subcutaneous LMWH injections and
using oral forms of anti-coagulation. Signs of DVT
occurring in the calf include oedema, tenderness and
redness of the area.
Infections Prophylactic IV antibiotics should be
given to reduce the risk of surgical infection.
Infections after arthroplasty are commonly caused
by Staphylococcus aureus and Staphylococcus
epidermidis (Mortazavi et al 2010). Infections may
be classified as superficial (affecting the superficial
wound site only), or deep, in which the bone or
the prosthesis are infected. Oral antibiotics are
usually sufficient to eradicate superficial wound
infections, although deep infection may require the
use of IV antibiotics and oral antibiotics (Darley and
MacGowan 2004).
Deep infection can result in extended periods of
hospitalisation and in some instances the prosthesis
may have to be removed before the infection can be
resolved. This is because of the presence of a biofilm
secreted by bacteria which make them unresponsive
to antibiotic therapy.
Patients who have elective joint replacements
are admitted to hospital with the intention of
being discharged back to their home or residential
home as soon as they are fit. In some instances,
such as after trauma, the initial phases of
rehabilitation may take longer than anticipated.
It may be necessary to consider other options
for rehabilitation than remaining on an acute
ward. A holistic assessment should be made
for each patient and the multidisciplinary team
needs to be actively involved in determining the
best possible route of rehabilitation. Although
 Orthopaedics

there is always pressure to reduce the length of
inpatient stays, a rushed discharge, or discharge
without appropriate support in place, can result
in unnecessary re-admission to hospital (Bishop
2010). Understanding patients’ pre- and post-
operative healthcare needs facilitates effective
planning and care management (Su et al 2010).
Failure to do this will hinder discharge planning
and patient-focused care.
Recovery from hip and knee replacements is
often a slow process and the effect that surgery will
have on roles and relationships after discharge from
hospital is often underestimated. Many patients
will have to re-establish roles and relationships in
society which they may have relinquished because
of pain and restrictions present before surgery
(Grant et al 2009).
procedures involve helps nurses appreciate why
activities of daily living may become painful and
difficult after surgery. This allows practitioners
to anticipate what assistance may be required
and appropriately liaise with members of the
multidisciplinary team to provide equipment and
support before and after surgery.
Nurses need to be aware of the importance of
effective screening and assessment strategies at
pre-operative assessment clinics and in the
community so that actual or potential problems,
either with the intended surgery or with issues
about discharge arrangements, are identified.
Understanding the nature of the surgery enables
nurses to deliver excellent pre- and post-operative
care and anticipate any complications that may arise.

Conclusion
Online archive
Arthroplasty is a common procedure which greatly For related information visit our online archive
benefits many individuals and often results in of more than 6,000 articles and search using
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relevant anatomy and physiology and what surgical None declared

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