BERNICE HOWELL, RN

Joint surgery:Paving tiie way toHip and knee replacenfients canrelieve pain, allowing people tolive more active lives. Yournursing care can help thesepatients avoid postopcomplications.

J oint replacements are among the mostcommon and successful orthopedic surg-eries, 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 replace-ments (TKRs) performed every year—numbers that have more than doubledsince 1990. Most patients who undergo total joint replacement, or arthro-plasty, experience a dramatic reduction in pain and a significant improvementin their ability to function in daily life.

The growing number of joint replacement surgeries means an increasingnumber of patients who'll require the expert postop care aimed at preventingcomplications and additional surgery. That's where you come in, and whyyou need to be well-informed.

Arthritic patients can be helped

The main reason for joint replacement surgery is osteoarthriHs, which affects30 million Americans, most of them older adults." In normal, healthy joints,smooth, articular cartilage covers the ends of bones, and there's ample spacefor easy joint motion. Osteoarthritis wears away the cartilage,, resulting in de-

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

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a smooth recoveryformity and abnormal articulation, accompanied by pain and limited motion.^

Younger patients benefit from joint replacement surgery, too, includingthose with traumatic injury or debilitating illnesses such as rheumatoid ar-thritis. Another indication for the surgery is osteonecrosis, a disease resultingfrom the temporary or permanent loss of blood supply to the hip joint.^

An orthopedic surgeon evaluates a candidate for joint replacementsurgery by taking a detailed history and performing a physical examinationto assess the motion, strength, stability, and position of the diseased joint.X-rays are essential to establishing the diagnt>sis and determining whethersurgical inten'^ention is necessary.

Once surgery is scheduled, the patient may require further evaluation bya primary care physician or other specialists to detect conditions that couldinterfere with surgery or recovery. For example, it's important to rule outthe possibility of a urinary tract infection or dental disease. If undetectedand left imtreated, either of these conditions could result in disastrous con-sequences, as infection could spread through the bloodstream to the newartificial joint.

During THR, the orthopedic surgeon will clean the acetabular socket byremoving damaged cartilage and bone, then position and secure the artificialjoint surfaces to restore the alignment and function of the patient's hip. Manydifferent designs and materials are used in artificial hip joints. The ball com-ponent—an artificial femoral head and stem—is made of metal or ceramic, andthe metal socket component has a plastic, ceramic, or metal cup liner.^''

During TKR, the femur and the tibia may be replaced by prostheses made ofmetal alloys, high-grade plastics, and polymeric materials.' Most of the otherstructures of tiie knee, such as the connecting ligaments, remain intact."

The surgeon smootlis the rough edges of bones, and trims or removes dam-aged portions. If damage is restricted to tlie medial or lateral surface of theknee joint, he may consider a procediu'e called unicompartmental artliroplasty,which essentially involves only half a prosthesis. It's a simpler procedure thatallows for a greater degree of knee flexion following surgery.^'

For either THR or TKR, the surgeon may use polymetliylmethacrylate, a fast-setting bone cement, to secure the artificial joints. Non-cemented prostheses,first introduced m the 1980s, are generally placed in younger, active patientswith stronger bones. Tlie prosthesis may be coated with textured metal or aspecial 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 asthose specific to joint replacement. Nursing priorities are to prevent compli-cations, manage pain, and teach patients how to care for themselves after

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discharge. (See the patient information handout onpage 35.)

With total joint replacement surgery comes the riskof deep vein thrombosis (DVT), pulmonary embolism(PE), nerve injury, dislocation of the artificial joint, andir\fection. The risk of complicahons is greater for pa-tients who are obese or have peripheral vascular dis-ease or diabetes. These conditions can delay woimdhealing. Excess weight also places increased stress onthe components and adjacent bones."

Your diligent assessment and nursing care areessential to the prevention and early identification ofpostop complications. In addition to standard postopinterventions, such as teaching patients to cough anddeep breathe, and use an incentive spirometer, yourinterventions will focus on the following potentialproblems:^

DVT and PE. To prevent DVT and its tife-threatening consequence, PE, the Seventh AmericanCollege of Chest Physicians (ACCP) Conference onAntitlirombotic and Thrombolytic Therapy recom-mends that patients who undergo elective hip or kneereplacement surgery receive one of the following: a vit-amin K antagonist such as warfarin (Coumadin), theantithrombotic drug fondaparinux (Arixtra), or lowmolecular weight heparin—enoxaparin (Lovenox) ordalteparin (Fragm^in), for example." Depending onwliich agent and dose are chosen, the regimen maybegin before surgery or six to 24 hours postop."^

DVT prophylaxis may continue for several weeks, asstudies show that 90'^ of the fatal PEs in THR patientsoccur within four weeks of surgery."^" Teach patients tobe alert for the signs of DVT and PE and to seek help ifthey develop shortness of breatli, chest pain, an unex-plained cough, bloody sputum, or leg pain, tenderness,warmth, swelling, or discoloration. (More informationon DVT will appear in the February 2007 issue of RH.)

STAT Facts

Deep vein thrombosis and infection are amongthe risks of joint replacement surgery.

Distocation occurs less frequently in total kneereplacements than in totol hip replacements.

A new artificiol joint should lost 15 years orlonger, depending on the patient's activitylevel.

Immobility is a risk factor for DVT, so early postopambulation is important. Bed rest is recommended theday of surgery, but most patients are assisted out of bedand, if tolerated, started on physical therapy on the firstpostop day.

Effective pain control is crucial to early ambulation.Patients may get an epidural, patient-controlled anal-gesia (PCA), or oral medications, as ordered. Teachyour patient how to properly use his PCA and toemploy relaxation techniques like focused breathing.A patient whose pain level is tolerable will be moreactive and willing to engage in physical therapy.^

Don't underestimate the potential benefits of mobil-ity. Early ambulation not only reduces tlie risk of DVT,it prevents other postop pulmonary and neurovascularproblems as well.^

Peroneal nerve injury. This complication mayoccur after TKR as a result of nerve compression dur-ing the procedure, the use of traction, or ischemia.Complete peroneal nerve palsy can cause weakness ofthe foot musculature and may result in foot drop. Aspart of your postop care, keep the wound dressingloose and ensure that the knee remains flexed.** Footdrop—also caused by lying in bed too long—is pre-vented or treated with a splint or an ankle and footorthosis to assist with ambulation.^

To detect problems like peroneal nerve injury, per-form a neurovascular assessment every two hours forthe first 24 hours after surgery, then every eight hoursuntil discharge. Notify the surgeon immediately of anynew neurovascular deficits.**

Dislocation of the artifidat joint. Following THR,dislocation most often happens during the first postopmonth." To avoid internal and external rotation of thehip joint, keep the patient's feet straight and slightlyapart while he's sitting or lying down. Tell the patientnot to cross his legs or ankles, and place an abductorpillow between his legs while in bed. Teach him to con-tinue these practices even after he's been disdiarged.

The patient also shouldn't flex his hip more than 90degrees, so advise him to use an elevated commodeseat in the hospital as well as at home, refrain from sit-ting in low chairs, and use an assistive reaching deviceinstead of leaning forward to pick things up.

Hip precautions usually remain in effect for four to12 weeks.'" Be aware that the THR prosthesis mayresult in tmequal leg lengths. If this happens, the sur-geon may reconmiend, after a follow-up exam six to12 weeks postsurgery, that the patient be fitted with ashoe lift.'"

Dislocation occurs less frequently in TKR than inTHR. Use ice packs on postop knees for 48 hours. Place

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:an be

a pillow under the patient's leg from the calfto the heel, avoiding the popliteal spacedirectly behind the knee.

Later, teach the patient not to sit for longperiods with the knee bent and to avoiddeep knee bends and kneeling. Regardlessof the type of surgery the patient had, rein-force your teaching with written instruc-tions that he can use once he leaves thehospital.

Infection. This complication occurs inless than 2% of joint replacement patients,but its consequences—including furthersurgery and removal of the diseased implantsevere.^'' You'll monitor for wound infection immedi-ately postop, but after discharge, it's essential thatpatients notify their physician if they have fever, fluidbuildup in the operative site, inflammation, or persis-tent pain that's not relieved by rest."

If the infection becomes chronic, tlie patient mayhave to undergo a two-stage surgical revision. The sur-geon will need to remove the implant and debride thesoft tissue by irrigating the wound. Then he'll implanttemporar)' antibiotic-laden cement beads or a prosthe-sis that delivers medication directly to the area and pro-vides stability to the joint.'^ When the infection is elimi-nated, the surgeon will implant another permanentprosthesis in six to eight weeks.**

Teach patients that the presence of any infectionincreases the risk that the infection will migrate to thesite of the implant. Both the American Dental Associa-tion and the Academy of Orthopaedic Surgeons recom-mend that for two years following joint replacementsurgery, patients take prophylactic antibiotics prior toundergoing dental procedures. Such procedures mayinclude teeth cleaning, extraction, dental implant,endodontic surgery, placement of orthodontic bands, orinjection of local anesthetic into the gums."

Educate patients before discharge

Patients undergoing joint replacement are usuallyhospitalized for about three to five days. After dis-charge, they may go to an inpatient rehabilitationfacility, or directly home with arrangements for vis-its from a physical therapist. With today's shorterhospital stays, patients are often discharged beforeachieving functional milestones like managingstairs. Remind patients that their surgery won't besuccessful without proper postop rehabilitation toregain function of the joint and strengthen muscles.

Advise patients that the motion of their artificial

For two yearsafter joint

repiocement,patients shouldtake antibioticsbefore baving

any dentalprocedures.

joint isn't likely to be the same as that of anormal joint. However, it should functionwell enough to allow them to participate inthe activities of daily living.'' Adequateknee motion, in particular, is critical to theresumption of normal, daily activities suchas walking, negotiating stairs, and gettingup from a seated position, which demandsknee flexion of 90 degrees or more."'

After surgery, a TKR patient may need touse a continuous passive motion machine,which will slowly and gently Ilex and ex-tend the knee, to improve the knee joint's

range of motion. Knee stiffness usually resolves withinsix to eight weeks postop.

If limited motion persists beyond that time, addi-tional treatment measures may be necessary, includingsurgical manipulation under anesthesia, arthroscopiclysis of adhesions, or arthrotomy with extensive softtissue release.'"

Patients resume most activities of daily living at sixto eight weeks postop. They may hesitate to ask, soyou'll need to offer guidance on when they can resumesexual activity—usually in four to eight weeks—andhow they can do so without dislocating their newjoints. For tips on how to approach this subject, andinformation on safe positions, see "New meaning forsafe sex" in the January 2003 issue of RN, availableonline at www.mweb.com.

If a patient's plans include travel and his prostheticimplant is made of metal, let him know that the pros-thesis may set off metal detection devices at airportsecurity checkpoints. Some surgeons provide patientswith a card or note to this effect, which patients canthen present at airports or other facilities where secu-rity is an issue.

Smaller incisions, shorter stays

No discussion of joint replacements would be completewithout mention of the newer "minimally invasive"procedures. Are they worthy of all the publicity? Andhow do they differ from standard joint replacement?

Minimally invasive surgery has been promoted asthe newest advancement in joint replacement proce-dures, allowing surgeons to perform joint replacementusing smaller incisions.

Traditional THR involves a 10-inch to 12-inch inci-sion, while a single minimally invasive liip incisionmay measure only 3 to 6 inches. Likewise, a TKR thatusually involves an 8-inch to 10-inch incision can beaccomplished with a 4-inch to 6-inch incision. '"'•'"'

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Still cinother minimally invasive procedure for THRinvolves a two-incision technique. Using X-rays toguide him, the surgeon makes a 2-inch to 3-inch inci-sion in the groin for placement of the socket, and a1-inch to 2-inch incision in the buttock for placementof the stem.

While the larger opening created during traditionalhip surgery allows ample space for the surgeon towork and provides complete visualization of the joint,it also causes disruption of the soft tissue, meaningmore substantial blood loss and a longer period ofpostop rehabilitation.'*''' A smaller incision causes lessdisruption of the soft tissue, and therefore less bloodloss, a shorter hospital stay, and shorter postop reha-bilitation.

But the surgery may take up to two or three times aslong to perform as traditional hip replacementsurgery, increasing the risks associated with anesthe-sia.'" The smaller incision means there's less directvisualization and less room for the surgeon to work.And because a greater amount of retraction is requiredto open the incision, damage may occur to the skin ormusculature.'"

In response, special instruments have been createdfor these types of surgical procedures. Such instrumentsinclude lighted retractors, low-profile reamers, and off-set acetabular/femoral instruments, which can mudimore easily accommodate a smaller incision."*

The results of studies to assess postop recovery and

rehabilitation following minimally invasive jointreplacement procedures have been promising, withhospital discharge noted as early as the day of surgeryfor both THR and TKR.''' But it's wise to keep in mindthat the long-term effects have yet to be confirmed.'^

Whatever the surgical technique, in the absence ofcomphcations, a new artificial joint is expected to last15 years or longer, depending on the patient's activitylevel. Over time, however, the fixation may wear outor loosen from the bone, and surgical revision may benecessary. To ensure that the new artificial joint con-tinues to function properly, long-term follow-up isrecommended.''' Advise your patients to go for peri-odic X-rays, which may reveal evidence of osteoly-sis—bone loss—a sign of implant loosening that mayoccur months or years before the patient becomessymptomatic.

With your care and teaching, joint replacementpatients can achieve the best possible outcomes. Manyof them will enjoy pain-free movement for years tocome. RN

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REFERENCES

1. American Association of Hip and Knee Surgeons. "Minimallyinvasive and smail incision joint replacement surgery: What sur-geons 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 andrevision total hip and knee arthroplasty in the United States from1990 through 2002. J Bone Jo/nfSurg^m, a7[7). 1487,3. American Academy of Orthopaedic Surgeons, "Total hipreplacement," 2006. http://orthoinfo.aaos.org/fact/thr_report-ctm?Tnread_lD=504&topcategory=Joint%20Replacemem (26Oct. 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 kneereplacement surgery- Br J Nurs, 73(13). 782.7. American Academy of Orthopaedic Surgeons. "Kneeimplants." 2001, http://orthoinfo.aaos.org/fact/thr_report.cfmVThreadJD =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 throm-boembolism: The seventh ACCP conference on antithromboticand 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

orthopedic and rheumatologic disorders. 3. Total hip arthro-plasty rehabilitation. Arch Phys Med Rehabil, 86(3 Supp11). S56.11. Phillips. C , Barrett, J. A., el al. (2003). Incidence rates of dis-location, pulmonary embolism, and deep infection during the firstsix months after elective total hip replacement. J Bone Joint SurgAm. 85•A^^). 20.12. Malek, M. M., Fanelli. G. C. et al. (2001). Knee surgery: Com-plications, pitfalls and salvage. New York: Springer-Verlag.13. Harwin, S. P. (2002). The diagnosis and management ofinfected total knee replacement. Seminars in Arthroplasty.^3^^). 9.14. American Academy of Orthopaedic Surgeons. "Minimally in-vasive hip replacement." 2004. http://orthoinfo.aaos.org/fact/thr.report.cfm?Thread_ID^471&topcategory=Joint%20Repiac6ment (26 Oct. 2006).15. American Academy of Orthopaedic Surgeons. "Minimally in-vasive total knee replacement." 2005. http://orthoinfo.aaos.org/fact/thr_report. cfm?Ttiread JD^472&topcategory=Joint%20Replacement (26 Oct. 2006).16. Waldman, B, J. "Advancements in minimally invasive total hiparthroplasty." 2003. www.orthosupersite.com/print.asp7rlD=2306 (14 Nov. 2006).17. Berger. R. A., Jacobs, J. J., et al. (2004). Rapid rehabilitationand recovery with minimally invasive total hip arthroplasty. ClinOrthop Relai Res, Dec(429), 239.18. Teeny, S. M.. York. S. C. et al, (2003). Long-term fotlow-upcare recommendations after total hip and knee arthroplasty. JArtiiroplasty. ;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 OrthopaedicSurgeons estimates that there aremore than how many total kneereplacements (TKRs) performed everyyear?a. 127.000.b. 193.000.C. 271,000.d. 365.000.

Postop nursing care to preventperoneal nerve injury for a patient withTKR 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 followingmay be replaced by a prosthesis?a. Acetabulum.b. Rbula.c. Tibia.d. Talus.

4. All of the following are complicationsof 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 jointreplacement patients should receivewhich of the following?a. Acetaminophen.b. Fondaparinux (Arixtra).c. Vitamin K.d. Urokinase (Abbokinase).

6. Studies show that 90% of fatal PEsin total hip replacement {THR) occurwithin how many week(s) followingsurgery?a. One week.b. Two weeks.c. Three weeks.d. Four weeks.

7. All of the following are signs of a PEthat the nurse should teach the patientto report EXCEPT:a. Clear spulum.b. Shortness of breath.c. Chest pain.d. Unexplained cough.

8. Physical therapy following total jointreplacement 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 jointreplacement surgery usuallyhospitalized?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 measuresshould the nurse implement followingTHR to prevent dislocation of theartificial 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 replacementsurgery should patients takeprophylactic antibiotics priorto undergoing dental procedures?a. Six months,b. One year.c. 18 months.d. Two years,

12. Postop nursing care following TKRincludes: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 wattfor a new implant once a postopinfection following joint replacementsurgery 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 mainreason for joint replacement surgery?a. Osleoarthntis,b. Osleonecrosis.c. Osteoporosis.d. Rheumatoid arthritis.

15. How is minimally invasive THR surgerydifferent 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 lasthow many years?a. Seven years.b. Nine years.c. 12 years.d. 15 years.

17. Postop care of the patient undergoinga THR includes all EXCEPT;a. The drain yi ll be removed the tfiird post-

operative 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 patientundergoing totat joint replacementincludes: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.

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 usinga 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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