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Joint surgery: Paving the way to a smooth recovery


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CE credit is no longer available for this article. (Expired January 2009)


 

Originally posted January 2007

By Bernice Howell, RN

BERNICE HOWELL is an RN for Allegheny Orthopedic Associates at Allegheny General Hospital in Pittsburgh. The author has no financial relationships to disclose.

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

Joint replacements are among the most common and successful orthopedic surgeries, giving more people the opportunity to remain active well into their golden years.1

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 year—numbers that have more than doubled since 1990.2 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.3

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 osteoarthritis, which affects 30 million Americans, most of them older adults.2 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 deformity and abnormal articulation, accompanied by pain and limited motion.4

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.5

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 diagnosis and determining whether surgical intervention 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 untreated, 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 component—an artificial femoral head and stem—is made of metal or ceramic, and the metal socket component has a plastic, ceramic, or metal cup liner.3,6

During TKR, the femur and the tibia may be replaced by prostheses made of metal alloys, high-grade plastics, and polymeric materials.7 Most of the other structures of the knee, such as the connecting ligaments, remain intact.7

The surgeon smooths the rough edges of bones, and trims or removes damaged portions. If damage is restricted to the medial or lateral surface of the knee joint, he may consider a procedure called unicompartmental arthroplasty, which essentially involves only half a prosthesis. It's a simpler procedure that allows for a greater degree of knee flexion following surgery.6

For either THR or TKR, the surgeon may use polymethylmethacrylate, a fast-setting bone cement, to secure the artificial joints. Non-cemented prostheses, first introduced in the 1980s, are generally placed in younger, active patients with stronger bones. The prosthesis may be coated with textured metal or a special bone-like substance, which allows bone to grow into the prosthesis.3

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 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 infection. The risk of complications is greater for patients who are obese or have peripheral vascular disease or diabetes. These conditions can delay wound healing. Excess weight also places increased stress on the components and adjacent bones.8

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:8

DVT and PE. To prevent DVT and its life-threatening consequence, PE, the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic 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 heparin—enoxaparin (Lovenox) or dalteparin (Fragmin), for example.9 Depending on which agent and dose are chosen, the regimen may begin before surgery or six to 24 hours postop.9

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.10,11 Teach patients to be alert for the signs of DVT and PE and to seek help if they develop shortness of breath, 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 RN.)

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.4

Don't underestimate the potential benefits of mobility. Early ambulation not only reduces the risk of DVT, it prevents other postop pulmonary and neurovascular problems as well.4

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.8 Foot drop—also caused by lying in bed too long—is prevented or treated with a splint or an ankle and foot orthosis to assist with ambulation.12

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.8

Dislocation of the artificial joint. Following THR, dislocation most often happens during the first postop month.11 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 discharged.

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.10 Be aware that the THR prosthesis may result in unequal leg lengths. If this happens, the surgeon may recommend, after a follow-up exam six to 12 weeks postsurgery, that the patient be fitted with a shoe lift.10

Dislocation occurs less frequently in TKR than in THR. Use ice packs on postop knees for 48 hours. Place a pillow under the patient's leg from the calf to the heel, avoiding the popliteal space directly behind the knee.

Later, teach the patient not to sit for long periods with the knee bent and to avoid deep knee bends and kneeling. Regardless of the type of surgery the patient had, reinforce your teaching with written instructions that he can use once he leaves the hospital.

Infection. This complication occurs in less than 2% of joint replacement patients, but its consequences—including further surgery and removal of the diseased implant—can be severe.3,8 You'll monitor for wound infection immediately postop, but after discharge, it's essential that patients notify their physician if they have fever, fluid buildup in the operative site, inflammation, or persistent pain that's not relieved by rest.8

If the infection becomes chronic, the patient may have to undergo a two-stage surgical revision. The surgeon will need to remove the implant and debride the soft tissue by irrigating the wound. Then he'll implant temporary antibiotic-laden cement beads or a prosthesis that delivers medication directly to the area and provides stability to the joint.13 When the infection is eliminated, the surgeon will implant another permanent prosthesis in six to eight weeks.8

Teach patients that the presence of any infection increases the risk that the infection will migrate to the site of the implant. Both the American Dental Association and the Academy of Orthopaedic Surgeons recommend that for two years following joint replacement surgery, patients take prophylactic antibiotics prior to undergoing dental procedures. Such procedures may include teeth cleaning, extraction, dental implant, endodontic surgery, placement of orthodontic bands, or injection of local anesthetic into the gums.8

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 joint isn't likely to be the same as that of a normal joint. However, it should function well enough to allow them to participate in the activities of daily living.6 Adequate knee motion, in particular, is critical to the resumption of normal, daily activities such as walking, negotiating stairs, and getting up from a seated position, which demands knee flexion of 90 degrees or more.12

After surgery, a TKR patient may need to use a continuous passive motion machine, which will slowly and gently flex and extend the knee, to improve the knee joint's range of motion. Knee stiffness usually resolves within six to eight weeks postop.

If limited motion persists beyond that time, additional treatment measures may be necessary, including surgical manipulation under anesthesia, arthroscopic lysis of adhesions, or arthrotomy with extensive soft tissue release.12

Patients resume most activities of daily living at six to eight weeks postop. They may hesitate to ask, so you'll need to offer guidance on when they can resume sexual activity—usually in four to eight weeks—and how they can do so without dislocating their new joints. For tips on how to approach this subject, and information on safe positions, see "New meaning for safe sex" in the January 2003 issue of RN, available online at www.rnweb.com.

If a patient's plans include travel and his prosthetic implant is made of metal, let him know that the prosthesis may set off metal detection devices at airport security checkpoints. Some surgeons provide patients with a card or note to this effect, which patients can then present at airports or other facilities where security is an issue.

Smaller incisions, shorter stays

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 hip 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.14,15

Still another 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.14,15 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.14 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.16

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 much more easily accommodate a smaller incision.4

The results of studies to assess postop recovery and 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.17 But it's wise to keep in mind that the long-term effects have yet to be confirmed.16

Whatever the surgical technique, in the absence of complications, 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.18 Advise your patients to go for periodic X-rays, which may reveal evidence of osteolysis—bone loss—a sign of implant loosening that may occur months or years before the patient becomes symptomatic.18

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.

REFERENCES

1. American Association of Hip and Knee Surgeons. "Minimally invasive and small 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 al. (2005). Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am, 87(7), 1487.

3. American Academy of Orthopaedic Surgeons. "Total hip replacement." 2006. http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=504&topcategory=Joint%20Replacement (26 Oct. 2006).

4. Hohler, S. E. (2004). Minimally invasive total hip arthroplasty. AORN J, 79(6), 1244.

5. Arthritis Foundation. "Osteonecrosis." 2006. www.arthritis.org/conditions/DiseaseCenter/osteonecrosis.asp (26 Oct. 2006).

6. Lucas, B. (2004). Nursing management issues in hip and knee replacement surgery. Br J Nurs, 13(13), 782.

7. American Academy of Orthopaedic Surgeons. "Knee implants." 2001. http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=279&topcategory=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., et al. "Prevention of venous thromboembolism: The seventh ACCP conference on antithrombotic and thrombolytic therapy." 2004. www.chestjournal.org/cgi/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 arthroplasty rehabilitation. Arch Phys Med Rehabil, 86(3 Suppl 1), S56.

11. Phillips, C., Barrett, J. A., et 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, 85-A(1), 20.

12. Malek, M. M., Fanelli, G. C., et al. (2001). Knee surgery: Complications, pitfalls and salvage. New York: Springer-Verlag.

13. Harwin, S. F. (2002). The diagnosis and management of infected total knee replacement. Seminars in Arthroplasty, 13(1), 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%20Replacement (26 Oct. 2006).

15. American Academy of Orthopaedic Surgeons. "Minimally invasive total knee replacement." 2005. http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=472&topcategory=Joint%20Replacement (26 Oct. 2006).

16. Waldman, B. J. "Advancements in minimally invasive total hip arthroplasty." 2003. www.orthosupersite.com/print.asp?rID=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 Relat Res, Dec(429), 239.

18. Teeny, S. M., York, S. C., et al. (2003). Long-term follow-up care recommendations after total hip and knee arthroplasty. J Arthroplasty, 18(8), 954.


Life after joint replacement surgery

The goal of total joint replacement is to relieve pain in your damaged joint. Hip and knee replacements are most common, but joint replacement can also be performed on the ankle, foot, shoulder, elbow, and fingers.

Following surgery, you may have a bulky dressing and a drain to remove fluid buildup around your wound. The surgeon will remove the drain after a day or two. You may also have to wear elastic hose and possibly compression stockings and pneumatic sleeves, which are connected to a machine that circulates air around your legs to help keep blood flowing.

Pain management will be important in your early recovery. Initially you'll receive pain medication through an IV so that you can regulate the amount of medication you need. After a day or two, injections or pills will replace the IV. You'll also have to take antibiotics to prevent infection and blood-thinning medication to help keep blood clots from developing.

Your orthopedist will encourage you to get up shortly after your operation. You may begin walking as soon as the day after surgery, at first with a walker, crutches, or cane. A physical therapist will teach you how to use your new joint.

You may be able to go home in three to five days, or you may need to spend several weeks in an intermediate care facility, such as a rehab center, first. If you go home right away, you'll need to properly care for your wound by keeping the area clean and dry. Your surgeon or nurse will tell you how to care for your incision, when you can bathe, and, if you have a dressing, how and when to change it.

Notify your doctor if the wound appears red or begins to drain, or if your temperature exceeds 100.5° F (38° C). Take your temperature twice a day. Swelling is normal for the first three to six months after surgery. Apply an ice pack for 15 – 20 minutes at a time, a few times a day.

Chest pain, shortness of breath, an unexplained cough, bloody sputum, or leg pain, tenderness, warmth, swelling, or discoloration are signs of a possible blood clot. Notify your doctor immediately if you experience any of these things.

For at least six weeks after a total hip replacement, when it's time to rest or sleep, lie on your back with your legs slightly apart, or on your side, and put an abduction pillow or a regular pillow between your knees, as instructed by your orthopedist or nurse. If you've had a knee replacement, you can safely sleep on your back, on either side, or on your stomach. You can resume sexual activity in four to eight weeks, but must avoid positions that may cause accidental dislocation of the new hip.

The motion of your joint will generally improve after surgery, but the extent of improvement will depend on how stiff your joint was before the surgery. Joint replacement surgery has a greater than 90% success rate. When complications occur, most are treatable. New joints generally last at least 15 years.

SOURCES:
1. American Academy of Orthopaedic Surgeons. "Total joint replacement." 2000. http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=18&topcategory=Joint%20Replacement (26 Oct. 2006).
2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. "Joint replacement surgery and you." 2005. www.niams.nih.gov/hi/topics/arthritis/jointrep.htm (26 Oct. 2006).
3. American Academy of Orthopaedic Surgeons. "Activities after a knee replacement." 2001. http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=275&topcategory=Joint%20Replacement (26 Oct. 2006).
4. American Academy of Orthopaedic Surgeons. "Activities after a hip replacement." 2005. http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=274&topcategory=Joint%20Replacement.
5. Whittington, F. W., Mansour, S., & Sloan, S. L. (2001). Sex after total joint replacement. Atlanta: Media Partners.


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In the second installment of our two-part series we review medication safety and the steps JCAHO requires you and your facility to take to keep patients safe.


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