patient with joint replacement

artho

a prefix meaning joint

arthroscopy

the repair of joint problems through the operating arthroscope or open joint surgery

arthroplasty

forming a “new joint”

hemiarthroplasty

the replacement of one of the articular surfaces (ex half of hip joint)

osteotomy

surgical cutting of the bone

prosthesis

artificial substitute for a missing part of the body (replacement)

THA/THR

total hip arthroplasty/total hip replacement

TKA/TKR

total knee anthroplasty/total knee replacement

hip, knee, finger joints

replaceable parts

shoulder, elbow, wrist, ankle

less frequently replaced

arthritis

d/t damage to joints can lead to pain and decreased mobility and function

• osteoarthritis: more common in older adults

• rheumatoid arthritis: can happen in children

(individual that gets joint replacement)

trauma → functional joint damage

from fractures

• certain hip fractures

• ex break hip at trochanter area which cuts off blood supply leads to necrosis of that joint

(individual that gets joint replacement)

congenital deformity → functional joint damage

hip dysplasia: incorrectly formed/not fully formed hip joints (not formed properly)

(individual that gets joint replacement)

tumors

__ can invade and cause death of bone

(individual that gets bone replacement)

avascular necrosis

if any joint is w/o blood supply, it will not get O2 or nutrients = joint death/necrosis

• sickle cell anemia: clotting from sickle cells and no longer distribute O2 and nutrients

(individual that gets bone replacement)

replacing a joint with an artificial one can __

increase mobility, use, joint stability, & relieve pain

(mobility, functionality, stability, comfort)

when do people get joint replacement?

after all other, more conservative therapies for healing and health have failed

• PT physical therapy

• medication (pain control/decrease inflammation)

• joint injections

• weight loss

• activity modification (using a cane)

(people try other options first and last resort is surgery for joint replacement)

R hip prosthesis

joint stem important bc this depends on the person (tall vs short)

component material

plastic (polyethylene): particularly for the cup (hip socket & lining) to make it smooth for rotation

metal: cobalt chrome or titanium (for joint stem)

ceramic: actually a metal oxide (ball of new hip; seems to last longer)

cement: actually more of a filling compounds; hold “after market parts” in place

• problem with cement, over years it can dry, flake off and you can get loosening of parts

cementless prosthesis

more common now; prosthesis is hammered into more precisely bored hole in the femur

• see far fewer disadvantages

cementless hip prosthesis advantages

avoid cement relate problems (flaking or dried cement)

minimal risk of prothesis bone bond loss

• prosthesis has porous coating so the actual bone grows into the porous coating which allows overtime for a stable joint since it becomes united

cementless hip prosthesis disadvantages

risk of bone marrow chuncks forced into circulatory during shaft replacement

potential need for weight bearing restriction

thigh pain (larger prosthesis)

loosening of fibers from porous coated surface

requires good circulation to injury site so it may not be appropriate

cemented hip prosthesis

the prosthesis is placed into a bored opening in the femur and surrounded by the bone cement

bored opening does not have to be precise

cemented hip prosthesis advantages

surgical skill deviations

early weight bearing

is smaller, lighter prosthesis

is more cost effective

cemented hip prosthesis disadvantages

cement may cause circulatory interruptions

with age, cement can crack → bonding loss between prosthesis and bone → joint instability

knee prosthesis

before: left has lost its cushioned plate between bones and now there’s friction (bones are right on top of each other)

• the bump = bone spurs are inflammation of bone → causes excess bone growth

after: joint prosthesis allowing for smooth movement

• smooth base (plasticky base) on bottom portion; metallic piece fitted over the top of femur

complications of joint replacement

dislocation/loosening (osteolysis) of artificial joint (inflammation in the area that does not allow for it to be stable)

infection at surgical site

thromboembolism

complications of immobility

long term

• heterotopic ossification: extensive bone growth

• avascular necrosis: lack of blood supply to the area d/t damaging of blood vessels

• loosening of the joint: may not loosen at first but can in many years down the line

nursing goals

minimize discomfort/pain

prevent infection of surgical site (do not change sterile dressing frequently as it actually helped prevent infection; maybe air out site for faster healing)

prevent/minimize negative consequences of immobility

prevent dislocation/loosening of prosthesis (certain position can prevent this)

post op nursing responsibilities

vital signs/neurovascular checks as ordered (q 1-2 hours)

maintain body/limb alignment (to prevent stress on other joints)

home health/social service for rehab referrals

control pain

• medications: IV, PO, PCA (patient controlled analgesia), nerve block

  • as needed and before planned activities

  • nerve block: local anesthetic and less pain (usually for knee replacement) more likely to participate in therapy = more likely to progress

    • became a part of procedure rather than giving lots of analgesics

• individualized strategies

  • reposition

(postop nursing responsibilites)

respiratory toilet

prevent atelectasis, pneumonia through coughing, deep breathing, incentive spirometer, OOB, fluid

• C-DB, IS

(postop nursing responsibilities)

monitor incision

infection, bleeding, record/drainage, drain output, maintain clean/dry dressing (no damp dressing because it can cause bacteria growth)

(post op nursing responsibility)

prevent DVT

thrombus preventive therapy

• Lovenox, Coumadin, Aspirin, others

AE hoses/SCDs

activity and weight-bearing as allowed by surgeon

• OOB ASAP, with order

PROM (passive range of motion)

assess skin integrity

investigate:

• complaints of itching, burning (especially heels)

• redness of bony prominences

OOB to promote healing

(postop nursing responsibilities)

nutrition/hydration

balanced diet for healing

energy for PT/activity

(postop nursing responsibilities)

neurovascular assessment/concerns

surgery can damage nerves and vessels; need to assess beyond surgery

• if replaced shoulder → check hands

• if replaced knee → check feet

neurovascular assessment/concerns (early ~ 3Ps)

pain: unrelieved with medication or repositioning/elevation

paresthesia: numbness, tingling, pins/needle sensation

pallor: cap refill time > 3 secs, bluish fingers/toes

neurovascular assessment/concerns (late ~ 3Ps)

polar: skin temperature - cool/cold finger/toes

paralysis: unable to move fingers/toes

pulses: palpable pulses, doppler pulse, no pulse

dislocation of hip prothesis human response

increased pain, swelling, immobilization

shortening of affected leg

abdominal internal/external rotation (sign that hip is no longer in its socket)

restricted movement

“popping” sensation of affected hip

prevent prosthesis dislocation

PROPER POSITIONING: maintain abduction for some replacements

• put a wedge between 2 legs (abductor pillow) because when you keep legs together/crossed legs → increases chance of hip dislocation

sometimes instruction to not flex hip > 90 degrees (hip higher than knee)

• when you try to pick up something from the floor or tying your shoes

no internal or external rotation of the affected leg/hip

• knee pointing up straights

depends on the type of procedure; more common for posterior approach procedures

hip dislocation risk

greatest during the first 3 months post-op

other risk factors: age, bone loss, RA, cognitive impairment, implant issues

• may not remember all the precautions

important to know the SPECIFIC precautions from surgeon (depends on surgical approach)

give printed literature with pictures to patient and review BEFORE discharge

dislocation of knee prosthesis

human response

• pain or swelling after/with movement

• an obvious deformity of the knee (no longer aligned properly, looks strange)

• numbness in the foot d/t pressure on the nerves

• no pulses in the foot (decrease pulse) d/t pressure on the blood vessels

(less common than hip dislocation)

nursing intervention - prevent knee dislocation

proper positioning

• maintain leg in full extension (fully straight)

  • towel roll under ankle of operative leg

• reposition towel roll frequently to prevent nerve damage

knee immobilizer (aka POKI: post operative knee immobilizer)

• foam wrapped around leg with hole for knee

• has rigid back and keeps legs straight to maintain joint stability when OOB

nursing interventions- maintain joint function

polar pack (aka bio chill)

• wrap that goes around the knee attached to cooler via tube

• cooling circulates through wrap

• decreases inflammation and pain (provides comfort)

nursing interventions- maintain joint function

CPM (continuous passive motion)

• put leg and slowly extends & flexes knee

• can wear at night since it promotes venous return and prevents stiffening of joint

nursing interventions- maintain joint function

documentation

note and document differences

• in time on operative limb

• difference between operative limb and nonoperative limb

general discharge instructions

continue with PT as ordered

medication education

• education on anticoagulant to prevent blood clot

when to contact PCP/Surgeon

• elevated temp/fever, drainage from surgical site, sudden increase in pain, significant changes in ROM, gait instability

general discharge instructions (hip)

follow specific positonig guidelines (approach dependent)

general discharge instructions (knee)

avoid prolonged kneeling positions

no running or involvement in sporting activities requiring high speed running and/or jumping until OK with MD/PT