Joint Replacement

Arthro

prefix meaning joint

Arthroscopy

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

Arthroplasty

forming a new joint

Hemiarthroplasty

the replacement of one of the articular surfaces

Osteotomy

surgical cutting of the bone

Prosthesis

artificial substitute for a missing part of the body

Types

THA → total hip arthroplasty → total hip replacement of THR

TKA → total knee arthroplasty → total knee replacement or TKR

Replaceable Parts

hip

knee

finger joints

less frequently → shoulder, elbow, wrist, ankle

Recipients

arthritis → osteoarthritis or rheumatoid arthritis

trauma → functional joint damage (certain hip fractures)

congenital deformity → functional joint damage

tumors

avascular necrosis

Outcomes

to increase mobility

to increase use

to increase joint stability

to relieve pain

mobility, functionality, stability, comfort

When

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

ex: PT, meds, joint injections, weight loss, and activity modification

Component Materials

plastic (polyethylene)

metal → cobalt chrome or titanium

ceramic → actually a metal oxide

cement → actually more of a filling compound that holds after market parts in place

Cementless Hip prosthesis

prosthesis is hammered into more precisely bored hole in the femur

Cementless Advantages

avoid cement related problems and minimal risk of prosthesis bone bond loss

Cementless Disadvantages

risk of bone marrow chunks forced into circulation during shaft placement potential need for weight bearing restriction

thigh pain

loosening of fibers from porous coated surface

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

Cemented Hip Prosthesis

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

bored opening does not have to be precise

Cemented Advantages

surgical skill deviations

early weight bearing

is smaller and lighter

is cost effective

Cemented Disadvantages

cement may cause circulatory interruptions

with age cement can crack and bonding loss between prothesis and bone causes joint stability

Joint Replacement Complications

dislocation and loosening (osteolysis) of the artificial joint

infection at the surgical site

thromboembolism

complications of immobility

long term → heterotopic ossification, avascular necrosis, and loosening of the joints

Nursing Goals

minimize discomfort and pain

prevent infection of surgical site

prevent and minimize negative consequences of immobility

prevent dislocation and loosening of prosthesis

Control Pain Postop

medications → IV, PO, PCA, nerve block

given as needed and before planned activities

individualized strategies → repositoning

Monitor Incision Postop

infection

bleeding

record drainage and drain output

maintain clean and dry dressing

Prevent DVT Postop

thrombus prevention therapy → lovenox, coumadin, eliquis, aspirin

AE hose and SCDs

activity and weight bearing as allowed by surgeon

out of bed ASAP with order

PROM

maintain body and limb alignment and respiratory toilet (C-DB and incentive spirometer)

Assess Skin Postop

investigate complaints of itching and burning, especially hells

redness of bony prominences

Nutrition Postop

balanced diet for healing

energy for PT and activities

home health and social service for rehab referrals

Neurovascular Early P

pain → unrelieved with meds or repositioning/elevation

paresthesia → numbness, tingling, pins/needles sensation

pallor → cap refill time over 3 secs, bluish fingers and toes

Neurovascular Late P

polar → skin temp is cool with cold fingers and toes

paralysis → unable to move fingers and toes

pulses → palpable pulses, doppler pulse, or no pulse

Hip Prosthesis Response

increased pain, swelling, and immobilization

shortening of affected leg

abnormal internal and external rotation

restricted movement

popping sensation of affected hip

Prevent Prosthesis Dislocation

proper positioning to maintain abduction for some replacements

sometimes instructions to not flex hips over 90 degrees

no internal or external rotation of the affected hip or leg

Hip Dislocation

risk is greatest during the first 3 months postop

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

important to know the specific precautions from the surgeon

give printed literature with pictures to patient and review before discharge

Knee Prosthesis Dislocation

pain or swelling after movement

an obvious deformity of the knee

numbness in the foot

no pulses in the foot

Prevent Knee Dislocation

proper positioning with maintaining leg in full extension

towel roll under ankle of operative leg

reposition towel roll frequently to prevent peroneal nerve damage

Maintain Joint Function

polar pack to reduce postop swelling

knee immobilizer to maintain joint stability when out of bed

CPM to prevent joint flexion contracture

Documentation

note differences in time on operative limb

differences between operative limb and non-operative limb

Discharge Instructions

hip → follow specific positioning guidelines

knee → avoid prolonged kneeling, no running or involvement in sporting activities requiring high speed running or jumping until OK with MD/PT

continue PT as ordered

medication education

when to contact surgeon → elevated temp/fever, drainage from surgical site, sudden increase in pain, significant change in range of mobility, unstable gait