TOTAL JOINT REPLACEMENT

I. Total Hip Arthroplasty or Total Hip Replacement

a. Anatomy

The hip is one of the body's largest joints. It is a ball-and-socket joint. The socket is formed by the
acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of
the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions
the ends of the bones and enables them to move easily.

A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a
small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to
the joint.

Normal hip anatomy.

Common Causes of Hip Pain

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis,
and traumatic arthritis are the most common forms of this disease.
 Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in
people 50 years of age and older and often in individuals with a family history of arthritis.
The cartilage cushioning the bones of the hip wears away. The bones then rub against each
other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by
subtle irregularities in how the hip developed in childhood.
 Rheumatoid arthritis. This is an autoimmune disease in which the synovial membrane
becomes inflamed and thickened. This chronic inflammation can damage the cartilage,
leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of
disorders termed "inflammatory arthritis."
 Post-traumatic arthritis. This can follow a serious hip injury or fracture. The cartilage may
become damaged and lead to hip pain and stiffness over time.
  Avascular necrosis. An injury to the hip, such as a dislocation or fracture, may limit the
blood supply to the femoral head. This is called avascular necrosis (also commonly referred
to as "osteonecrosis"). The lack of blood may cause the surface of the bone to collapse,
and arthritis will result. Some diseases can also cause avascular necrosis.
 Childhood hip disease. Some infants and children have hip problems. Even though the
problems are successfully treated during childhood, they may still cause arthritis later on
in life. This happens because the hip may not grow normally, and the joint surfaces are
affected.

In hip osteoarthritis, the smooth articular cartilage wears away and becomes frayed and rough.

Description

In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed
and replaced with prosthetic components.
 The damaged femoral head is removed and replaced with a metal stem that is placed into
the hollow center of the femur. The femoral stem may be either cemented or "press fit"
into the bone.
 A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the
damaged femoral head that was removed.
 The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a
metal socket. Screws or cement are sometimes used to hold the socket in place.
 A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow
for a smooth gliding surface.
(Left) The individual components of a total hip replacement. (Center) The components merged into an
implant. (Right) The implant as it fits into the hip.
The decision to have hip replacement surgery should be a cooperative one made by you, your family, your
primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins
with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.

Candidates for Surgery

There are no absolute age or weight restrictions for total hip replacements.

Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who
undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually.
Total hip replacements have been performed successfully at all ages, from the young teenager with
juvenile arthritis to the elderly patient with degenerative arthritis.

There are several reasons why the doctor may recommend hip replacement surgery. People who benefit
from hip replacement surgery often have:
 Hip pain that limits everyday activities, such as walking or bending
 Hip pain that continues while resting, either day or night
 Stiffness in a hip that limits the ability to move or lift the leg
 Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

NURSING MANAGEMENT:
1. Assist in sitting position, place chair at 90 degree angle to bed ans stand on unaffected side / pivot
patient to unaffected side to prevent dizziness and orthostatic hypotension
2. Maintain abduction on affected leg when in supine position with pillow between legs to avoid
extreme internal or external rotation
 II. TOTAL KNEE REPLACEMENT

a. ANATOMY

Normal knee anatomy. In a healthy knee, these structures work together to ensure smooth, natural
function and movement. The knee is the largest joint in the body and having healthy knees is required to
perform most everyday activities.

The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia),
and the kneecap (patella). The ends of these three bones where they touch are covered with articular
cartilage, a smooth substance that protects the bones and enables them to move easily. The menisci are
located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the
joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the
knee strength. All remaining surfaces of the knee are covered by a thin lining called the synovial
membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero
in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony,
resulting in pain, muscle weakness, and reduced function.

The most common cause of chronic knee pain and disability is arthritis. Although there are many types of
arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-
traumatic arthritis.
 Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in
people 50 years of age and older, but may occur in younger people, too. The cartilage that
cushions the bones of the knee softens and wears away. The bones then rub against one
another, causing knee pain and stiffness.
 Rheumatoid arthritis. This is a disease in which the synovial membrane that surrounds the
joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage
and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most
common form of a group of disorders termed "inflammatory arthritis."
 Post-traumatic arthritis. This can follow a serious knee injury. Fractures of the bones
surrounding the knee or tears of the knee ligaments may damage the articular cartilage
over time, causing knee pain and limiting knee function.
Osteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of
arthritis.

Description

A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing"
because only the surface of the bones are actually replaced.

There are four basic steps to a knee replacement procedure.

 Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia are
removed along with a small amount of underlying bone.
 Position the metal implants. The removed cartilage and bone is replaced with metal
components that recreate the surface of the joint. These metal parts may be cemented or
"press-fit" into the bone.
 Resurface the patella. The undersurface of the patella (kneecap) is cut and resurfaced with
a plastic button. Some surgeons do not resurface the patella, depending upon the case.
 Insert a spacer. A medical-grade plastic spacer is inserted between the metal components
to create a smooth gliding surface.

(Left) Severe osteoarthritis. (Right) The arthritic cartilage and underlying bone has been removed and
resurfaced with metal implants on the femur and tibia. A plastic spacer has been placed in between the
implants. The patellar component is not shown for clarity.

Total knee replacement is a surgical procedure whereby the diseased knee joint is replaced with artificial
material. The knee is a hinge joint which provides motion at the point where the thigh meets the lower
leg. The thighbone (or femur) abuts the large bone of the lower leg (tibia) at the knee joint. During a total
knee replacement, the end of the femur bone is removed and replaced with a metal shell. The end of the
lower leg bone (tibia) is also removed and replaced with a channeled plastic piece with a metal stem.
Depending on the condition of the kneecap portion of the knee joint, a plastic "button" may also be added
under the kneecap surface. The artificial components of a total knee replacement are referred to as the
prosthesis.

The posterior cruciate ligament is a tissue that normally stabilizes each side of the knee joint so that the
lower leg cannot slide backward in relation to the thighbone. In total knee replacement surgery, this
ligament is either retained, sacrificed, or substituted by a polyethylene post. Each of these various designs
of total knee replacement has its own particular benefits and risks.

Picture of a total knee replacement

Is Total Knee Replacement for You?

The decision to have total knee replacement surgery should be a cooperative one between you, your
family, your family physician, and your orthopaedic surgeon. Your physician may refer you to an
orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.

When Surgery Is Recommended

There are several reasons why your doctor may recommend knee replacement surgery. People who
benefit from total knee replacement often have:

 Severe knee pain or stiffness that limits your everyday activities, including walking, climbing
stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks
without significant pain and you may need to use a cane or walker
 Moderate or severe knee pain while resting, either day or night
 Chronic knee inflammation and swelling that does not improve with rest or medications
 Knee deformity — a bowing in or out of your knee
 Failure to substantially improve with other treatments such as anti-inflammatory
medications, cortisone injections, lubricating injections, physical therapy, or other
surgeries

Candidates for Surgery

There are no absolute age or weight restrictions for total knee replacement surgery.

Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who
undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually.
Total knee replacements have been performed successfully at all ages, from the young teenager with
juvenile arthritis to the elderly patient with degenerative arthritis.

Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components:

 A medical history. Your orthopaedic surgeon will gather information about your general
health and ask you about the extent of your knee pain and your ability to function.
 A physical examination. This will assess knee motion, stability, strength, and overall leg
alignment.
 X-rays. These images help to determine the extent of damage and deformity in your knee.
 Other tests. Occasionally blood tests, or advanced imaging such as a magnetic resonance
imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues
of your knee.

NURSING CARE FOR JOINT REPLACMENT

PREOPERATIVE CARE
• Assess the client’s knowledge and understanding of the planned operative procedure. Provide
further explanations and clarification as needed. It is important that the client have a clear and
realistic understanding of the surgical procedure and expected results. Knowledge decreases anxiety
and increases the client’s ability to assist with postoperative care procedures.
• Obtain a nursing history and physical assessment, including range of motion of the affected joints.
This information not only allows nurses to tailor care to the needs of the individual but also serves as
a baseline for comparison of postoperative assessment data.
• Explain necessary postoperative activity restrictions. Teach how to use the overhead trapeze for
changing positions. The client who learns and practices moving techniques before surgery can use
them more effectively in the postoperative period.
• Provide or reinforce teaching of postoperative exercises specific to the joint on which surgery is to
be performed. Exercises are prescribed postoperatively to (a) strengthen muscles providing joint
stability and support, (b) prevent muscle atrophy and joint contractures; and (c) prevent venous stasis
and possible thromboembolism.
• Teach respiratory hygiene procedures such as the use of incentive spirometry, coughing, and deep
breathing.Adequate respiratory hygiene is imperative for all clients undergoing joint replacement to
prevent respiratory complications associated with immobility and the effects of anesthesia. In
addition, many clients undergoing total joint replacement are elderly and may have reduced
mucociliary clearance.
• Discuss postoperative pain control measures, including use of patient-controlled analgesia (PCA) or
epidural infusion as appropriate. It is important for the client to understand the purpose and use of
postoperative pain control measures to allow early mobility and reduce complications associated with
immobility.
• Teach or provide prescribed preoperative skin preparation such as shower, shampoo, and skin scrub
with antibacterial solution. These measures help reduce transient bacteria that may be introduced
into the surgical site.
• Administer intravenous antibiotic as ordered.Antibiotic therapy is initiated before or during surgery
and continued postoperatively to further reduce the risk of infection.

POSTOPERATIVE CARE
• Check vital signs, including temperature and level of consciousness, every 4 hours or more
frequently as indicated. Report significant changes to the physician. These routine assessments
provide information about the client’s cardiovascular status and can give early indications of
complications such as excessive bleeding, fluid volume deficit, and infection.
• Perform neurovascular checks (color, temperature, pulses and capillary refill, movement, and
sensation) on the affected limb hourly for the first 12 to 24 hours, then every 2 to 4 hours. Report
abnormal findings to the physician immediately. Surgery can disrupt the blood supply to or
innervation of the affected extremity. If so, rapid intervention is important to preserve the function
of the extremity.
• Monitor incisional bleeding by emptying and recording suction drainage every 4 hours and assessing
the dressing frequently. Significant blood loss can occur with a total joint replacement, particularly a
total hip replacement.
• Reinforce the dressing as needed. The dressing is usually changed 24 to 48 hours after surgery but
may need reinforcement if excess bleeding occurs.
• Maintain intravenous infusion and accurate intake and output records during the initial
postoperative period. The client is at risk for fluid volume deficit in the initial postoperative period
because of blood and fluid loss during surgery, as well as the effects of the anesthetic.
• Maintain bed rest and prescribed position of the affected extremity using a sling, abduction splint,
brace, immobilizer, or other prescribed device. Proper positioning of the affected extremity is vital in
the initial postoperative period so that the joint prosthesis does not become dislocated or displaced.
• Help the client shift position at least every 2 hours while on bed rest. Shifting of position helps
prevent pressure sores and other complications of immobility.
• Remind the client to use the incentive spirometer, to cough, and to breathe deeply at least every 2
hours. These measures are important to prevent respiratory complications such as pneumonia.
• Assess the client’s level of comfort frequently. Maintain PCA, epidural infusion, or other prescribed
analgesia to promote comfort. Adequate pain management promotes healing and mobility.
• Help the client get out of bed as soon as allowed.Teach and reinforce the use of techniques to
prevent weight bearing on the affected extremity, such as the over-head trapeze, pivot turning, and
toe-touch. Early mobility prevents complications such as pneumonia and thromboembolism, but
appropriate techniques must be used to prevent injury to the operative site.
• Initiate physical therapy and exercises as prescribed for the specific joint replaced, such as
quadriceps setting, leg raising, and passive and active range-of-motion exercises. These exercises help
prevent muscle atrophy and thromboembolism and strengthen the muscles of the affected extremity
so that it can support the prosthetic joint.
• Use sequential compression devices or antiembolism stockings as prescribed. These help prevent
thromboembolism and pulmonary embolus for the client who must remain immobile following
surgery.
• For the client with a total hip replacement, prevent hip flexion of greater than 90 degrees or
adduction of the affected leg. Provide a seat riser for the toilet or commode. These measures prevent
dislocation of the joint.
• Assess the client with a total hip replacement for signs of prosthesis dislocation, including pain in
the affected hip or shortening and internal rotation of the affected leg.
• For the client with a total knee replacement, use a continuous passive range-of-motion (CPM) device
or range-of-motion exercises as prescribed.Dislocation is not a problem with a knee replacement, and
more emphasis is placed on range-of-motion exercises in the early postoperative period.
• Maintain fluid intake and encourage a high-fiber diet. Administer stool softeners or rectal
suppositories as needed. Immobility contributes to the potential problem of constipation; these
measures help maintain regular fecal elimination.