THR and TKR

PresenterNavreet Kaur SainiM Sc Nsg Student AIIMS

ModeratorMr. L. Gopichandran Lecturer AIIMS

STATISTICSOstheoarthritis is one of the ten most disabling diseases in developed countries (WHO, 2010b). Worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic osteoarthritis, including moderate and severe forms.

TKR/ 1,00,000 pop (2009)

THR / 1,00,000 Pop (2009)

Goals of Joint Replacement Surgery

Relieve pain!!!

Restore function, mobility

PREOPERATIVE ASSESSMENT OF PATIENTS UNDERGOING TJR

Posture And GaitBone integrity and Joint function-

• Range of motion• Palpation• Muscle strength• Skin changes• Neurovascular Status

TOTAL HIP REPLACEMENT

Anatomy—Hip

Total Hip replacement• Total Hip replacement is the

replacement of a severely damaged hip with an artificial joint.

HISTORY OF THRThe earliest recorded attempts at hip replacement (Gluck T, 1891), which were carried out in Germany, used ivory to replace the femoral head (the ball on the femur).

On September 28, 1940 at Columbia Hospital in Columbia,South carolina Dr. Austin T. Moore (1899–1963), an American surgeon, reported and performed the first metallic hip replacement surgery.

The original prosthesis he designed was a proximal femoral replacement, with a large fixed head, made of the Cobalt-Chrome alloy Vitallium. It was about a foot in length and it bolted to the resected end of the femoral shaft (hemiarthroplasty)

In 1960 a Burmese orthopaedic surgeon, Dr. San Baw (29 June 1922 – 7 December 1984), pioneered the use of ivory hip prostheses to replace ununited fractures of the neck of femur when he first used an ivory prosthesis to replace the fractured hip bone of an 83 year old Burmese Buddhist nun, Daw Punya

HISTORY OF THRLow friction arthroplasty- was lubricated with synovial fluid. The small femoral head (7/8" (22.2 mm)) was chosen for it would have lower friction against the acetabular component and thus wear out the acetabulum more slowly. Unfortunately, the smaller head dislocated more easily. Alternative designs with larger heads such as the Mueller prosthesis were proposed. Stability was improved, but acetabular wear and subsequent failure rates were increased with these designs. The Teflon acetabular components of Charnley's early designs failed within a year or two of implantation.

HISTORY OF THRThis prompted a search for a more suitable material. A German salesman showed a polyethylene gear sample to Charnley's machinist, sparking the idea to use this material for the acetabular component.

The Ultra High Molecular Weight Polyethylene or UHMWPE acetabular component was introduced in 1962. Charnley's other major contribution was to use polymethylmethacrylate (PMMA) bone cement to attach the two components to the bone. For over two decades, the Charnley Low Friction Arthroplasty, and derivative designs were the most used systems in the world. It formed the basis for all modern hip implants.

NEW V/S OLDInitial hip designs were made of a one-piece femoral component and a one-piece acetabular component. Current designs have a femoral stem and separate head piece.Metal implants are in practice compared to ivory in old times.

IndicationsArthritis(degenerative joint disease, rheumatoid arthritis )Femoral neck fracturesFailure of previous reconstructive surgeries(failed prosthesis, osteotomy)Problems resulting from congenital hip disease

THR: Indications

TYPES OF HIP REPLACEMENTTotal hip replacement (THR) or total hip arthroplasty (THA) - Replacement of the femoral head and the acetabular articular surface

Hemiarthroplasty - Replacement of only the femoral head

Bipolar hemiarthroplasty - A specific form of hemiarthroplasty in which a femoral prosthesis is used with an articulating acetabular component; the acetabular cartilage is not replaced; the principle of this procedure is to decrease the frictional wear between the femoral head prosthesis and the cartilage of the acetabulum.

BIPOLAR HEMIARTHROPLASTY

THA Implants

THR IMPLANTS

Implant ChoiceCemented:

• Elderly (>65)• Low demand• Better early fixation• late loosening

IMPLANT CHOICE Cemented joint

replacement (cemented joint arthroplasty) - A procedure in which bone cement or polymethylmethacrylate (PMMA) is used to fix the prosthesis in place in the joint

Cementless:• Younger• More active• Protected weight-bearing first 6 weeks• Better long-term fixation

IMPLANT CHOICE Ingrowth, or

cementless, joint replacement (ingrowth, or cementless, arthroplasty) - A procedure that does not involve bone cement to fix the prosthesis in place; an anatomic or press fit with bone ingrowth into the surface of the prosthesis leads to a stable fixation; this procedure is based on a fracture-healing model.

Technique: Total Hip Replacement

Femoral neck resection

Acetabular reaming

Insertion of acetabular component

Reaming/broaching of femoral component

Insertion of femoral component

Femoral head impaction

Final implant

THR

Nursing Interventions

Pre Operative Management

Assessment

Hydration status (skin and mucous membrane,vital

signs,urine output and lab values)

Current medication history

Possible infection (h/o cold,dental problems,UTIs or

other infections within 2 wks before surgery)

Nursing diagnosisAcute pain related to orthopedic problem,swelling or

inflammation

Risk for ineffective regimen management related to

insufficient knowledge or lack of available support and

resources,

Impaired physical mobility related to pain,swelling and

possible presence of an immobilization device.

Risk for situational low self esteem,disturbed body image or

functional impairement related to impact of

musculoskeletal disorder.

Post Operative management

Pain related to Total Hip Replacement

Assess patient for pain using a standard pain intensity scaleAsk patient to describe discomfortAknowledge existance of pain;inform patient about available analgesics or muscle relaxants.Use pain modifying techniques:Use analgesics Change position within prescribed limits

Modify environmentNotify surgeon about persistent painEvaluate and record discomfort and effectiveness of pain modifying techniques

Impaired physical mobility related to positioning,weight bearing and activity restriction after surgery.

Maintain proper position of the hip joint(abduction,neutral rotation,limited flexion)

Keep pressure off heel

Instruct and assist in position changes and transfer.Instruct and supervise isometric quadriceps and gluteal setting exercises. In consultation with physical therapist instruct and supervise progressive safe ambulation within limitations of weight bearing prescription.

Offer encouragement and support exercise regimen.Instruct and supervise safe use of ambulatory aids.

Hemorrhage,neurovascular compromise,dislocation of prosthesis,DVT and infection related to surgery.

HemorrhageMonitor vital signs, observing for shock.Note character and amount of drainageNotify surgeon if patient develops shock or excessive bleeding and prepare for administration of fluids,blood component therapy and medications.Monitor hemoglobin and hematocrit values.

Neurovascular dysfunction

Assess affected extrimity for colour and temperature.Assess toes for capillary refill response.Assess extrimity for edema and swelling.report patients complains of leg tightness.Elevate extrimity(keep leg lower than hip when in chair).

Assess for deep,throbbing painAssess for pain on passive flexion of footAssess for change in sensation and numbness.Assess ability to move foot and toes.

Assess pedal pulses in both feet.Notify surgeon if altered neurovascular status is noted.

Dislocation of prosthesis

Position patient as prescribed.Use abducter splint or pillow to maintain position and to support extremitySupport legs and place pillows between legs when patient is turning and side lying;turn to the unaffected side.Avoid acute flexion of hip(head of bed at 60 degrees or less)

Dislocation of prosthesisAvoid crossing legs.Assess for dislocation

of prosthesis(extremity shortness,internally or externally rotated,severe hip pain,pt.unable to move extrimity).

Notify surgeon if possible dislocation.

Deep vein thrombosisUse elastic compression stockings or sequential compression device as prescribed.Remove stockings for 20 min twice a day and provide skin care.Assess popliteal,dorsalis pedis and posterior tibial pulses.Assess skin temperature of legsAssess for Homans sign every 8 hrly

Avoid pressure on popliteal blood vessels from equipments or pillows.Change position and increse activity as prescribed.Supervisee ankle exercises hourly.Monitor body temperatureEncourage fluids.

InfectionMonitor vital signs Use aseptic techniques for dressing change and emptying of portable drainage.Assess wound appearance and character of drainage.Assess complaints of pain.Administer prophylactic antibiotics if prescribed and observe for side effects.

Risk for ineffective health maintenance related to THR.

Assess home environment for discharge planning.Encourage patient to express concerns about care at home;explore together possible solution of the problem.Assess availability of physical assistance for health care activities.

Teach caregiver home health care regimen.Instruct patient on post hospital care:Activity limitation(hip precautions,weight bearing limits)Exercise instructionsSafe use of ambulatory aidsWound care Measures to promote healing

Medications, if anyPotential problemsContinuing health care supervision and management

Avoiding hip dislocation after replacement surgery

Methods for avoiding displacement include the following:Keep the knees apart at all timesPut a pillow between the legs when sleepingNever cross the legs when seatedAvoid bending forward when seated in a chair.Avoid bending forward to pick up an object on the floor.

Use a high seated chair and a raised toilet seat.Do not flex the hip to put on clothing such as pants, stockings,socks or shoes.

Positions to avoid after THRDo not cross the Affected leg at the centre of the body

Hip should not be bent more than 90 degree

Affected leg should not be turn inward while lying down

Complications

ACUTE InfectionDVTThromboemboli

smExcessive

wound drainage

CHRONIC Heel pressure

ulcerHeterotrophic

ossificationAvascular necrosisDislocation of

prosthesis

TKR

Anatomy—Knee

Total Knee Replacement (TKR).

A total knee replacement (TKR) or total knee arthroplasty is a Surgery that resurfaces an arthritic knee joint with an artificial metal or plastic replacement parts called the 'prostheses'

Total Knee replacement surgery is considered for patients who have severe pain functional disability related to joint surfaces destroyed by:ArthritisBleeding into the joint(hemophilia)

TYPES OF PROSTHESISFixed Bearing: A fixed-bearing prosthesis is the most common knee replacement implant in use today. The components are as described above but the polyethylene cushion of the tibial component is fixed to the metal platform base.

Mobile Bearing: The difference between a fixed-bearing implant and a mobile bearing implant is in the bearing surface. They allow patients a few degrees of greater rotation to the medial and lateral sides of their knee.

Medial Pivot (also known as Rotating Platform): In a rotating platform, the polyethylene insert can rotate slightly around a conical post, thereby copying the activity of the natural knee joint.

Type of prosthesisMetal and acrylic prosthesis designed to provide the pt. with a functional,painless, stable joint may be used.If pts ligaments are weakened,a fully constrained or semiconstrained prosthesis may be used to provide joint stability.A nonconstrained prosthesis depending on the patient’s ligaments for joint stability may be used.

Knee Replacement—Implants

Patellar component

Knee Replacement—Bone Cuts

Knee Replacement—Implants

Knee Replacement—Implants

TYPES OF TKRTotal knee

replacement (TKR) or total knee arthroplasty (TKA) - Replacement of the articular surfaces of the femoral condyles, tibial plateau, and patella.

Unicompartmental knee replacement (unicompartmental arthroplasty) - Replacement only of the medial or lateral tibiofemoral compartment of the knee.

NURSING INTERVENTIONS…

Pre Operative Management

Assessment

Hydration status (skin and mucous membrane,vital

signs,urine output and lab values)

Current medication history

Possible infection (h/o cold,dental problems,UTIs or

other infections within 2 wks before surgery)

Nursing diagnosisAcute pain related to orthopedic problem,swelling or inflammation

Risk for ineffective regimen management related to insufficient

knowledge or lack of available support and resources,

Impaired physical mobility related to pain,swelling and possible

presence of an immobilization device.

Risk for situational low self esteem,disturbed body image or

functional impairement related to impact of musculoskeletal disorder.

Post Operative management

Continuous passive motion(CPM) device

Pts leg is put in this device,which increases circulation and range of motion of knee joint

Rate and amount of extension and flexion are prescribed. Usually 10 degrees of extension and 50 degrees of flexion are prescribed initially increasing to 90 degrees of flexion with full extension by discharge.

Encourage the patient to use the device most of the timeIf satisfactory flexion is not achieved, gental manipulation of knee joint under GA may be necessary about 2 wks after surgery. Post operatively, the knee is dressed with a compression bandage.

Ice may be applied to control edema and bleeding.Assess the neurovascular status of the legEncourage active flexion of the foot every hour when the patient is awake.

COMPLICATIONS TKRACUTEInfectionImplant failureLimited range

of motionPeroneal nerve

parlysis

CHRONIC Dislocation of

thrombosisDislocation of

prosthesisOsteolysis

Dislocation/Instability

Infection

Wear of Articular Bearing Surface

Osteolysis

Peri-Prosthetic Fracture

Implant Failure

Major Osseous Defects

Major Osseous Defects

A wound suction drain removes fluid accumulation in the joint.Drainage ranges from200 to 400 ml during the first 24 hours after surgery and diminishes to less than 25ml by 48 hoursThe colour ,type and amount of drainage are documented and any excessive drainage or change in the characteristics of drainage are promptly reported to the physician.

Assist the patient to get out of the bed on the evening or the day after surgery.Protect the knee with immobilizer(splint,cast or brace) and is elevated when the patient sits in the chair.

After dischargePatient may continue to use the CPM device at home and may undergo physical therapy on an outpatient basis.Late complication: infection,loosening and wear of prosthetic components.

REHABILITATION AFTER TJR

PATIENT EDUCATIONConsiderations:Pain managementWound careMobility Self carePotential problems

Discuss with patients the methods to reduce pain:Periodic restDistractions and relaxation techniquesMedication therapy: action,administration,schedule,side effects

Instruct the patient to:Keep incision clean and dryTake care of wounds and change the dressingRecognize signs of wound infection like pain, swelling,drainage,fever etc

Explain that sutures or staples will be removed 10-15 days after surgery

Teach patient about:Safe use of assistive devices.Wt. bearing limitsHow to change positions frequentlyLimitations on hip flexion and adductionHow to stand without flexing hip acutely

Avoidance of low seated chairs.Sleeping with pillow between legs to prevent adduction.Gradual increase in activities and participation in prescribed exercise regimen

PROSTHESIS AFTER TKR

Assess home environment for physical barriersEncourage patient to accept assistance with ADLs during early convalescence until mobility and strength improves

Assess patient for developing of potential problems and instruct pt.to report signs of potential problems :Dislocation of prosthesis: increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation.DVT:calf pain.swelling,pulmonary embolism

Wound infection:swelling,purulent drainage,pain,feverPulmonary emboli:sudden dyspnea,tachypnea,pleuritc chest pain

Discuss with patient the need to continue regular health care and screening

Common queries after TJR What activities are permitted following total joint

replacement surgery?On recovery, one may return to most activities, including walking, climbing a flight of stairs, gardening, and golf. Some of the best activities to help with motion and strengthening are swimming and cycling.What activities should I avoid after total joint replacement surgery?One should avoid impact activities, such as running and jogging, and vigorous racquet sports like squash or tennis.

Common queries after TJR

When can I return to work after total knee replacement surgery?When you can return to work after total knee replacement surgery depends on your profession. If your work is sedentary, you may return to work as early as two to four weeks after the operation. If your work is more rigorous, you may require more time, sometimes up to twelve weeks before you can return to full duty.

Common queries after TJR When can I travel after total joint replacement

surgery?The patient is allowed to travel post-op as soon as they feel comfortable. It is recommended that they get up to stretch or walk at least once in an hour, every hour, when taking long trips. This is important to help prevent blood from clotting. Long flights (or long car rides, for that matter) may increase the risk of a blood clot. Often, in some cases, the use of a blood thinner such as aspirin may be indicated after consultation with a physician.

Common queries after TJRWill an implant set off a metal detector say, at an

airport?Since knee implants are made of metal, there’s a chance they could set off metal detectors; whether it actually does so depends, of course, on the type of implant that has been put in and the sensitivity of the security checkpoint equipment. It is customary to provide the patient who has undergone a TKR with a special card or certificate to keep with oneself, explaining that they have a knee implant.When can I start driving after total joint replacement surgery?Driving is not recommended for at least eight weeks after the operation, especially if one is on a course of strong painkillers like narcotics.

Common queries after TJRHow long will my new joint last and can a second

replacement be done? A joint implant’s longevity will vary from patient to patient. All implants have a limited life expectancy, and how long they last would depend on an individual’s age, weight, activity level and medical condition. By and large, over 90% of knee replacements will be functioning well even 10 to 15 years after the operation. With continued improvements in knee replacement technology, a new knee may soon last well beyond this time period.

Exercises AfterTKR

A Specific Inpatient Aquatic Physiotherapy Program ImprovesStrength After Total Hip or Knee Replacement Surgery:A Randomized Controlled Trial

Ann E. Rahmann, BPhty, Sandra G. Brauer, PhD, Jennifer C. Nitz, PhD

Objective: To evaluate the effect of inpatient aquatic physiotherapy in addition to usual ward physiotherapy on the recovery of strength, function, and gait speed after total hip or Knee replacement surgery. Interventions: Participants were randomly assigned to receive supplementary inpatient physiotherapy, beginning on day 4: aquatic physiotherapy, nonspecific water exercise, or additional ward physiotherapy.Main Outcome Measures: Strength, gait speed, and functional ability at day 14.

REASEARCH INPUT

Results: At day 14, hip abductor strength was significantly greater after aquatic physiotherapy intervention than additional ward treatment (P.001) or water exercise (P.011). No other outcome measures were significantly different at any time point in the trial, but relative differences favored the aquatic physiotherapy intervention at day 14. No adverse events occurred with early aquatic intervention.

Conclusions: A specific inpatient aquatic physiotherapy program has a positive effect on early recovery of hip strength after joint replacement surgery. Further studies are required to confirm these findings. Our researchOur research indicates that aquatic physiotherapy can be safely considered in this early postoperative phase.

Patient Education Before Hip orKnee Arthroplasty Lowers Length of Stay

Richard S. Yoon, BS, Kate W. Nellans, MD, MPH, Jeffrey A.et al... From April 2006 to May 2007, 261 patients

undergoing primary unilateral total hip arthroplasty or total knee arthroplasty were offered voluntary participation in a one-on-one preoperative educational program. Length of stay (LOS) and inpatient data were monitored and recorded, prospectively. Education participants enjoyed a significantly shorter LOS than nonparticipants for both total hip arthroplasty (3.1 ± 0.8 days vs 3.9 ± 1.4 days; P = .0001) and total knee arthroplasty (3.1 ± 0.9 days vs 4.1 ± 1.9 days; P = .001).

A Targeted Home- and Center-Based Exercise Programfor People After Total Hip Replacement: A Randomized Clinical Trial Mary P. Galea, PhD, Pazit Levinger, PhD, Noel Lythgo, PhD, Chris Cimoli, et al…

Objective: To examine the physical function, gait, and quality of life of patients after total hip replacement (THR) randomly assigned to either a targeted home- or center-based exercise program.Design: Randomized controlled trial.Setting: Rehabilitation research center in Australia.Participants: Twenty-three patients with unilateral THR were randomly assigned to a supervised center-based exercise group (n11) or an unsupervised home-based exercise group (n12).

Intervention: The center-based group completed an 8-week targeted exercise program while under the direct supervision of a physiotherapist. After initial instruction, the home-based group completed the 8-week targeted exercise program at home without further supervision.Main Outcome Measures: Quality of life, physical function,and spatiotemporal measures of gait.

Results: No significant interaction (group by time) or main of grouping were found. Within each group, quality life,and

stair climbing improved significantly (P.05) as did Timed Up & Go test and 6-minute walk test performances (P.05). Walking speed increased by 16cm/s (P.01), cadence by 8 steps/min (P.05), step length by 4.7cm (P.05), and double-support time reduced by a factor of 16%. Step length symmetry showed significant improvement (P.05) over time. Step length differential between the affected and unaffected limbs reduced from 4.0 to 2.7cm.

Conclusions: The targeted strengthening program was effective for both the home- and center-based groups. No group differences were found in the majority of the outcome measures.This finding is important because it shows that THR patients can achieve significant improvements through a targeted

strengthening program delivered at a center or at home

Bed exercises following total hip replacement:a randomised controlled trial Toby O. Smith a,∗, Charles J.V. Mannb

Objectives :To determine whether the addition of bed exercises after primary total hip replacement (THR) improves functional outcomes and

quality of life, in adult patients, during the first six postoperative weeks.

Design :Single-blind randomised controlled trial.

Setting :Inpatient and outpatient orthopaedic departments at a National Health Service hospital.Participants :Sixty primary elective THR patients.

Intervention :Patients were assigned at random to receive either a standard gait re-education programme and bed exercises, or the standard gait re-education programme without bed exercises after THR. The bed exercises consisted of active ankle dorsiflexion/plantarflexion, active knee flexion, and static quadriceps and gluteal exercises

Results: There was no statistically significant difference in ILOA scores between the two groups on the third postoperative day [gait reeducation

and bed exercise group median 40.5, interquartile range (IQR) 17.5 to 44.5; gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70]. Although there was a small difference between the median ILOA scores atWeek 6 between the two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to 12.5; P = 0.05), this difference was not statistically or clinically significant. There was no difference between the groups in duration of hospital admission, SF-12 scores or postoperative complications at Week 6.

Conclusion :This study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education

programme following THR does not significantly improve patient function or quality of life.

Summary THRIndicationsTechniqueComplicationsNursing managementTKRIndicationsImplants ComplicationsNursing management

ConclusionPREVENTION IS BETTER THAN CURE.

Nurses should educate patients about measures to prevent arthritis.

IF IT HAPPENS- PROPER HEALTH EDUCATION SHOULD

BE GIVEN AFTER TJR.

ReferencesMedical Surgical Nursing (Brunner and Suddarth 10th edition )www.emedicine.comwww.wikipedia.comwww.google imageshttp://emedicine.medscape.com/article/320061-overview#aw2aab6b9

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