Arthroplasty: Joint Replacement

• Arthroplasty involves the surgical replacement of a diseased joint with artificial components made of metal or plastic due to conditions like osteoarthritis, osteonecrosis, rheumatoid arthritis, trauma, or congenital anomalies.
• Total Knee Arthroplasty (TKA) replaces the distal femoral component, tibia plate, and patellar button and is considered when conservative treatments are ineffective.
• Goals of hip and knee arthroplasty include pain elimination, restored joint motion, improved functional status, and enhanced quality of life.
• Knee and hip arthroplasty are used to treat degenerative diseases, ex: osteoarthritis and rheumatoid arthritis.
• Osteonecrosis is bone necrosis caused by insufficient blood supply, often linked to trauma or long-term steroid use.

Expected Findings

• Pain is felt when bearing weight on the affected joint.
• Joint crepitus and stiffness occur.
• Joint swelling primarily affects the knees.

Risk Factors

• Older adults face increased risks of medical complications related to chronic conditions. Ex: hypertension, diabetes, coronary artery disease, and obstructive pulmonary disease.

Contraindications

• Recent or active infections increase the risk of prosthesis failure.
• Arterial impairment in the affected extremity complicates the procedure.
• Inability to adhere to the postsurgical regimen.
• Comorbid conditions, ex: uncontrolled diabetes or hypertension, advanced osteoporosis, progressive inflammatory conditions, or unstable cardiac or respiratory conditions.

Diagnostic Procedures

• Review diagnostic test results before the procedure.

Pre-Procedure: Nursing Actions

• Complete blood count (CBC), urinalysis, electrolytes, blood urea nitrogen (BUN), and creatinine levels are checked to assess surgical readiness and rule out anemia, infection, or organ failure.
• Epoetin alfa can be prescribed to increase hemoglobin levels for clients with mild anemia.
• Chest x-rays are done to rule out any pulmonary contraindications for surgery (infection, tumor).
• Electrocardiogram (ECG) is done to establish a baseline rhythm and identify any cardiovascular contraindications (dysrhythmia).

Pre-Procedure: Client Education

• Autologous blood donation should be considered, where the client donates blood for use during or after surgery.
• The surgical site should be scrubbed with antiseptic soap the night before and the morning of the surgery.
• Wear clean clothes and sleep on clean linens the night before surgery.
• Take prescribed antihypertensive and other allowed medications with a sip of water the morning of the surgery.

Intra-Procedure

• General or spinal anesthesia
• Joint components are surgically removed and replaced with artificial ones.
• Components can be cemented or cement-less, in cement-less procedures, bone grows into the prosthesis for stabilization, delaying weight-bearing for weeks.

Post-Procedure: Client Education

• Extensive physical therapy is needed to regain mobility, with potential discharge to home or a rehabilitation facility.
• Outpatient or in-home therapy may be necessary, postoperative care involves incentive spirometry, possible transfusions, surgical drain management, dressing care, pain control, transfer assistance, exercises, and activity limitations.
• Monitor incisions for infection: fever, redness, swelling, purulent drainage.
• Incision should be cleaned daily with soap and water.
• Monitor for DVT, pulmonary embolism, and bleeding, especially if taking anticoagulants. (swelling, redness, pain in calf), pulmonary embolism (shortness of breath, chest pain).

Knee Arthroplasty: Nursing Actions

• Provide post-operative care and prevent complications such as anemia, infection, neurovascular compromise, or venous thromboembolism.
• Older adults are at higher risk for complications related to chronic conditions like hypertension, diabetes, coronary artery disease, and obstructive pulmonary disease.
• A continuous passive motion (CPM) machine helps knee motion, circulation, and prevents scar tissue.
• CPM use should follow the prescribed duration, turn off during meals.
• Flexion of the knee should be limited to avoid flexion contractures.
• Avoid placing pillows behind the knee or using a knee gatch position.
• Place a pillow under the lower calf and foot will cause a slight extension of the knee joint or place it flat on the bed to prevent flexion contractures.
• Use a small blanket or pillow above the ankle to keep the heels off the bed to avoid pressure injuries.
• Administer prescribed medications to promote participation in early ambulation.
• Analgesics: Opioids (epidural, PCA, IV, oral), non-steroidal anti-inflammatory drugs (NSAIDs).
• Antibiotics: Administer prophylaxis 30-60 minutes before incision and continue for 24 hours postoperatively.
• Anticoagulants: Warfarin, fondaparinux, rivaroxaban, or low-molecular-weight heparin (enoxaparin), sequential compression devices, foot pumps, or anti-embolism stockings to prevent venous thromboembolism.
• Apply ice or cold therapy to the incision to reduce swelling.
• Monitor neurovascular status of the surgical extremity every 2 to 4 hours, and compare with the other extremity.
• Watch for bleeding and signs of hypovolemia (hypotension, tachycardia).
• Monitor the compression bandage and wound suction drain for excessive drainage.
• Monitor the autotransfusion drainage system, if used, and re-infuse blood as prescribed.

Interprofessional Care

• Physical therapy is important to assist with mobility, usually starting on the first day after surgery with a knee immobilizer in place; weight-bearing is determined by the provider.

Knee Arthroplasty: Client Education

• Dislocation is uncommon, kneeling and deep-knee bends are limited indefinitely.