Total Hip Arthroplasty

Total Hip Arthroplasty

• This procedure involves replacing the acetabular cup, femoral head, and femoral stem.

Disease Prevention

• The goal of hip arthroplasty is to eliminate pain, restore joint motions, and improve a client's functional status and quality of life.
• Knee and hip arthroplasty are used to treat degenerative diseases like osteoarthritis and rheumatoid arthritis.

Diagnostic Procedures (Pre-Procedure)

• Testing includes a CBC, urinalysis, electrolyte levels, BUN, and creatinine.
• Assess surgical readiness to rule out anemia, infection, or organ failure.
• Epoetin alfa can be prescribed pre-op to increase hemoglobin (Hgb) in clients with mild anemia.
• A chest X-ray is done to rule out pulmonary surgical contraindications such as infection or tumors.
• An electrocardiogram (ECG) gathers a baseline rhythm to identify cardiovascular surgical contraindications like dysrhythmia.

Client Education (Pre-Procedure)

• Consider autologous blood donation where the client donates blood for use during or after the procedure.
• Scrub the surgical site with prescribed antiseptic soap the night before and the morning of surgery to decrease bacterial count and reduce the chance of infection.
• Clients should wear clean clothes and sleep on clean linens the night before surgery.
• Antihypertensive and other surgeon-approved medications should be taken with a sip of water the morning of surgery.

Intra-Procedure

• General or spinal anesthesia can be used.
• Joint components are removed and replaced with artificial components.
• Components can be cemented in place, while cementless components allow bone to grow into the prosthesis for stabilization.
• Weight-bearing is delayed several weeks until the femoral shaft has grown into the prosthesis.

Client Education (Post-Procedure)

• Extensive physical therapy is required to regain mobility, with discharge possible to home or an acute rehab facility.
• If discharged home, outpatient or in-home therapy must be provided.
• Post-op care includes incentive spirometry, transfusion, surgical drains, dressing, pain control, transfer, exercises, and activity limitation.
• Monitor for incisional infection, indicated by fever, increased redness, swelling, and purulent drainage.
• Incision should be cared for by cleaning daily with soap and water.
• Monitor for deep vein thrombosis (DVT), indicated by swelling, redness, and pain in the calf, as well as pulmonary edema (SOB, chest pain) and bleeding, especially if the patient is taking an anticoagulant.

Safety Considerations

• Avoid crossing ankles or legs across the body to prevent hip joint dislocation.
• Use a raised toilet seat.
• Neurovascular checks should be performed.

Nursing Care

• Provide post-op care and prevent complications.
• Check the dressing site frequently for bleeding and monitor/record drainage.
• Monitor daily lab values, including hemoglobin (Hgb) and hematocrit (Hct) levels, as these can continue to drop for 48 hours after surgery.
• Autologous blood from pre-surgery donation or salvaged intraoperatively can be used for post-op blood replacement.
• Monitor the neurovascular status of the surgical extremity (movement, sensation, color, pulse, cap refill) every 2-4 hours, comparing with the contralateral extremity.
• Provide early ambulation, transferring the patient out of bed from their unaffected side into a chair or wheelchair.
• Weight-bearing status is determined by the orthopedic surgeon based on the choice of cemented (usually partial/full weight-bearing as tolerated) vs. non-cemented prostheses (usually only partial or minimal weight-bearing until after a few weeks of bone growth).
• Use assistive devices like walkers and adaptive equipment like raised toilet seats, grab bars, and shower chairs when caring for the client.
• Apply ice to the surgical site following ambulation as a non-pharmacological measure to decrease pain and discomfort.
• Place the client in a supine position with the head slightly elevated, with the affected leg in a neutral position with a pillow or abduction device between the legs when turning to the unaffected side.
• Avoid turning the client to the operative site to prevent hip dislocation, unless prescribed.
• Use total hip precautions to prevent dislocation of the new joint.
• Monitor for new joint dislocation indicated by acute onset of pain, reports of hearing "a pop", and internal or external rotation and shortening of the affected extremity.

Medications

• Provide prescriptions as ordered
• Analgesics include opioids (epidural, PCA, IV, oral) and NSAIDs.
• Antibiotics are generally administered 30-60 minutes before the surgical incision for prophylaxis and continued for 24 hours post-op to prevent infection.
• Anticoagulants like Warfarin, dalteparin, fondaparinux, rivaroxaban, and low molecular weight heparin (enoxaparin) may be required.
• Anticoagulant prescriptions (warfarin, aspirin) may be required for several weeks after surgery.

Client Education

• Use raised toilet seats and assistive items (long-handled shoehorns, dressing sticks) to prevent strain on the prosthesis/avoid hip flexion greater than 90 degrees.
• Follow all position restrictions to avoid dislocation.
• Use straight chairs with arms.
• Use an abduction pillow or regular pillow, if prescribed, between the legs while in bed (and with turning, if restless or in altered mental state).
• Externally rotate the toes.
• Avoid hip flexion greater than 90 degrees.
• Avoid low chairs.
• Do NOT cross legs.
• Do NOT internally rotate the toes.
• Avoid turning to the operative side unless prescribed.

Complications: Venous Thromboembolism

• Can manifest as DVT or PE, a life-threatening complication after total hip arthroplasty.
• Older adult clients are at the greatest risk for venous thromboembolism (DVT and/or PE) due to age and compromised circulation before surgery.
• Clients who are obese or have a history of venous thromboembolism formation are at increased risk.

Nursing Actions

• Monitor for s/s of PE: acute dyspnea, tachycardia, and pleuritic chest pain.
• Follow venous thromboembolism prophylaxis: pharmacological management, anti-embolic stockings, and sequential compression devices or foot pumps while in bed.
• Encourage plantar flexion, dorsiflexion, and circumduction exercises to prevent clot formation.
• Encourage early ambulation with physical and occupational therapy.