2023_MSK_Disorders_Joint_replacement_student_version (2).pptx
Transcript
MSK Disorders: JOINT REPLACEME NT njknb D. Browman, F23 1 Learning Objectives Describe • the pathophysiology • clinical manifestations • nursing care for the client with hip & knee arthroplasty Identify the alterations in: • comfort, activity, and safety that occur because of hip & knee arthropl...
MSK Disorders: JOINT REPLACEME NT njknb D. Browman, F23 1 Learning Objectives Describe • the pathophysiology • clinical manifestations • nursing care for the client with hip & knee arthroplasty Identify the alterations in: • comfort, activity, and safety that occur because of hip & knee arthroplasty Describe the potential complications of joint replacement 2 Arthroplasty = Joint Replacement • The reconstruction or replacement of a joint • How many hip and knee replacements were conducted in Canada between… – 2006-2007 • As per Lewis text (3rd ed) : 62,196 – 2013-2014 • As per Lewis text (4th ed) : 109, 639 – 2017–2018 (5th ed) • As per Lewis test (5th ed): 129,000 – most 65 years or older and were obese 3 Types of Arthroplasty Some terminology: • Hemiarthroplasty – replacement of part of a joint • Total joint replacement • 10D focus: hip and knee arthroplasty – Arthroplasty is available for elbows, shoulders, joints of the fingers, wrists, hips, knees, ankles, and feet 4 Some abbreviations • • • • THA THR TKA TKR 5 When is hip/knee replacement surgery recommended? 1. Pain that limits everyday activities 2. Pain that continues while resting 3. Inadequate pain relief 4. Stiffness / decreased ROM 5. Deformity of knee • Goal? – To relieve pain – To improve or maintain ROM – To correct deformity 6 HIP ARTHROPLA STY 7 A synovial membrane surrounds the hip joint Fluid lubricates the cartilage and eliminates almost all friction during hip movement Part of the pelvis (Ball) Upper end of the femur Ligaments connect the ball to the socket (provides stability to the joint) Cartilage (cushions bone ends; enables 8 Conditions leading to the need for THR: 10D Diseases: – Osteoarthritis – Avascular necrosis/ osteonecrosis – Dislocations – Femoral neck fracture 9 Osteoarthritis (OA) A normal hip: An arthritic hip: 10 OA: Osteophytes/Bone spurs • A large bone spur that has developed on the ball of an arthritic hip • Form as the body tries to repair itself by building extra bone • Causes more pain, swelling, and immobility of the joint 11 Avascular Necrosis • Occurs when the blood flow to the femoral head is limited • Possible causes: – An injury to the hip • a joint dislocation • femoral neck fracture • As a result: – Collapse of the joint surface of the femoral head 12 13 An MRI scan of the hips Left: a normal femoral head Right: bone changes of AVN (femoral head) • Mm 14 What do you think happened here? Norm al ? 15 16 Implant Components = Prosthetic Components -Components of a THA: • a metal ball replaces the head of the femur • the ball is attached to a metal stem that fits inside the femur • a metal socket with a plastic lining replaces the acetabulum . Materials • The metal is typically stainless steel or a metal alloy of cobalt, chrome or titanium • The plastic is a durable material called polyethylene • Other materials, ceramics, may 17 be used Before and after 18 Arthoplasty: Prosthetic Components • They may be cemented into place – methyl methacrylate bonds to the bone OR • May be pressed directly into bone to allow bone to grow Decision to press fit or to onto the cement is based on a number components of factors: the quality and strength of the client’s bone 19 • (Left) A non-cemented femoral component • (Center) Shows the porous surface for bone ingrowth • (Right) The femoral component and the acetabular component working together 20 • (Left) The acetabular component shows the plastic (polyethylene) liner inside the metal shell • (Right) The porous surface of this acetabular component allows for bone ingrowth – The holes around the cup are used if screws are needed to hold the cup in place 21 Screws holding the cup in place 22 Total Hip Replacement Procedure • https://orthoinfo.aaos.org/en/treatme nt/total-hip-replacement-animation/ 23 Cement vs non-cement • Cementless THAs may provide longer-term prosthesis stability – Why? • Some surgeons use cementless devices for all clients – they are most often recommended for: • younger, more active clients • clients with good bone quality where bone ingrowth into the porous surface of the components can be achieved • Cemented THAs are recommended for: – less active, older adults with compromised bone strength – 10-15 yrs; Problem: Cemented THAs may loosen or become dislocated with time • requires revision surgery 24 Anterior vs posterior approach • The difference is how the surgeon opens the body to reach the hip joint • Posterior approach – cuts through the buttock muscles to reach the hip joint • Anterior approach – moves the muscles aside rather than cutting through them 25 Advantages of anterior approach •Less damage to major muscles –surgeon works between muscles (doesn’t cut through muscle) (< repairs are needed at the end of the surgery) •Less post-operative pain –If muscles are not cut < pain (\ < pain meds are needed) •Faster recovery –Post-op WBAT •Decreased risk of hip dislocation –Muscles that naturally prevent the hip from dislocating are not disturbed •Better range of movement –Flex hip or sit with crossed legs without risking hip dislocations 26 Potential disadvantages of using an anterior approach • Obese or very muscular people may not be good candidates – additional soft tissue can make it difficult for the surgeon to access the hip joint • It is a technically demanding surgery – Anterior incision provides restricted view of hip joint, making it a technically demanding procedure • There is potential for nerve damage – Resulting in numbness in the thigh 27 Minimally invasive techniques Minimally invasive Traditional THA Length of surgical incision • 15 to 30 cm (6 to 12 in) procedure Length of surgical incision • 10 cm (4 in) or even less 28 29 Activity restrictions with posterior approach • Hip precautions to avoid dislocation: – Limit rotation and flexion of the hip • No adduction past midline • No internal rotation • No hip flexion beyond 90 degrees • In place average 6-8 weeks post-op 30 Ensure precautions are maintained Can a client cross his/her legs while sitting? 31 A client should NOT cross his/her legs while sitting What joint movement is being demonstra ted here? 32 Clients shouldn’t cross their legs in bed either 33 • To maintain abduction – Use of an abduction pillow/splint 34 35 Abduction pillows • In some hospitals, they are no longer regularly used – uncomfortable and unnecessary in most cases – What can be used instead? • Who might use abduction pillows? • For devices with straps, loosen the straps every 2 hours and check the cl's skin for irritation or breakdown 36 To maintain hip alignment What joint movement is being demonstrated here? 37 Ensure precautions are maintained When in a sitting position, can a client bend down to pick up a tissue that fell to the floor? 38 No, a client should not bend down. Instead, he/she should use a reacher 39 No hip flexio n beyon d 90 degre es 40 Using a wedge cushion • Knees should not be higher tha 41 Toileting • Get the client out of bed • In some cases, need to use a bedpan – Regular vs fracture bedpan? 42 Ensure precautions are maintained How should a client put on pants? Which leg is dressed first? – Why? 43 The client needs to use the reacher • https://www.youtube.com/watch?v=Z rZ6bx5GUMw 44 Ensure precautions are maintained Should the client use a regular toilet seat? 45 The client should use an elevated toilet seat 46 Ensure precautions are maintained Can the client position him/herself in a side lying position? 47 48 • The procedure for post-op turning/lying down is controversial and specified by hospital policy or surgeon preference • In most cases, you are safe to turn the client toward either side as long as the abduction device or other pillow is in place • Some surgeons allow only turning directly onto one side or the other 49 Ensure precautions are maintained How should the client put on socks and shoes? 50 The client needs to use dressing aids Sock aid Long handled shoehorn • https://www.youtub e.com/watch?v=Us 0bcyyoAaE 51 52 Weight bearing status • A client with a cemented or hybrid prosthesis is usually allowed immediate PWB or FWB to tolerance • One with an uncemented prosthesis cannot tolerate FWB until bony ingrowth occurs – Typically, only PWB is permitted for the first few weeks or until there is x-ray evidence of bony ingrowth – OR client may remain NWB for weeks 53 KN EE ARTHRO PLASTY 54 Cushions, reduces friction, aids in smooth movement “Shock absorbers" that cushion the jointthe femur Hold and tibia together provide stability (shinbone) 55 Causes of chronic knee pain • 10D disease: – Osteoarthritis 56 • (Left) Normal knee: space between the bones indicates healthy cartilage (arrows) • (Right) Knee that has become bowed from arthritis shows severe loss of joint space (arrows) 57 • (Left) Severe osteoarthritis • (Right) The arthritic cartilage and parts of bone has been removed and resurfaced with metal implants on the femur and tibia – A plastic spacer has been placed in between the implants. • Both: The patellar component is not shown for clarity 58 Prosthetic Components Three components: • The femoral component • The tibial component • made of a durable plastic usually held in a metal tray • The patellar component • made of plastic The metal: a metal alloy of cobalt, chrome, and molybdenum or titanium The plastic : a longlasting material called polyethylene 59 Knee implants 60 • (Left) Severely arthritic knee • (Right) TKR – Note that the plastic spacer inserted between the components does not show up in an x-ray. 61 Total Knee Replacement Procedure • https://orthoinfo.aaos.org/en/treatme nt/total-knee-replacement-animation/ 62 63 Cement or cementless prothesis • The ideal fixation (cement or cementless) of a TKA is still being debated • The main question: – is the use of cement more efficient than press-fit fixation in terms of ensuring durable stability • Hybrid 64 Dislocation? • Dislocation is not typical with TKA 65 Knee flexion and full extension is important – race against formation of scar tissue • Post TKA, scar tissue can build up inside the knee, causing the knee joint to stiffen – It can result in a permanent inability to bend and straighten the knee • To promote 90-degree knee flexion: – Passive and Active flexion exercises • Client, nurse and physiotherapist work collaboratively 66 A knee immobilizer • A knee immobilizer such as a Zimmer, may be ordered to stabilize the knee and promote knee extension – Used at rest and during mobilization – Worn up to 4 weeks post-op • Make sure that the immobilizer is of the correct length for the client and that it does not rub on the heel or groin 67 Weight bearing status • If cemented prosthesis: – WBAT post-op day 1 because of the immediate fixation of the components • If noncemented prosthesis : – may have restricted weight bearing for approximately 6 wk until bony ingrowth into the components has been shown on x-ray 68 Use of pillows • NO pillows should be placed under the client's knee while in bed – promotes flexion contracture • Prevents full extension 69 70 Joint replaceme nt 71 Realistic Expectations • Dramatic reduction of hip and knee pain • Significant improvement in ability to perform ADLs • What are some realistic activities? – Use it, don’t abuse it • Even with normal use and activity: wear and tear • Excessive activity or being overweight may speed up normal wear – cause the hip replacement to loosen and 72 become painful Post-Op Assessments • Neuro-vascular assessment – Nerve status (includes 3 assessments) – Circulatory status (includes 5 assessments) – CWST: colour, warmth, sensation, and movement – Always compare bilaterally • Pain assessment • Skin / wound assessments • Activity level – Understanding of WB status/precautions – Use of walking aid 73 Mobility • Out of bed and moving relatively early – in some instances, the evening of the surgery, but no later than postoperative day 1 – Want to prevent complications associated with immobility 74 Pain control • varies depending on the surgeon's preference • In acute period, may include – patient-controlled analgesia Nurse programs computerized PCA pump – I.V. analgesics as prescribed to deliver – oral analgesics prescribed medication – other dose and lockout interval. Ensures safe, therapeutic drug administration. With appropriate dose intervals (e.g., 10 minutes), usually an appreciable analgesic effect and/or mild sedation is achieved before patient can access the next dose; thus, there 75 Length of stay – will vary from 1 to 5 days • for hip sx: depending on the approach used during surgery – Surgical complications may increase the length of stay 76 Risks and complications • • • • • Infection Blood Clots Leg Length Inequality Dislocation Loosening 77 Infection • May occur superficially in the wound or deep around the prosthesis • It may happen while in the hospital or after at home • Minor infections of the wound are generally treated with antibiotics • Major or deep infections may require more surgery (eg: irrigation with antimicrobial solution and debridement/removal infectious tissue (I&D)) and/or removal of the prosthesis and antibiotics • **Any infection in the body can spread to the joint replacement** 78 Infection Warning signs of infection: • Shaking, chills (onset of fever) • Fever • Increasing redness, warmth, tenderness, or swelling of the wound • Drainage from the wound • Increasing hip pain with both activity and rest • Decreased mobility 79 80 Venous thromboembolism • Thrombus (blood clot) may form in the leg veins • Occur when blood flow slows due to inactivity or prolonged bed rest – d/t inactivity of muscles that normally assist in pumping action of venous blood • These clots can be life-threatening if 81 Recognizing the signs of a blood clot Warning signs of blood clots • Pain in calf and leg that is unrelated to the incision • Tenderness, redness, and heat to calf • New or increasing swelling of thigh, calf, ankle, or foot Warning signs of pulmonary embolism • Sudden shortness of breath, tachypnea • Sudden onset of chest pain • Localized chest pain with coughing 82 Prevention of VTE: • anticoagulants (enoxaparin (Lovenox), heparin) – Interfere with clotting factors • compression stockings • ankle pumping exercises • early mobilization 83 Leg-length Inequality after hip replacement • Surgeon makes every effort to make leg lengths even • One leg may end up longer or shorter than the other – Gait, posture are affected – Lower back pain • Use a shoe lift on one side 84 Dislocation of hip replacement • Occurs when the ball comes out of the socket • The risk is greatest in the first few months after surgery while the tissues are healing • If the ball does come out of the socket, – A closed reduction – Revision surgery 85 Dislocation Preventative measures: • Maintain proper body weight • Maintain good body alignment & positioning • Maintain weight bearing and ROM restrictions Signs of hip dislocation include: • Feeling/hearing a “pop” • increased hip pain • shortening of the affected leg; lump in buttock • internal rotation • loss of function If any of these clinical manifestations occur, keep the client in bed and notify the doctor immediately 86 Loosening and Implant Wear • Over years, the hip prosthesis may wear out or loosen • This is most often due to everyday activity • If loosening is painful, a second surgery called a revision may be necessary 87 Don’t forget: The home environment Must be assessed for safety • Remove all floor rugs, doorway obstacles, ambulation hazards • Proper equipment – Elevated toilet seat – Pillows to place between legs – Showering equipment • Bath chair • Hand-gripping supports • Long handled sponge – Reacher 88 Bathroom 89 In the home 90 • Thank you • References available upon request 91 • Perkins, A. (2021). Total hip replacement explained. Nursing Made Incredibly Easy! 19(1), p. 2835. • Perkins, A. (2020). Total knee replacement explained. Nursing Made Incredibly Easy! 18(6), p. 3440. 92
