Post-Operative Complications in Patients Undergoing Joint Replacements

Abstract

Musculoskeletal conditions are increasing, and in the United States 50 Million people are diagnosed with arthritis. It is the most common disability affecting the work of 21 million adults over the age of 18, and this number will continue to grow in the next 20 years. (Center for Disease Control and Prevention [CDC], 2012) We will see that the number of joint replacement surgeries will be significantly higher; knee replacements more than 6 times and hip replacement will be almost tripled by 2030. (CDC, 2012) The two main reasons one will undergo a joint replacement are as follows: to decrease extreme pain and to increase range of motion from arthritis; overall to improve the quality of life. Surgeries are not without risks; there are many challenges that make joint replacements more complicated. Surgical knee and hip replacements can improve one’s mobility and decrease pain, but any surgery can be dangerous. Potential complications after surgeries include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, and pneumonia. Nurses specialized in orthopedics work hard to improve surgical outcome; they follow protocols and meet core-measures in order to reduce the post-operative complications. The main goal of the nurse is to help patients recover faster, thus reducing the length of stay in the hospital.

Post-operative Complications in Patients Undergoing Joint Replacements

Musculoskeletal conditions are increasing. More people with arthritis are undergoing artificial joint replacement to improve their quality of life by increasing mobility and decreasing or eliminating pain. During these surgeries the arthritic joint is replaced by an artificial joint.

Types of joint replacements

The two most common types of joint replacements are knee and hip replacements, often referred to as arthroplasty. According to the CDC 676,000 knee replacements and 327,000 hip replacements were completed in the United States in 2009. (CDC, 2012) Both knee and hip replacement can be partial or total. Total knee surgeries replace all three compartments (Figure 1.) of the knee joint, while partial surgeries can replace one or two of those three parts. Total hip surgeries replace the thighbone (femoral stem) and the socket (acetabular cup), while during partial- or hemiarthroplasty the socket is not replaced. (Figure 2.) Knee replacements are considered elective procedures, but hip replacements can be elective and non-elective. Both partial- and total hip replacements can be used to correct fractures, when previous internal fixation fails or the fracture occurred at the femoral neck.

Although replacement of other joints, such as ankle, shoulder, elbow, and wrist are possible, they occur significantly less often. At this time there are no numeric data found in the United States regarding these procedures, but according to the National Joint Registry of UK (NJR), 492 ankle replacements were recorded in 2011, compared to 80,314 hip and 84,653 knee replacements. Data collection of shoulder and elbow replacements began in April 2012, and there are no numbers available at this time. (2012)

Reasons for joint replacements

The primary reason for joint replacement surgery is osteoarthritis, which is a slowly progressing disorder characterized by the gradual loss of cartilage in the joints. This can result from aging or excessive load of healthy joints. Up to 90% of people over the age of 65 have radiographic changes consistent with arthritis. (Core Curriculum for Orthopaedic Nursing, [CCON], 2007) Other reasons are rheumatoid arthritis, an autoimmune disorder, in which the body attacks its own synovial membrane and traumatic arthritis, an injury to the joint, such as fractures.

Complications and prevention

Joint replacement surgeries are relatively safe, but there are potential complications associated with any types of surgery. Post-operative complications are similar after most joint replacement surgeries, but we will concentrate on knee- and hip replacement from now on. What are these complications and how can we prevent them?

Blood clots

Patients undergoing total joint replacement are at risk for developing deep vein thrombosis (DVT) and/or pulmonary embolism (PE). These diagnoses following total joint replacement occurred at a rate of 649 per 100,000 total joint replacement surgical stays. (HCUP, 2008) Immobility increases these risks, thus early mobilization and ambulation after surgery is important. A study completed by Henrik Husted et al. (2010) showed that when patients are mobilized as early as 4 hours after surgery, there was a 0% mortality rate from DVT and PE. Deep vein thrombosis occurred 0.6% of cases of total knee arthroplasty (TKA), and 0.51% in total hip arthroplasty (THA). Pulmonary embolism noted in 0.3% of patients after TKA, while none after THR. He also said, that anticoagulant medication therapy is recommended at least 10 days following knee replacements and 10-35 days after hip replacement surgery. (p. 599)

A mechanical way of preventing blood clots by aiding circulation is the application of an intermittent pneumatic compression device, also known as flowtrons. These should be applied during surgery and should be used until patient’s INR (international ratio used in adjusting of Coumadin/Warfarin) reaches 2.0, unless the patient is ambulating. Studies show, without prophylaxis, the occurrences of DVT can be as high as 42-57% in hip- and 41-85% in knee arthroplasty; PE can be between 0.9-28% in hip- and 1.5-10% in knee arthroplasty. (G. Angelli, 2011) Physical therapy should work with patients and educate them regarding range-of-motion exercises of the ankles and feet.

Pneumonia and length of stay

Early mobilization will also help avoid pulmonary complications. Adverse respiratory outcomes can develop 2-3 days after surgery, but can be prevented by the education of patients. A study (Graul, 2002) completed over 2 years, monitored adverse outcomes after joint replacement in two hospitals for a total of 1631 patients; one facility with high-volume and the other with low-volume joint replacements. In the low-volume hospital (LVH) atelectasis/pneumonia was the most common adverse reaction, while the high volume hospital (HVH) showed only 3 occurrences; that is 0.26% in HVH, and 2.78% in LVH. Fluid can collect in the lungs after any surgery. To prevent pneumonia, patients need to be educated on deep breathing and coughing. Exercise of the lungs after surgery, by the use of incentive spirometry, can reduce lung complications; smoking cessation helps both breathing and the healing of surgical wound. This same