Nagle, Judith A. MSN, CNOR, FNP-BC
A HIP FRACTURE can be an unexpected, stressful, and life-changing event for a patient and family. They may experience fear, anxiety, and loss of control because they don't know what will happen or what to expect after surgery. Nurses can answer questions, explain the OR routine and what to expect, and provide comfort and reassurance to the patient and family.
Age is the primary risk factor for hip fractures, and as the baby boomer generation ages, the incidence of hip fractures is likely to increase. Hip fracture rates increase exponentially with age among men and women. Patients age 85 and older are about 15 times more likely to sustain a hip fracture than those between 60 and 65.1
Fifteen to 25% of patients die within 1 year after a hip fracture, and an estimated 270,000 to 350,000 patients each year are hospitalized and suffer disability or loss of independence after a hip fracture.2 These fractures cost an estimated $9.8 to $15 billion per year in the United States.3
This article discusses arthroplasty, the surgery used to restore motion to a joint and function to the muscles, ligaments, and other soft tissues that control the joint (see Reviewing normal joint anatomy and Breaking down hip fractures). The article's focus is on hip hemiarthroplasty, a procedure in which the head and neck of the femur are replaced with a prosthesis, and the acetabulum isn't modified.4
Understanding the procedure
Hemiarthroplasty may be unipolar (in which the head of the femur is fixed to the stem) or bipolar (in which an additional polyethylene bearing is placed between the stem and the endoprosthetic head component).4 The goals of arthroplasty are simple—to relieve pain, provide motion with stability, and correct deformity.
Hemiarthroplasty has been widely used for femoral neck fractures for many years. The procedure has several advantages. The surgical procedure is relatively straightforward, and it eliminates the risks of nonunion and fixation failure. These risks are associated with reduction and internal fixation procedures and contribute to the increased rate of revision surgery.5
Hemiarthroplasty is almost exclusively used now for femoral neck fractures in older adults, and is the surgery of choice for hip fractures in patients who can ambulate only minimally or have limited physical function.
The endoprostheses designed in the 1960s for hip arthroplasty consisted of a one-size femoral stem and head component. During the 1980s, the bipolar system in conjunction with a femoral stem became increasingly popular with orthopedic surgeons. Bipolar prostheses are intended to reduce the shear stresses affecting the acetabular surface and decrease the motion and friction between the prosthetic head and the acetabulum that's common with the conventional unipolar prosthesis.6
Recent data, however, have led some surgeons and engineers to reevaluate the use of bipolar prostheses. Bipolar motion appears to subside after fibrous growth has occurred, allowing for only unipolar motion.6 If the prosthesis dislocates, a unipolar head is easier to reduce with a closed reduction, as opposed to the more mobile bipolar head.5
Advanced age is the most important risk factor for a proximal femoral fracture. Older adults have decreased proprioception and loss of protective responses, which increase their likelihood of falling. Also, because older adults tend to walk more slowly than younger adults, they fall on their side rather than forward, often striking the lateral thigh and hip on the ground.7
Other medical risk factors for hip fracture include a history of falls, sedentary lifestyle, arthritis, diabetes, osteoporosis, cardiac and neurologic diseases, visual impairment, nutritional deficiencies, and confusion or impaired cognition. Environmental risk factors include inadequate lighting, scatter rugs or carpets, slippery floors or tubs, uneven walking surfaces, pets underfoot, inappropriate assistive devices, and loose or poorly fitting clothing and footwear.8
Preparing for surgery
Check the patient's ID, verify surgical consent, make sure the surgical site is marked, and ensure that the patient and family understand the surgery. Answer any questions they may have. This initial interview, although brief, lets the nurse build a relationship with the patient and family. Confirm that the completed history and physical exam are in the medical record, and ask pertinent questions about the patient's surgical and medical histories, allergies, and medications. Evaluate the patient's limitations (such as decreased hearing or vision), range of motion (ROM) of unaffected and affected extremities, skin condition (open areas, abrasions, or bruising that may have occurred from the fall), and mental status. Document all of your assessment findings.
After completing the preoperative evaluation, notify the surgeon, anesthesia provider, and implant coordinator about any patient-care-related concerns.
Once the patient arrives in the OR, the patient's ID, surgical consent, and surgical site will be verified. A checklist, such as the World Health Organization (WHO) Surgical Safety Checklist, will be used to keep communication open among team members.
As the patient enters the surgical suite, and before anesthesia induction, the anesthesia provider will discuss patient-specific concerns with the perioperative team: allergies, possible airway difficulties, estimated blood loss, and interventions to minimize hypothermia.
Because a fractured hip is painful, the patient will receive sedation or analgesia before being moved to the OR table. At least four staff members should work as a team to transfer the patient to the OR table—this decreases shear and friction of the patient's skin and helps to maintain both patient and staff safety.9
Venous thromboembolism (VTE), an umbrella term that includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most common preventable causes of hospital deaths and a particular risk for patients undergoing orthopedic procedures. Risk factors for VTE in the perioperative phase include venous stasis, acquired hypercoagulable state, endothelial injury, and positioning of the limb intraoperatively.6 Before anesthesia induction, VTE prophylaxis will be initiated with intermittent pneumatic compression. A sequential compression device is applied preoperatively and remains on the nonoperative extremity during the procedure.
Without appropriate VTE prophylaxis, more than 50% of patients develop DVT after major orthopedic procedures, and up to 30% develop PE.6 Overall, more than 900,000 patients in the United States develop DVT each year, and 500,000 patients develop PE. Together, these conditions cause about 300,000 deaths.6
For a hip hemiarthroplasty, patients are placed in the lateral position on the nonoperative side. All team members are responsible for proper patient positioning by maintaining correct body alignment. The spine, head, and neck should all be in the neutral position.10 OR staff place a roll beneath the patient's ribs just below the axilla to relieve pressure on the brachial plexus and axillary vessels of the dependent shoulder.10 The upper arm is placed on a padded stand or armrest, positioned neutral in relation to the shoulder and 90 degrees from the body.10 The patient's dependent leg is flexed at the hip and knee to provide stability. The knee is padded along the lateral and medial sides to reduce the risk of damage to the peroneal nerve.
These pressure points on the patient's dependent side are also padded for protection: the ear, acromion process, ribs, ilium, greater trochanter, and the lateral malleolus. A safety strap is applied over the patient's dependent leg, along the thoracic area (leaving space for two fingers, so as not to impede lung expansion), and on both arms to secure the patient to the OR table.
Figure. Acetabulum...Image Tools
Once the patient is properly positioned, the surgical team preps the surgical site. If hair needs to be removed, clippers are used as close to the surgical start time as possible. The prep (with iodine povacrylex 0.7% with isopropyl alcohol or 2% chlorhexidine gluconate with 70% isopropyl alcohol) includes the area from the patient's umbilicus down the leg circumferentially, including the foot. The hip is draped, including the leg on the affected side, to allow for trial ROM during surgery. This helps guide the surgeon to the ROM allowed before the implant impinges, and the maximum ROM limits to prevent postoperative dislocations. (The ROM limits will affect the patient's postoperative activity limitations.)
The lateral position lets the surgeon use an anterior or posterior approach to the hip, along with modifications of each approach. Based on the surgeon's experience or the patient's inability to follow hip precautions, one surgical approach may be chosen over the other.
Pause for safety
Before the incision, the surgeon leads a surgical pause or time out to confirm the patient's identification (name and date of birth or medical record number), the position needed for surgery, site verification, and availability of the correct equipment and implants. The surgeon confirms that antibiotics have been given, VTE prophylaxis has been initiated, and the essential imaging is displayed. The surgeon at this time also discusses how long the surgical procedure will take, how much blood loss is anticipated, and any critical steps or changes to the original surgical plan that the team needs to know about. The anesthesia provider is asked about any patient-specific concerns, and the nursing team is asked about sterility concerns or other issues.
Although ensuring patient safety is everyone's responsibility, primary responsibility falls to the perioperative nurse, who must maintain the sterile field, keep communication open, and oversee supplies.
An anterior approach, in which the anterior third of the gluteus medius is released, may be used for patients with limited mobility such as those with advanced dementia, neurologic disorders such as Parkinson disease, or flexion contractures.11 (Patients with dementia also may not be able to follow postoperative instructions, increasing their risk of hip dislocation.) The anterior approach leaves the patient with a weak abductor muscle.
In the more commonly used posterior approach, the surgeon releases the piriformis muscle along with the capsule to gain access to the hip joint. At closing, the piriformis and capsule are reattached to provide stability to the hip joint.
Regardless of the approach used, after the surgeon makes the skin incision, the soft tissues are dissected down to the capsule and the hip joint, with electrocautery used to control bleeding. The femoral head is removed and measured, using a caliper or ruler, to approximate the size of the femoral head for a trial. Specialty trays often contain a guide or “flag” used to measure the angle of the femoral neck cut to allow for the endoprosthesis.
With a canal finder, the femoral canal is opened, and the femoral reamers are gradually increased to enlarge the canal. The femoral broaches (templates) are now used to shape the canal for the femoral implant. The broaches are also progressively increased to fit the femur. Once the femoral stem is chosen, a head and neck are trialed for ROM, impingement, stability, and leg length. With the use of modular systems, the surgeon can trial different neck lengths for stability and to prevent impingement to get to the patient's optimal ROM.
At this time, the surgeon will decide whether the prosthesis is a secure enough fit to use a press fit (biological fixation), or if the femoral stem will need to be cemented (see Sticky situation). Cementing also is indicated if the patient's bone is severely osteopenic or the bone stock is inadequate. Once implant size is chosen, the implants are shown to the surgeon for confirmation (usually the femoral stem and head), and opened sterilely onto the surgical field.
If the prosthesis is to be cemented, the surgeon notifies the anesthesia provider and the circulating nurse to monitor the patient for hemodynamic instability. Cement application occasionally causes cardiac dysrhythmias and cardiorespiratory collapse. As the cement hardens, it causes an exothermic reaction that can lead to vasodilation. If the patient's fluid volume is low, hypotension can result and pressure support may be needed.
Before the prosthesis is implanted, the first closing count for the case is performed to prevent a sponge from being implanted with the femoral prosthesis. Next, the femoral canal is irrigated and brushed with a canal brush to clean it of debris. A cement restrictor is placed into the canal below the tip of the implanted stem—this prevents cement from migrating further down the femoral canal.
A centralizer or spacer is placed at the end of the stem to keep the distal tip of the implant in the center of the cement mantle. Potentially fatal complications can arise if bone marrow embolizes into the circulation, or from a direct toxic effect of cement.12 The surgeon first implants the femoral component, this time using the real prosthesis and checking leg lengths and the head and neck components of the prosthesis for stability during ROM. Once the hip components are implanted, the surgical wound is irrigated with an antibiotic solution and closing begins. The second closing sponge and needle counts should begin at this time, to ensure that no sponges are left in the wound.
At skin closure, the WHO Safe Surgery sign-out checklist is completed with the surgical team, confirming the following information has been verified: the procedure, any specimens obtained, postoperative issues, anesthesia provider concerns, and surgical counts completed.
The patient's incision is dressed, and the patient is placed supine on the OR table for endotracheal extubation. Any time the patient is moved from the lateral position, the hip could dislocate. A surgical team member is responsible for keeping the patient's operative leg from flexion and internal rotation when transferring the patient to the postoperative bed. At this time, the team member also helps the perioperative nurse apply the graduated compression stocking and sequential compression device on the patient's operative leg, along with the abductor pillow. These are placed before moving the patient off the OR table because of the risk of dislocating the prosthesis while moving the patient to the bed.
The postanesthesia care unit report includes the patient ID, preoperative diagnosis, procedure performed, allergies and reactions, medications (specifically antibiotics and local medications), airway and oxygenation status, temperature, vital signs trends and hemodynamic stability, estimated blood loss, I.V. fluids and blood products administered, urine output, drains, intraoperative position, sensory deficits, surgical complications, and postoperative concerns, including pain management.6
To reduce the risk of hip dislocation in a confused patient, a knee immobilizer may be used. Postoperative care is similar to that for patients who've had total hip arthroplasty. Neurovascular assessment, pain management, hemodynamic monitoring, and anticoagulation are the nursing priorities in the immediate postoperative period.
Encourage early mobilization with the help of a physical therapist and an assistive device such as crutches or a walker. Early mobilization can prevent pulmonary complications, VTE, pressure ulcers, and generalized deconditioning.13
Remember that hip dislocation occurs in the same direction as the approach used to gain access to the hip joint: an anterior approach dislocates anteriorly and a posterior approach dislocates posteriorly. The type of approach defines the patient's restrictions and ROM, which the physical therapist and the nurse need to know.
In addition to hip dislocation, potential complications of hip arthroplasty include postoperative delirium, which is nearly universal in patients with existing cognitive impairment, but may also occur in patients with no history of confusion.8
Depending on the patient's previous living arrangements, pre- and postoperative health status, and family and social support, the patient may be able to return home after surgery, or may need rehabilitation or long-term care placement.14 Start planning at admission for the patient's discharge. The physical therapy regimen will begin in the hospital and will continue in either the home, with home care services, or in a rehabilitation facility for a few weeks after discharge.
All patients and families will need education about the postoperative anticoagulation protocol, the need for prophylactic antibiotic therapy before dental care, and dislocation precautions. (See Avoiding hip dislocation after surgery.) Also talk to the patient about eliminating the environmental factors that may have precipitated the fall.
By understanding hip hemiarthroplasty and how to care for your patient, nurses can help patients get back on their feet faster.
Reviewing normal joint anatomy
Joints are articulations where bones are joined to one another or where two bone surfaces come together. Ligaments connect bone to bone and provide stability to a joint by encircling the bone or securing the ends of the bones in place. Cartilage, a layer of elastic, resilient supporting tissue, forms a cap over the bone ends to provide protection and support the bone during weight-bearing activities. Cartilage also provides a smooth gliding surface for joint movement.6 The hip joint is a ball-and-socket joint, with the head of the femur moving freely in the acetabulum. The joint is lined with a synovial membrane that secretes fluid to help with motion. Muscles and ligaments stabilize the joint, and the joint capsule also minimizes some joint movement, as well as providing the blood supply to the femoral head.6 The blood supply of the hip joint has three sources—capsular vessels, intramedullary vessels, and a contribution from the ligamentum teres. In adults, the more important source of femoral head blood supply is the capsular vessels.5
Breaking down hip fractures
Femoral neck fractures are also known as intracapsular hip fractures, and by definition occur in the region of the proximal femur (which is within the hip capsule). Intracapsular hip fractures often lead to a disruption of the blood supply to the femoral head, and thus nonunion and osteonecrosis are frequent complications of this injury.7
Data from randomized clinical trialsare insufficient to conclude whethercemented or noncemented arthroplastyis superior.12 An arthroplastyusing a cemented implant may beassociated with increased mortalitycompared with an arthroplasty usingan uncemented implant. Althoughthe mechanisms involved aren'tfully understood, they involve cardiorespiratorydisturbances caused byvenous and pulmonary embolizationof bone marrow contents and methylmethacrylate particles from thecement.15
On the other hand, an uncementedimplant may be associated with designspecificcomplications such as stressshielding, thigh pain, and a higher risk ofperiprosthetic fracture.15 Patients whoseimplants weren't cemented also had lessintraoperative blood loss and shortersurgeries than those whose implantswere cemented.15 Postoperatively, therewere no differences in the length of incision,postoperative blood loss, need forblood transfusions, or length of stay.
Source: Bucholz RW, Heckman JD, Court-BrownCM, Tornetta P, eds. Rockwood and Green's Fracturesin Adults. 7th ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2010:1578.
Avoiding hip dislocation after surgery16
Following proper positioning after hip surgery can help patients reduce the risk of hip dislocation before the prosthesis stabilizes. Hip dislocation, a serious complication that causes pain and loss of function, must be fixed under anesthesia.
To minimize risks, patients should avoid the positions illustrated below when a posterior approach to hemiarthroplasty has been used; this is the most common approach used for hip fractures. Abduction, neutral rotation, and flexion of less than 90 degrees are permitted. Tell patients that after hip replacement, they should:
* keep their knees apart at all times.
* never cross their legs while seated.
* keep their knees lower than their hips when seated.
* avoid bending forward when sitting in a chair.
* avoid bending forward to pick up objects on the floor.
* use a high-seated chair and a raised toilet seat.
* put a pillow between their legs when sleeping.
* avoid flexing the hip when putting on pants, stockings, socks, or shoes.
© 2011 Lippincott Williams & Wilkins, Inc.