Nagle, Judith A. MSN, CNOR, FNP-BC
Hip fractures 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. Perioperative 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 percent 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, suffer disability, or loss of independence after a hip fracture.2 These fractures cost an estimated $9.8 billion to $15 billion per year in the United States.3
This article focuses on 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). Specifically, the article focuses 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 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 only minimally ambulate, or who don't function at a very high level.
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 increased in popularity with orthopedic surgeons. Bipolar prostheses aim 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 some surgeons and engineers reevaluating 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
Figure. Reviewing no...Image Tools
Advanced age is the most important risk factor for a proximal femoral fracture. Older adults have decreased proprioception and loss of protective responses, which increases 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 but aren't limited to inadequate lighting, scatter rugs or carpets, slippery floors or tubs, uneven walking surfaces, inappropriate assistive devices, and loose or poorly fitting clothing and footwear.8
Preparing for surgery
The perioperative nurse is the liaison between the patient, surgeon, anesthesia provider, prosthesis coordinator, and OR nursing staff. Interview the patient and the family before beginning the setup. Check the patient's ID, verify surgical consent, make sure the surgical site is marked, and assure 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 is on the chart, and ask pertinent questions about the patient's previous surgical and medical histories and allergies. Evaluate the patient's limitations (such as hearing or vision), range of motion (ROM) of unaffected extremities, skin condition (open areas, abrasions, or bruising that may have occurred from the fall), and mental status. Document all findings on the OR flowsheet.
After completing the preoperative evaluation, tell the surgeon, anesthesia provider, and implant coordinator about any special provisions or equipment needed. A preoperative briefing with the surgical team should cover which side the fracture is on, the positioning devices needed or preferred by the surgeon, whether a unipolar or bipolar prosthesis will be implanted, and the method of prosthesis fixation (cemented or uncemented). Once these questions have been answered, setup can begin.
Setting up the OR
The sterile supplies needed for hip hemiarthroplasty include the basic orthopedic instrument set; a saw and drill; specialty instruments for the prosthesis; sterile drapes, gowns, sutures, gloves; and skin preparation equipment. Unsterile supplies include the positioning device and any additional padding such as an axillary roll, venous thromboembolism (VTE) prevention equipment, and warming equipment.
The patient arrives in the OR
Figure. Breaking dow...Image Tools
Once the patient arrives in the OR, recheck the patient's ID, surgical consent, and make sure the correct site is marked. Use a checklist, such as the World Health Organization (WHO) Surgical Safety Checklist, to keep communication open between team members. As the patient enters the surgical suite, and before anesthesia induction, the anesthesia provider discusses 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 a sedative or additional pain medication before he or she is moved to the OR table. At least four personnel should work as a team to move the patient to the OR table—this decreases shear and friction of the patient's skin and maintains staff safety.9
Before anesthesia induction, initiate prophylaxis for VTE, one of the most common preventable causes of hospital death and a particular risk for patients undergoing orthopedic procedures. Sequential compression devices are applied preoperatively, and remain on the nonoperative extremity during the procedure. VTE is an umbrella term covering deep vein thrombosis (DVT) and pulmonary embolism (PE). Risk factors for VTE in the perioperative phase include venous stasis, acquired hypercoagulable state, endothelial injury, and positioning of the limb intraoperatively.6
Without 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 of these persons develop PE, which causes about 300,000 deaths.6
For a hip hemiarthroplasty, patients are placed in the lateral position lying on the nonoperative side. All team members are responsible for positioning. Maintaining body alignment is crucial to proper patient positioning. The spine, head, and neck should all be in the neutral position.10 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 Place the upper arm on a padded stand or armrest, positioned neutral in relation to the shoulder and 90 degrees from the body.10 Flex the patient's dependent leg at the hip and knee to provide stability. Pad the knee along the lateral and medial sides to reduce the risk of damage to the peroneal nerve.
Also pad and protect these pressure points on the patient's dependent side: the ear, acromion process, ribs, ilium, greater trochanter, the lateral aspect of the ankle. Apply a safety strap 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.
Once the patient is positioned, the surgical team preps the patient. If hair removal is needed, use clippers and start as close to the surgical start time as possible. Prep from the patient's umbilicus down the leg, including the foot. Drape the hip, 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 patient's inability to follow hip precautions, one surgical approach may be used more than the other.
Before the incision, the surgeon leads a pause to confirm the patient's identification (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 applied, and the essential imaging is displayed. The surgeon at this time also discusses how long the case 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 patient safety is always a collaboration among a multidisciplinary team, the 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 dementia, neurologic disorders such as Parkinson disease, or flexion contractures, who don't walk much.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 decided, 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 decided, 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 for hemodynamic instability. Cement occasionally can cause cardiac dysrhythmias and cardiorespiratory collapse on application. As the cement hardens, it causes an exothermic reaction that can lead to vasodilation. If the patient's fluid volume is low, BP can drop and pressure support may be needed.
Before the prosthesis is implanted, perform the first closing count for the case, 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 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 implants 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 assure that no sponges are left in the wound.
At skin closure, follow the WHO sign-out checklist with the surgical team, confirming 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 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 moving the patient to the postoperative bed. The team member also helps the perioperative nurse place the graduated compression stocking and sequential compression device on the patient's operative leg at this time, 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.
Figure. Sticky situa...Image Tools
In the PACU
The postanesthesia care unit (PACU) 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, patient 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.
Figure. Avoiding hip...Image Tools
Encourage early mobilization, which 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.
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.
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 replacement 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, perioperative nurses can help patients get back on their feet faster.
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© 2011 Lippincott Williams & Wilkins, Inc.