LEANING ON HER CANE, Nancy Whitaker, 62, hobbles into the orthopedic surgeon's office. Her arthritic right hip has been hurting for years, but lately her pain's gotten worse despite regular use of a nonsteroidal anti-inflammatory drug. (See How arthritis takes a toll on joints)
She says the pain keeps her from enjoying her walks with her dog and disturbs her sleep at night. Besides pain, she has functional impairment that makes climbing stairs or getting up from a chair difficult. Her cane and other walking aids don't help much.
She's been referred to an orthopedic surgeon to determine if she's a candidate for total hip arthroplasty (or total hip replacement) to replace the diseased bones and cartilage of her hip joint with an artificial joint. (See Anatomy of a hip) The goals of total hip arthroplasty include improving Ms. Whitaker's mobility by relieving pain and improving her hip function.
Thanks to recent surgical innovations, many patients like Ms. Whitaker can now be treated with minimally invasive total hip arthroplasty. The primary difference between minimally invasive and conventional approaches is how the surgeon exposes and gains access to the hip joint.
Conventional total hip arthroplasty requires an incision that's 10 to 16 inches (25 to 40 cm) long; in contrast, the minimally invasive procedure can be performed with one or two small incisions measuring 4 inches (10 cm) or less. When two incisions are used, one is for the acetabular component and one is for the femoral component.
The minimally invasive procedure involves splitting and dividing muscles whenever possible, instead of cutting them, so it's less traumatic than traditional surgery and promotes better healing and joint stability. Patients typically lose less blood, go home sooner—sometimes on the evening of surgery—and recover faster with a smaller scar. Although anesthesia choices are the same for either procedure, the minimally invasive one is less likely to require a blood transfusion, thus lowering surgical risks.
In this article, I'll explain how to prepare and care for a patient a undergoing this increasingly common type of total hip arthroplasty and what to teach her before she goes home.
Meeting the criteria
Talking with the surgeon, Ms. Whitaker learns that she meets the criteria for having total hip arthroplasty:
- Her hip pain interrupts her sleep.
- Medications no longer relieve the pain.
- The pain limits her activities of daily living and social activities.
- Her function is impaired by her arthritis.
She doesn't have any contraindications to total hip arthroplasty: active infection, unstable medical conditions, rapidly progressive neurologic disease, any process that's rapidly destroying bone, or insufficient or absent abductor muscles.
She also learns that she meets the criteria for a minimally invasive approach because she's not morbidly obese, she has no severe femoral deformities, she has healthy (not osteoporotic) bone—and she's motivated to participate in postoperative physical therapy.
Traditional surgery would be indicated for her if she needed revision hip surgery or repair of traumatic fractures involving a previously inserted prosthesis. It's also more appropriate for someone who's morbidly obese or who has severe femoral deformities.
Understanding the repair process
To perform the minimally invasive procedure, the surgeon will need specialized equipment for the smaller incisions; he'll use lighted retractors to help him see and surgical instruments that will fit the small incision better. Fluoroscopy or computer navigation may be used to help guide him during preparation and insertion of the prosthetic components.
Because they encourage bony growth, porous implants are an improvement over traditional cemented implants. Over time, the patient's bone cells grow into the implant's porous surface, holding the implant in place.
Assessing and testing before surgery
Before surgery, assess and document the patient's overall health and physical condition. Preexisting illnesses and infections should be treated before any total hip procedure so she's as healthy as possible.
Standing orders vary from surgeon to surgeon, but preoperative testing typically includes complete blood cell count, serum chemistry screen, urinalysis, prothrombin time, and partial thromboplastin time. Blood to be typed and screened or crossmatched may be ordered. Some patients may opt for autologous blood donation. A patient who's older than 40 or who has a significant medical history or chronic health problems will probably need a chest X-ray and electrocardiogram as well. Cervical spine X-rays may be ordered for patients with rheumatoid arthritis of more than 5 years duration if general anesthesia is planned. Also, to determine the condition of her bone and the soft tissues of her hip, she may need anterior/posterior pelvic X-rays or bone scan, with or without computed tomography scan, or magnetic resonance imaging.
Ask the patient if she has any allergies to medications such as antibiotics or analgesics, to metals such as nickel, and especially to latex. She'll need to give her informed consent for the procedure.
Teach your patient preoperatively about what to expect and what she'll need to do. Instruct her not to eat or drink before surgery as directed by the anesthesia provider. She may be having general anesthesia, an epidural, or a combination.
Also tell her about the preoperative shower with antiseptic soap she'll be taking at home before coming in for surgery. If she takes medications, tell her which ones she can take the day of surgery and which she should avoid and for how long before the surgery. Teach her how to use patient–controlled analgesia if she might be using it postoperatively.
To prevent venous thromboembolism, some patients will begin taking low-molecular-weight heparin (LMWH) before surgery. Others will begin taking LMWH, fondaparinux, or an adjusted vitamin K antagonist after surgery. Teach your patient about the drug and dosage her surgeon prescribes.
Even before surgery is considered, she'd be using a walker or cane to see if it helps improve her function. Before surgery, the physical therapist will make sure she's using her assistive device correctly.
Routine teaching includes coughing and deep-breathing exercises she'll perform postoperatively. Let her know what signs and symptoms she'll need to report after she goes home. Teach her how to recognize signs and symptoms of an infection, deep vein thrombosis, and pulmonary embolism. Advise her to eat a balanced diet to help with healing and encourage her to continue to walk after she goes home. Tell her about specific exercises that restore mobility and strength to her hip. She'll need to follow safety precautions to prevent falls. Physical and occupational therapists will teach her how to move safely and give her other tips to improve her functioning and to prevent her hip from dislocating after she goes home. These tips include not crossing her legs and not bending her hips more than 90 degrees.
Care after surgery
A patient like Ms. Whitaker will probably go home sooner than someone having traditional surgery, but she needs the same postoperative nursing observations and care, including the following:
- monitoring her vital signs, paying particular attention to her cardiovascular and pulmonary status
- observing for postoperative bleeding
- encouraging early ambulation
- assessing for signs and symptoms of venous thromboembolism
- checking the surgical site for signs and symptoms of infection
- controlling pain, nausea, and vomiting.
Back on her feet
Ms. Whitaker returns home the same day as her surgery and resumes walking her dog in a few weeks. She'll need to continue using her cane for a while. She says she's happy to be free from pain and to get her life back to normal so quickly.
How arthritis takes a toll on joints
The most common form of arthritis, osteoarthritis, affects 30 million Americans. Pain occurs because the articular cartilage on the femoral head and inside the acetabulum wears thin, letting the bones rub together.
Rheumatoid arthritis, an autoimmune disease, affects 2.1 million Americans. The body responds to an unknown trigger. Antigen-antibody complexes deposit in the synovium and cause an inflammatory response, including warmth, pain, redness, and swelling. Rheumatoid arthritis attacks and destroys the soft tissue, bone, and cartilage in affected joints.
Osteonecrosis or avascular necrosis occurs when the blood supply to the femoral head is interrupted or destroyed. Causes include trauma such as dislocation or fracture, some glandular diseases, alcoholism, and long-term corticosteroid treatment.
Conservative treatments for osteoarthritis and rheumatoid arthritis involve medications, rest, and physical therapy before total joint arthroplasty is considered. Osteonecrosis of the femoral head may respond to early surgical decompression and bone grafting to encourage growth of new blood vessels to the femoral head.
Sharon E. Hohler is Surgical Nurse, Orthopedics, at St. Francis Medical Center in Cape Girardeau, Mo.