Post THR and TKR patient's care

1. AUM NOORHAZAMIN

2. NORMAL JOINTS
 Allow for movement
between bones
 Each bony surface of
the joint is lined with
cartilage
 Cartilage provides
smooth friction-free
movement, nutrition
to the joint, and
provides shock
absorption

7. INDICATION FOR ARTHROPLASTY :
• Progressive pain
• Analgesic dependant
• Deterioration of ADL
• Disturb sleep
• Depression

8. Advantage of Joint Replacement Surgery
• Effective – relief pain &
correct deformity
• Long lasting
• Return of quality of life

9. CONTRAINDICATION FOR
ARTHROPLASTY :
• Active infection
• Charcot joint
• Poor skin coverage
• Lack of muscle control
• Inability to participate in post operative
rehab

11. Knee joint.
 Hinge joint is largest joint
in the body
 The thigh bone (femur) and
the shin bone (tibia) meet to
form the knee joint
 The knee cap (patella) covers
and protects the knee joint
 Cartilage covers the end of
the knee bones and “cushion”
the knee for smooth, easy
movement

28. AFTER THE OPERATION :
• Adequate pain relief
• Early mobilization
• Continuous passive motion exercise
• Cryotherapy
• Extended duration VTE prophylaxis
• Early oral alimentation and enhanced
nutrition
• Maintain ADL

29. POST TKR CARE :
• Rest in bed
• Leg elevated
•Monitor neurovascular
•ROM, ankle foot pumping & static quadriceps exercise
Day of
Operation
• Up and walking
• Train to use walking aids over steps, stairs and level
ground
1-8 Days
•2 weeks to 1 month
•First doctor appointment
•Getting back on feet without walking aids
1st Phase
Rehabilitation
•Painless walking
•Back to normal outdoor activities and stair climbing
•Most functions return within 3 to 6 months
2nd Phase
Rehabilitation

31. POST OPERATIVE PAIN MANAGEMENT :
• Multimodal drug therapy regime :
 Opioids (neural hyperpolarization & reduce
excitability) Morphine, Oxycodone,
Tramadol
 Selective COX-2 inhibitors (less GI effects)
Celebrex, Arcoxia, Dynastat
 NSAIDs (inhibit inflammatory mediators)
Voltaren
 Gabapentin (reduce hyper-excitability of neuron)
Lyrica, Neurontin
 Paracetamol

33. PRESERVE KNEE MOTION
• Use pillow under a foot to maintain knee
extension & prevent flexion contracture

34. RANGE OF MOTION REQUIREMENT :
ACTIVITY MINIMUM ROM
Swing phase of gait 65⁰ of flexion
Activities of daily living 90⁰ of flexion
Manipulating stairs 95⁰ of flexion
Rising from standard chair 105⁰ of flexion

35. EARLY MOBILIZATION GOAL :
• Prevention of VTE events
• Prevention of stiffness & contracture,
and enhance final range of motion
• Early return to day-to-day activities

37. QUADRICEPS SET
• Tighten quadriceps to straighten knee. Hold 5-
10 seconds. (10X / 2 minutes : 1 minute rest)

38. KNEE STRENGTHENING EXERCISE
• Hold knee fully straighten for 5 – 10 seconds.

39. BED SUPPORTED KNEE BENDS
• Hold knee maximally bend for 5 – 10 seconds
then straighten.

40. SITTING UNSUPPORTED KNEE BENDS
• Bend knee until touching floor. Slide body
forwards to further bend knee. Hold for 5 – 10
seconds then straighten knee.

41. USING STAIRS
• Always step with good leg going up. Operated
leg coming down (one step of a time initially).

45. Automatic Increase The ROM

47. CRYOTHERAPY
• Correlation between local temperature and
inflammatory to reduce pain.

52. VTE PROPHYLAXIS
• Incidence of DVT in patient not on prophylaxis
as high as 88%

55. EARLY ORAL ALIMENTATION & ENHANCED
NUTRITION
• Maintain hydration.
• More fiber to avoid constipation (often caused
by pain medications). Foods that contain fiber
include corn, peas, beans, avocados, whole
wheat pasta and breads, broccoli, almonds.
• High protein promotes wound healing &
muscular tone.
• Vitamin D supplement for bone strengthening.

56. EARLY ORAL ALIMENTATION & ENHANCED
NUTRITION
• Eat foods high in Vitamin C to help boost
immunity & absorb iron. Foods that are high
in vitamin C include oranges, cantaloupe, and
tomatoes.
• Enough calcium, which is needed to keep your
bones strong. Foods that are high in calcium
include milk, cheese, yogurt, dark leafy
greens, and fortified cereal.
• Additional calories for energy for
rehabilitation

57. AVOID VITAMIN K SUBSTANCES THAT
CONTRIBUTES CLOTTING :
• Broccoli
• Cauliflower
• Liver
• Cabbage

58. WEIGHT CONTROL :
• DO NOT INCREASE BMI!!!

60. ACTIVITY DAILY LIVING
• First 6 weeks :
 Limiting activities to walking with support
• Usually by 8th week :
 All forms of support discarded
• 6th to 8th weeks :
 Generally able to drive

61. EXERCISE ACTIVITIES :
• Low impact exercise :
 E.g. swimming allowed freely once wound
adequately healed
• Moderate level exercise :
 E.g. golf & tennis refrained until 3 months after
surgery
• High contact sport & high impact activities :
 Not allowed at any time

64. HIP JOINT
 Ball (femur) and socket
(acetabulum) joint
 Moves in three
directions
 Socket not lined
completely with
cartilage

82. POST OPERATIVE NURSING CARE
• Monitor vital signs closely
• Monitor level of sedation
• If the patient has a drain:
Expect 200 to 500 mL of
drainage during first 24
hours post-op, decreasing
to 30 mL after 48 hours
• Assess the dressing
regularly
• Help with deep breathing
and coughing to decrease
lung congestion
• Make sure hip precautions
are in place
• Assist with ambulation and
activities of daily living

83.  Pain management
o Initially: epidural analgesia, patient-controlled analgesia (PCA),
analgesic injections
o After first day: oral analgesic
o Proper positioning
 Early ambulation
o Walker, crutches
o Cane
 Hip flexion restriction
o Educate patients to not bend forward
 Interventions to prevent complications
POST OPERATIVE NURSING CARE

84. PREVENTING COMPLICATIONS
• DVT prophylaxis with anticoagulant therapy lasting
up to 6 weeks post-op and/or compression stockings
• Infection prevention with prophylactic antibiotics
• Postoperative pneumonia prevention with early
ambulation and coughing and deep breathing
exercises

85. PHYSICAL THERAPY
• Consists of gait training and mobility
• First the patient learns correct weight-bearing
practices
• Then skills such as going up and down stairs
• The patient need to continue perform exercises at
home after discharge

86. WALKING TRAINING
 Gait training begun on 2nd postoperative day, non
weight bearing with a walker :
 If cemented - early weight bearing to tolerance is
permitted
 If cementless - touchdown (toe touch) weight
bearing for 6-8 weeks.
 Patient can be discharged when patient can walk
on even surfaces, get out of bed, climb few steps.
 Follow-up at 6 weeks.
 Check x-ray are taken
 Full weight bearing advised

87. ACTIVITY DAILY LIVING
• Walking frame initially – progress depends on patient
• ROM exercise
• Abductor strengthening exercise
• Stairs – as soon as comfortable
• Driving – after 6 weeks

88. AVOIDING HIP
DISLOCATION
AFTER REPLACEMENT
SURGERY

89. HIP PRECAUTIONS :
• Prevent dislocation
–Keep legs abducted
–Place pillows between legs when sleeping
–Bend at waist (not more than 90 degrees)
–Push straight up off chair or bed when
getting up and don’t lean forward
–Use walker if needed
–Use equipment to help put on
socks/shoes

102. CAUSES OF TJR FAILURE
• Wear of articular bearing surface
• Aseptic/mechanical loosening
• Osteolysis
• Infection
• Instability
• Peri-prosthetic fracture
• Implant Failure

103. CAUSES OF REVISION SURGERY
PRIMARY REVISION
• Loosening (28%)
• Dislocation (24%)
• Fracture (18%)
• Infection (17%)
SECONDARY REVISION
• Dislocation (31%)
• Loosening (28%)
• Infection (22%)
• Fracture (7%)

104. Dislocation/Instability

105. Infection

106. Wear of Articular Bearing Surface

107. Osteolysis

108. Aseptic/Mechanical Loosening

109. Peri-Prosthetic Fracture
• Sri: PP fracture

110. Implant Failure

111. Major Osseous Defects