Joseph Perruccio, 79, had been active his entire life and enjoyed playing senior softball several times a week. At 71, Louise Richter continued to play doubles tennis and care for her grandchildren. But arthritis pain in the hip and knee threatened to cut them off from the activities they loved. Both Mr. Perruccio and Mrs. Richter opted for total joint replacement surgery and are now back to their full, active lives.

Mr. Perruccio and Mrs. Richter are typical of patients who have been able to return to their regular activities thanks to total joint replacement surgery. Each year, about 600,000 people in the U.S. have total hip replacements (THRs) or total knee replacements (TKRs), and this number is expected to escalate with the aging of the population.¹

The first module in this series focused on the impact of arthritis on aging joints, indications for replacing hip and knee joints, and medical and surgical management. This module describes the role in caring for patients who have undergone THR and TKR. It also reviews the key factors necessary for successful outcomes for patients having joint replacement surgery and stresses the pivotal role of the physical therapist in educating patients to manage the transition from hospital to home.

Not a Walk in the Park

The vast majority of joint replacement surgeries are successful. However, a total joint replacement is a major surgical procedure that involves risks such as joint dislocation, infection, and deep vein thrombosis (DVT) and its potentially life-threatening complication, pulmonary embolus (PE). With today’s shorter length of hospital stays, patients may return home from the acute care setting before they can achieve functional goals, such as transferring independently and negotiating stairs.¹ Of most concern is that patients leave the hospital long before the risk of serious and potentially life-threatening complications disappears.¹ From preoperative assessment through rehabilitation, PTs have many opportunities to help patients who have undergone hip and knee replacement surgeries achieve safe and effective outcomes.

Total joint replacement can cause significant pain. Patients who report their pain level as manageable resume activities more quickly.² Inadequately managed pain can cause a longer hospital stay, increase the chance of readmission, increase hospital costs and decrease patient satisfaction.³ Relaxation techniques, such as progressive relaxation and controlled breathing and imagery, can reduce pain. The PT can reassure the patient that postoperative pain is time-limited. Surgical incision pain decreases over days. As range of motion of the joint increases, joint stiffness decreases.^4,5 Analgesia options include IV and oral opioids or nonsteroidal anti-inflammatory drugs.^4,5 Pain can be treated prophylactically and anticipate patient activity, such as physical therapy sessions. PTs can encourage patients to use ice before and after exercise, to rate their pain, and to request analgesics to reduce pain that interferes with recovery activities.

Joint dislocation, the displacement of the newly implanted femoral head from the acetabulum of the hip, is the most common complication.² Dislocation precautions include avoiding extremes of hip flexion, adduction and rotation. With an anterior surgical approach, the patient is taught to avoid extremes of external rotation, extension, and abduction.¹ With a posterior surgical approach, the patient is taught to maintain abduction and to prevent hip flexion. For example, Mr. Perruccio’s new hip was implanted using a posterior approach. Thus, he should maintain his legs in abduction to maintain stability of the hip prosthesis. To do this, the staff used an abduction splint or abduction pillow and showed Mr. Perruccio how to prevent implant dislocation. Mr. Perruccio and his family were taught that he should avoid flexing his hip more than 90 degrees, avoid crossing his legs or ankles, and use a reacher to pick up objects rather than bending down from the waist.⁴ He was taught to get out of bed or a car by first stepping down with the unaffected leg to maintain abduction and to prevent acute flexion at the knee joint. Mr. Perruccio was also told to use an elevated commode seat to prevent hip dislocation.^4,6 Most patients like Mr. Perruccio can get out of bed with weight bearing as tolerated the day after surgery. Following THR, patients use walking aids for several weeks. As healing progresses, exercises to strengthen muscle groups speed the patient’s independence from walking aids.⁴ Optimally, patients should be taught bed and chair exercises and how to use mobility aids before surgery.^2,4 Regardless of the surgical approach, physical therapy goals focus on therapeutic exercise, transfer training, gait training, and instruction in activities of daily living (ADLs).¹

Preventing falls is another important part of patient teaching. Sustaining a fall during the first few weeks after surgery can damage the new hip, which may lead to more surgery. Stairs are a particular hazard until the new hip is strong and mobile. Patients should be taught to use canes, crutches, walkers or handrails or to get assistance from another person until they have sufficient balance, muscle flexibility and strength.⁷

After TKR, the immediate goal is to gradually and gently increase motion in the knee. Some surgeons order a knee immobilizer or large bulky dressings for the first several postoperative days. Other surgeons use a continuous passive motion machine to gently flex and extend the knee through a controlled range of motion.² Mrs. Richter participated in a postoperative regimen of exercises to reestablish muscle strength and knee range of motion. Her home exercise program includes active range-of-motion exercises, isometrics, heel slides, and straight leg raises with weekly increases in resistance.^1,7 Two months after surgery, Mrs. Richter continues to make progress with her exercise program.

Beware of Infection

Although the incidence of infection in total joint replacement is low, between 0.5% and 1%, it is a significant problem because it may require surgically removing the prosthetic components.^4,6,7 Because bacteria can enter the bloodstream during dental procedures, patients are advised to have procedures such as tooth extractions or periodontal therapy before joint replacement surgery.⁸ Surgery is delayed if the patient has any sign of an infection. Patients receive IV antibiotics immediately before and for 24 hours after surgery. Part of Mrs. Richter’s preoperative class focused on how to prevent infection. She learned that bacteria can travel via the bloodstream from distant sites to infect her implanted prosthesis.^4,7 Patients must know the symptoms of a potential joint replacement infection and should be instructed to notify their physicians should these symptoms occur.^4,6,7 Mr. Perruccio and Mrs. Richter carry identification cards that alert physicians and dentists that they have joint replacements. The card lists recommendations for prophylactic antibiotic coverage for invasive procedures. The American Academy of Orthopaedic Surgeons and the American Dental Association recommend antibiotic prophylaxis for two years after a primary joint replacement.⁸ The card also verifies that the patient has an artificial joint with metallic components that may activate metal detectors.^4,7

Threat of Thrombi

Joint replacement puts patients at increased risk for developing DVT that may evolve into a life-threatening pulmonary embolus. A history of previous DVT also increases the risk.⁹ THR can stimulate the formation of DVT because of the presence of what is known as Virchow’s triad: venous stasis, endothelial injury, and hypercoagulability.¹ Coagulation is encouraged by the presence of tissue debris, collagen or fats in the veins. Orthopaedic surgery often releases these materials into the blood system. During hip replacement surgery, reaming and preparing the bone to receive the prosthesis can also release chemical substances (antigens) that stimulate clot formation into the blood stream.² It is thought than many DVTs start to form during surgery, caused in part by twisting or by occlusion of the femoral vein during hip dislocation and prosthesis insertion.¹ To prevent thromboembolic complications, most acute care facilities and rehabilitation centers use a combination of nonpharmacological and pharmacological interventions.10 Nonpharmacological interventions include early ambulation, elastic compression stockings, intermittent pneumatic compression devices, and inferior vena cava filters.¹ Pharmacologic interventions include medications such as aspirin, heparin and low molecular weight heparin and warfarin to reduce the potential for coagulation.¹ Both DVT and pulmonary embolus may be asymptomatic and difficult to diagnose. Without mechanical and drug prophylaxis, as many as 80% of surgical patients would develop DVT, and 10% to 20% would develop pulmonary embolus.⁹ Even with intensive prevention measures, DVT and pulmonary embolus are the most common reasons for hospital readmission after joint arthroplasty procedures.⁹ DVT risk lasts for at least three months, but the risk is greatest two to five days after surgery. A second risk peak occurs about 10 days postoperatively, after patients have been discharged from acute care facilities.⁹ Surgeons are studying the use of regional rather than general anesthesia and intraoperative heparin to decrease the risk of DVT. With shortened hospital stays, the patient’s and family’s understanding of strategies to prevent DVT is crucial to avoid this potentially devastating complication.¹⁰

Patients should understand that DVT may cause no symptoms at all and can be caused by immobility following surgery — excellent motivation for patients to become mobile.⁴ Both Mr. Perruccio and Mrs. Richter learned to connect mobility and exercise with reducing their risk of DVT. Patients need to be taught DVT warning signs, such as increasing calf pain, especially when the foot is dorsiflexed or moved toward the head of the body (Homan’s sign); tenderness; redness; warmth; increased swelling in the calf, ankle and foot; and skin discoloration.

They must also be informed about the symptoms of a PE: sudden increased shortness of breath or chest pain, or localized chest pain with coughing and a low-grade temperature.⁴ Patients should seek medical help immediately if these symptoms occur.

Back at Home

Upon returning home, patients with THR or TKR require help from family or friends for some ADLs. Mr. Perruccio and Mrs. Richter are fortunate because they have support systems. Patients living alone will need help for several weeks with tasks such as cooking, shopping, bathing and doing laundry. Elderly patients and patients who live alone are discharged to skilled nursing facilities or rehabilitation facilities for short-term rehabilitation before returning home.¹

Some institutions provide patients with a home-planning checklist that helps guide their home management decisions. Patients with total joint replacements may feel insecure and overwhelmed after returning home.¹¹ Home care, with support from nurses and physical therapists, can help ease the transition by providing a safety assessment. Physical therapy can also be performed in outpatient settings, especially for patients who have had TKR.

Many patients do not understand that recovery is slow. Many have unrealistic expectations about full return to function. Pain during rehabilitation and the application to the home of skills learned in the hospital have been documented as sources of patients’ concern.¹¹ It is useful to ask the patient and the family how they would handle a specific postoperative situation to assess whether they can solve problems effectively. If PTs suspect that a patient’s coping skills may be inadequate for optimal recovery, they should arrange for follow-up care and support.

The evolution of managed care, decreased reimbursement and competition among providers have forced acute care institutions to critically examine care delivery.¹² Many have started preadmission programs and clinical pathways for joint replacement surgery aimed at improving efficiency and reducing length of stay.¹² Learning how to manage a joint replacement at home means that the patient and family must learn a great deal of information in a very short time.

PTs can bridge the gap between what patients and family members need to know and how much time they have to learn it. PTs must work closely with other interdisciplinary professionals to manage ever-shortening hospital stays for joint replacement surgery. The PT’s understanding of what and how to teach and the ability to individualize teaching are critical to maximizing patient outcomes. Nearly two out of three people age 65 and older read below the fifth-grade level, so the PT needs to assess the patient’s reading level and select materials that simply and effectively teach patients and families how to prevent complications.¹³

Along the Pathway

A clinical pathway outlines the key events and expected outcomes in the course of a procedure or hospitalization within a prescribed length of stay. By identifying and analyzing variances from the pathway, PTs can make changes to improve patient outcomes within an optimum length of stay. Through variance analysis, many organizations have found that late postoperative blood transfusions, weekend discharges and confusing postdischarge rehabilitation reimbursement guidelines by third party payers are barriers to timely discharge. These examples illustrate the role that PTs can play in working with others to establish clinical pathways and to participate in activities that improve the process. Daily communication among members of the interdisciplinary team will prevent complications and delays in discharge. The Centers for Medicare and Medicaid Services publishes data on joint replacement surgeries that organizations can use to benchmark patient outcomes.

In addition to providing excellent perioperative care for patients with total joint arthroplasty, PTs have a vital role in teaching patients and families how to achieve the important life changes they anticipate when having a joint replaced. Patients like Mr. Perruccio and Mrs. Richter, along with hundreds of thousands of Americans, have been able to return to healthy, productive lives in their communities.