Post-Operative Complications in Patients Undergoing Joint Replacements

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study concluded a better outcome when surgery was done in a specialized hospital. Hospital stays were shorter, and complications were less likely when specially trained physicians and nurses cared for the joint replacement patients. Length of stay was 3-4 days on average, starting from the day of surgery to the day of discharge. The total percentage of post-operative complications during the study was higher in the LVH, 6.6% vs. 2.3% for HVH. (pp. 60-64) The average length of stay decreased over the years after joint replacements (Husted, 2010) due to the use of epidural and spinal anesthesia. These types of anesthesia had less risks, and post-operative pain was well controlled with opioids. DVT’s/PE’s were prevented with early mobilization as explained earlier. (p. 600)

Infections

Although post-operative infections are on the decline in recent years (Jamsen et al. 2010), they are still one of the leading complications after joint replacements. (p. 660) Prevention of infections can save money in hospitals and eliminate unnecessary pain to the patients; it is more difficult to treat an existing infection due to the increase in multidrug-resistant bacteria. As described by Lindsay, Bigsby, and Bannister (2011), replaced joints can get infected from contamination of surgical wound or from an infection spreading throughout the body. (p. 206) Post-operative infections explained by Jamsen et al. (2010), such as early (less than 3 months after surgery), delayed (3-24 months), and late (more than 2 years after surgery). (p. 661) According to Trampuz & Zimmerli (2006), surgical infections are more common in the first 2 years following joint replacements. Infection of implants can have severe outcomes, thus rules for antibiotic use were implemented. Appropriate timing and selection of antibiotics are now a core measure in most hospitals. (The Joint Commission, 2012) Studies show, the best time to start intravenous antibiotic is within one hour of incision. All antibiotics should be completed within 24 hours of incision. (pp. 1089-1096)

Prosthetic joints can become infected from contamination of the surgical site, or from an infection travelling through the body. Proper skin preparation, including cleansing with chlorhexidine can reduce infection risk by 64%. Shaving of hair of the operative area should be avoided, due to skin excoriation, which increases the risk for infection. Clipping of hair or use of hair removal cream can cause less injury to the skin, thus reducing potential risks. (Lindsay, Bigsby, & Bannister, 2011) Medical and dental clearances are necessary to go forward with most major surgeries. Urinary tract infections should be ruled out or treated if there is one, before surgeries. Routine screen of MRSA (Methicillin resistant staphylococcus aureus) should be completed by nasal swab, and if MRSA present, should be decolonized by local medication.

Placement of a catheter is often needed after joint replacement, due to urinary retention from anesthesia. If the catheter was left in longer than one day it increases the risk for urinary infections, which can develop 5-70% of post-operative patients (as cited in Jaffe, 2011). Placement of urinary catheters after surgeries is an ongoing debate, because catheter associated urinary infections are not reimbursed by Medicare and insurance companies. (Centers for Medicare & Medicaid Services, [CMS] 2008) According to Parker (2011), catheter associated urinary infections are called “never events” (CMS, 2008) and should not arise if all prevention measures were in place and carried out. Although patients will receive prophylactic antibiotics for 24 hours, it is intended to prevent surgical infections and is not aimed towards the treatment of UTI’s; thus the easiest way of preventing urinary infections is to avoid the placement of urinary catheters when possible. In a study completed by Bigsby and Madhusudana, we can see about 40% of patient managed without a catheter after surgery. (2009)

Infection rates were noted to be lower when the surgery was done at a specialized hospital (Jemsen et al.2010). These hospitals follow guidelines and clinical pathways to improve patient outcome. A study (Barbieri et al., 2009) shows, hospitals that use clinical pathways, significantly reduce costs, length of hospital stay, number of post-operative complications, and improve the quality of care. (p. 5-8)

Joint revisions

Although prevention of surgical infections improved in the past years, artificial joints are at high risk for bacterial and fungal infections. (Trampuz & Zimmerli, 2006) Post-operative infections can be so severe that the patient has to undergo another surgery, where the artificial joint has to be removed and replaced; this correction may require one or two surgeries. Besides infections, other indications for joint revision include fractures and multiple dislocations of the artificial joints. Revision surgeries are more painful, require longer hospitalization and recovery; cost is 35 % higher compared to the initial surgery. Infection and dislocation can be prevented with patient education, which should be started well before the surgery (Best, 2005, p. 174-178). To prevent hip dislocation, patients should use an abduction pillow while in bed, and should be sitting with legs at least six inches apart while in a chair. Avoiding inward rotation of the foot, crossing of legs, and bending more than 90 degrees at the hip will aid in preventing dislocation of the artificial joint.

Higher infection rates were noted in patients who smoke, who are obese and/or are poorly controlled diabetics; in fact morbidly obese patients are at the highest risk (Jamsen et al. pp. 660-661). According to Dowsey et al. “mildly overweight patients are not a great risk”, but the risk for infection and complications grows with the increase in body weight. (2008) Research findings at Duke University Medical Center showed that 3.7 percent of obese patients had complications after joint replacement while in the hospital, compared to 2.6 percent for non-obese patients; the discharge to additional healthcare facilities from the hospital was “30 percent higher for diabetics and 45 percent higher in obese patients.” (2005)

Conclusion

Research has proven to be significant in reducing post-operative complications throughout the years. Graul stated “Lack of specific competency can contribute to both increased adverse outcomes and increased length of stay.” (2002) Nurses specialized in orthopedics work hard to improve surgical outcome: “Orthopaedic nurse specialists are the match of nursing knowledge and competence to provide high quality care to the total joint population” (Graul, 2002) When the proper pre- and postoperative care