Total hip and total knee replacement:
postoperative nursing management
Abstract
Patients having total hip replacement (THR) or total knee
replacement (TKR) surgery require skilled nursing care in order
to recover from surgery and anaesthesia. The first part of this
article will outline the key nursing management issues during the
postoperative stage of recovery. The second part will consider the
longer term recovery, including the risk of THR dislocation and
failure of the prosthesis due to loosening or infection. The role of the
nurse in primary and secondary care in monitoring and identifying
complications will be highlighted. This is the second of two articles
on nursing care for patients undergoing THR or TKR surgery. The
first article (Lucas, 2008) looked at preoperative nursing care.
Key words: Hip replacement n Knee replacement n Orthopaedics n
Postoperative care n Revision surgery n Surgery: patient care
otal hip replacement (THR) and total knee
T replacement (TKR) surgery are major life events.
Patients undergoing these procedures need skilled
nursing care so that they can recover from surgery and
enjoy the benefits of their new joint.
The first of these two articles (Lucas, 2008) outlined the
preoperative preparation necessary for positive postoperative
outcomes. It emphasized the importance of attention to
physical, psychological and social factors. This article outlines
the nursing management of patients in the immediate
postoperative period and in the recovery period, which
may last up to 1 year. It considers the different care settings
in which this recovery may take place, emphasizing that
nursing management will often take place outside the acute
orthopaedic ward.
Immediate recovery period: the first 5–7 days
Nursing management in this phase consists of facilitating
safe recovery from the anaesthetic and surgery, and the initial
stages of rehabilitation. Each will be considered separately.
Recovery from anaesthetic
THR and TKR surgery may be carried out using a variety
of anaesthetic techniques, depending on the patient’s medical
Brian Lucas is Orthopaedic Advanced Practice Nurse, Whipps Cross
University Hospital NHS Trust, London
Accepted for publication: September 2008
1410
Brian Lucas
condition, the anaesthetist’s skills and patient preference.
Patients may have a general, spinal or epidural anaesthetic,
or a combination of these (Royal College of Anaesthetists,
2008). Each carries its own risks, which patients should
be aware of. For those having general anaesthesia the risk
of death for a healthy person is 1 per 100 000 general
anaesthetics; for those having spinal or epidural anaesthesia,
less than 1 in 100 000 suffer significant permanent nerve
damage resulting in the loss of use of their legs (Royal
College of Anaesthetists, 2004).
Nurses have a responsibility to ensure that they play their
part in promoting recovery after anaesthesia and surgery
through the use of early warning systems (EWSs), in which
acceptable parameters for physiological signs, such as heart
rate, are set; any deviations from these are managed according
to an agreed protocol with early medical involvement
(Cullinane et al, 2005).
Pain relief
Adequate pain relief is essential, not only because it is a
fundamental aspect of good nursing care but also because it
allows patients to mobilize as soon as possible after surgery.
Depending on the type of anaesthesia used, postoperative
pain relief may consist of patient-controlled analgesia (PCA)
or epidural opiates for the first 24–48 hours, with a step-
down approach using paracetamol plus conventional non-
steroidal anti-inflammatory drugs and strong or weak opioids
as required (Fischer and Simanski, 2005).
It is important that nurses are aware of the benefits and
side-effects of the different types of analgesia used. This
will avoid misconceptions, e.g. that there is a high risk of
patient opioid dependency in short-term acute postoperative
recovery (Bell, 2000).
Wound care
Patients will have a surgical wound, which may be the
traditional length of 20–30 cm or, if patients have had
minimally invasive hip replacement surgery (MIHS), 10 cm or
less (Figure 1). MIHS is designed to reduce the complications
of a traditional incision, such as extensive tissue trauma,
thereby promoting faster healing and recovery (Lucas, 2006).
It is carried out with specially adapted instruments to allow
surgery with restricted access. However, it is a relatively new
technique and there are no long-term results to indicate
whether the restricted surgical vision at the time of surgery
has an impact on the correct placing of the hip prosthesis
(Lucas, 2006). Studies have shown that patients are happier
with a smaller, less visible scar (Wright et al, 2004), but they
British Journal of Nursing, 2008, Vol 17, No 22
Downloaded from magonlinelibrary.com by 137.154.019.149 on August 2, 2018.
 ORTHOPAEDIC NURSING

should be aware of the lack of long-term results for surgery Figure 1. Comparison of traditional and minimally invasive hip replacement scars: (a) traditional scar;
(b) minimal incision scar.
carried out in this way.
Minimal incision TKR surgery has been introduced in a
few centres recently, but it is not widespread and long-term
results are not available (Scuderi et al, 2004).
The wound may be closed with sutures or staples. Staples
are more commonly used as they allow faster closing of
the wound, and wound healing and patient satisfaction
results are similar to those for wounds closed with sutures
(Khan et al, 2006). Wound dressings may vary according
to local hospital policy; the evidence suggests that a
semi-permeable film dressing, such as Tegaderm® (3M
Health Care, Loughborough) may be preferable to a fabric
adhesive dressing, especially in reducing the incidence a b
of postoperative skin blistering (Jester et al, 2000). Film
dressings also allow nursing staff to visibly inspect the knee. Flexion is expected to be at least 90 degrees, which
wound without disturbing the dressing. The wound sutures is less than the 130 degrees of normal knee flexion, but
or staples are left intact for 10–12 days and will usually be sufficient to carry out everyday activities. Figure 4 illustrates
removed by primary care staff. knee flexion of approximately 90 degrees. Full extension
TKR surgery generally involves the insertion of a drain to of 0 degrees is present when the leg is lying straight on
prevent haematoma formation. This may be an autologous the bed; most patients can achieve this, although those
drain, where the drained blood is filtered and retransfused into who found this difficult before surgery because of knee
the patient within 6 hours of surgery (Haynes et al, 2003). osteoarthritis or previous trauma may not achieve full
For THR surgery the use of drains is controversial, with extension after surgery.
one study finding that there was no increase in haematoma Physiotherapists may decide to use a continuous passive
formation or wound healing problems when drains were motion (CPM) machine, which gently flexes and extends
not used (O’Brien et al, 1997). A drain is a potential source the knee according to the range set by the physiotherapist.
of infection, and if present should be removed as soon as This can result in greater knee flexion by the time of hospital
drainage is minimal, usually within 24 hours of surgery. discharge compared with patients who do not have CPM;
however, studies have shown that in the longer term there
Mobilization after THR surgery are few significant differences between those who have CPM
Mobilization consists of bed and chair exercises to strengthen and those who do not in terms of knee flexion, function
the muscles in the leg, and walking and other activities such or quality of life (Bennett et al, 2005). In many hospitals,
as climbing stairs. CPM therapy is therefore only used with patients who have
Ideally the patient will have been taught and have practised difficulties in achieving flexion through exercise.
the exercises before admission to hospital. These exercises Patients usually mobilize full-weight bearing after TKR
have to be performed at least three times a day for 6–8 weeks; surgery, before or after an X-ray, depending on surgeon
an example is shown in Figure 2. A physiotherapist normally preference. The use of crutches or walking sticks is usually
teaches the exercises, but nursing staff can help to ensure that advised for the first 4–6 weeks.
patients continue to perform them correctly, and encourage
patients to maintain the exercise behaviour.
After THR surgery, patients will usually start to walk with
the aid of a walking frame or crutches the day after surgery.
This may be before or after an X-ray, depending on surgeon
preference. For cemented prostheses, patients are usually
allowed to put full weight through the operated leg with
crutches or a frame, but for uncemented prostheses patients
may only be allowed to partially weight bear for 6–8 weeks
as this is believed to allow bone growth into the prosthesis
(Woolson and Adler, 2002). However, some studies have
shown that there are no adverse effects with early full weight
bearing on uncemented prostheses, and many surgeons now
allow this (Woolson and Adler, 2002). Figure 3 illustrates the
correct use of crutches when full-weight bearing.

Mobilization after TKR surgery

After TKR surgery, patients need to exercise the leg muscles Figure 2. Example of a postoperative exercise after THR surgery. Lying on your back, bend your
and also become confident in walking. It is important that unoperated side knee. Put a thick, rolled towel under your operated side knee. Pull your foot towards
patients are able to bend (flex) and straighten (extend) the a tighten your thigh muscle and straighten your knee. Hold for 5 seconds and relax.
you,

British Journal of Nursing, 2008, Vol 17, No 22 1411

Downloaded from magonlinelibrary.com by 137.154.019.149 on August 2, 2018.
Figure 3. Walking full-
weight bearing with
crutches: (a) Move the
crutches forward; (b)
Move the operated leg
forward, to the level
of the crutches; (c)
Move the unoperated
leg forward to the level
of the operated leg
and crutches.
a b
Venous thromboembolism prophylaxis
Venous thromboembolism (VTE) is the blocking of a blood
vessel by a blood clot. It includes both deep vein thrombosis
(DVT), a blood clot in a deep vein, and pulmonary embolism
(PE), a blood clot that breaks off from the deep veins and
travels through the circulation to block the pulmonary
arteries. THR and TKR surgery are high-risk surgeries for
VTE. It is calculated that without the use of prophylactic
measures the risk of VTE is 44% for patients having THR
surgery and 27% for patients having TKR surgery (National
Collaborating Centre for Acute Care, 2007).
Patient risk needs to be assessed by nursing staff using a tool
such as the Autar DVT risk assessment scale (Autar, 2007).
A review of the evidence shows that a mechanical method
of prophylaxis, i.e. graduated compression stockings, such
as T.E.D® anti-embolism stockings (Kendall, Hampshire),
intermittent pneumatic compression devices or foot impulse
devices, such as the A-V Impulse System (Orthofix, Texas,
US), is used alongside low molecular weight heparin or
fondaparinux (an injection to inhibit coagulation) for 4 weeks
after surgery (National Collaborating Centre for Acute Care,
2007). This has implications for patients on discharge as
they will need help to remove and reapply their graduated
compression stockings. They will also need to be taught how
to perform subcutaneous heparin injection, or arrangements
made for a relative or primary care nurse to administer the
injection.
Preparation for discharge – home circumstances
While it is traditionally the role of the occupational therapist
1412
c
to assess for and organize any home adaptations, nurses will
be involved in ensuring that patients are referred to an
occupational therapist if appropriate, and also in answering
any questions patients may have about their discharge
home. An assessment of the patient’s home circumstances
should be undertaken before admission and was discussed
in the first article (Lucas, 2008).
For patients who have had THR surgery, one of the
potential complications that requires assessment of the
home circumstances is the risk of dislocation, i.e. the
femoral component comes out of the acetabular cup. This
is an uncommon complication, with one study of 58 521
patients finding a dislocation rate of 3.9% within the first
26 weeks of surgery (Phillips et al, 2003). It is, however, a
worrying possibility for patients, and when it occurs is very
painful and distressing.
To reduce the risk of dislocation, patients are taught
not to flex their hip joint more than 90 degrees, i.e. not
to bend down or to bring their knee above their hip; this
may necessitate raising a patient’s bed and chair height and
providing a raised toilet seat. Patients are also taught to
avoid stretching their leg too far out to the side, not to cross
their legs and not to twist on their leg when turning. They
may also be advised to sleep on their back.
These precautions are most important in the first 8–
12 weeks after surgery, while the muscles and other soft
tissues heal around the joint replacement. A few research
studies have suggested that such precautions may not be
necessary and that patients should be allowed more freedom
of movement (Talbot et al, 2002; Peak et al, 2005). THR
British Journal of Nursing, 2008, Vol 17, No 22
Downloaded from magonlinelibrary.com by 137.154.019.149 on August 2, 2018.

dislocations are manipulated under anaesthesia in theatre to
relocate them, and the patient may have to wear a protective
hip brace for 2–3 months afterwards.
For patients who have had TKR surgery, their toilet, bed
and chair should be of a suitable height so that when they
stand up they are not straining their leg muscles during the
healing period. An ideal height is one where the hip is flexed
to 90 degrees when patients are sitting with their hip and knee
in alignment. A chair with armrests is preferable as it allows
patients to utilize their upper limb strength when standing up.
It is not usually necessary for patients who have had THR
or TKR surgery to bring their bed downstairs if they live
in a house, as they will be taught how to perform stairs
safely before discharge. Stair rails may need to be fitted for
safety reasons.
The first 6 weeks after discharge
Patients discharged after 4–5 days in hospital will still have
acute needs, such as wound care and administration of heparin
injections, and may need further physiotherapy. These services
are provided either by primary care staff such as district nurses,
or by dedicated early discharge schemes. Such schemes have
proved to be cost effective and popular with patients (Hill
et al, 2000), although it is suggested that patients should be
screened as to their suitability for early discharge (Jester, 2003).
This is because the impact of early discharge on patients and
their relatives or carers may be significant. Evidence suggests
that relatives often feel under pressure (Chow, 2001) and there
may need to be temporary adjustments in roles during the first
6–12 weeks after surgery (Showalter et al, 2000).
Patients are often apprehensive during the recovery period,
and those who have had THR surgery in particular worry that
they may dislocate their prosthesis. Dislocation is immediately
recognizable: the leg appears shorter and externally rotated
(the foot lies out to the side) and the patient has severe pain
and is unable to put weight on the leg. Nurses should ensure
that patients are aware that some discomfort after walking and
performing exercises is normal and does not indicate that the
hip has dislocated. Such discomfort is also common after TKR
surgery and patients should expect this in the recovery period.
Patients should be encouraged to continue their analgesia if
needed, so that they can continue to perform their exercises.
Longer term recovery and outcomes
Patients are usually seen in the outpatient clinic 6 weeks
after surgery, when an X-ray is performed to check the
alignment of the prosthesis. Such clinics are often run by
nurse practitioners and have been shown to provide safe
care with high patient satisfaction (Flynn, 2005). They allow
patients more time to ask questions and share concerns than
a traditional orthopaedic consultant appointment would do.
Patients are usually advised that they can start to increase their
activities, with commencement of driving and a return to
work at about 8–12 weeks after surgery. Walking aids are not
usually needed after the first 2 months, but can continue to
be used if patients lack confidence. Complete recovery may
take many more months, and for some patients, particularly
those who have had a TKR, it may take up to a year.
Satisfaction with surgery varies between THR and TKR
British Journal of Nursing, 2008, Vol 17, No 22
ORTHOPAEDIC NURSING
Figure 4. Knee flexion of approximately 90 degrees.
surgery patients; Table 1 shows the figures from a survey of
7000 patients 1 year after surgery (National Joint Registry,
2006). Patients who are not satisfied may have a functioning
joint prosthesis with no complications, but are unhappy
because they had unrealistic expectations of what activities
they would be able perform after surgery (Mahomed et al,
2002; Noble et al, 2006). Preoperative education to help
patients develop realistic expectations has been shown to
increase satisfaction with surgery (Mancuso et al, 2008).
Patient satisfaction is an important outcome measure,
but there are others, such as longevity of the prosthesis and
reasons why the prostheses fail and need to be replaced.
THR and TKR prostheses are long lasting: studies show
that 10 years after surgery, 90–95% of THRs (Berry et al,
2002) and TKRs (Vazquez-Vela Johnson et al, 2003) are still
functioning well. The main long-term problems are aseptic
wearing and infection.
The cause of aseptic loosening, i.e. loosening without
infection, is not completely understood. It is thought
to be a combination of migration (movement of the
prosthesis) and wear debris (metal/plastic components
that activate macrophages and stimulate bone destruction
around the prosthesis). Aseptic loosening accounts for up
to three-quarters of THR failures (Wimhurst, 2003) and
has been reported in one study as occurring in a third of
TKR patients (Sharkey et al, 2002). The most common
symptom is previously unexperienced pain in the joint,
but bone destruction may be detected on X-ray before
symptoms occur. If this destruction becomes too advanced
it makes revision surgery technically more difficult, and it
is suggested that patients should be monitored long term
after surgery (British Orthopaedic Association, 2007).
Such monitoring may be carried out in nurse-led clinics
Table 1. Satisfaction rates of THR
and TKR patients
Satisfied Not satisfied Not sure
THR patients 90% 3.5% 6.5%
TKR patients 82% 7% 11%
THR = total hip replacement; TKR = total knee replacement
Source: National Joint Registry (2006)
1413
Downloaded from magonlinelibrary.com by 137.154.019.149 on August 2, 2018.
 (Jackson, 2003).
Infection can occur at the time of surgery, while the
wound is healing, or in the longer term. In the last case,
it occurs through haematogenous seeding, when bacteria
from a distant infection travel to the joint replacement via
the bloodstream. Infections occur in approximately 1–2%
of TKR prostheses (Harwin, 2002) and 0.2–1.1% of THR
prostheses (Phillips et al, 2003). Nurses within primary
and secondary care are key in detecting early and late
infection, which manifests as physical symptoms (discharge,
redness, swelling, pain) and through abnormal blood results
(high white cell count, erythrocyte sedimentation rate and
C-reactive protein) (Della et al, 2004). Infection that cannot
be eradicated can lead to loosening of the prosthesis.
Both aseptic loosening and loosening caused by infection
may mean that the prosthesis has to be removed and a
revision replacement implanted. This is obviously devastating
for patients and they will require support to deal with the
uncertainty and disappointment of a failed joint replacement.
Conclusion
THR and TKR surgery are very successful in improving
quality of life for patients with osteoarthritis who cannot
manage their symptoms with conservative methods, such as
analgesia. Nurses should ensure that patients understand that
rehabilitation can take many months, and that some short-
term restrictions on activity are necessary in order to achieve
the full long-term benefits. While the long-term results are
very positive, there may be complications, such as loosening
of the prosthesis; both patients, and nurses caring for patients,
need to be aware of these so that symptoms can be identified
and managed as soon as possible. BJN
Autar R (2007) NICE guidelines on reducing the risk of venous
thromboembolism (deep vein thrombosis and pulmonary embolism) in
patients undergoing surgery. J Orthop Nurs 11(3–4): 169–76
Bell F (2000) A review of the literature on the attitudes of nurses to acute pain
management. J Orthop Nurs 4(2): 64–70
Bennett L, Brearley S, Hart J, Bailey M (2005) A comparison of 2 continuous
passive motion protocols after total knee arthroplasty: a controlled and
randomized study. J Arthroplasty 20(2): 225–33
Berry D, Harmsen S, Cabanela M, Morrey B (2002) Twenty-five year
KEY POINTS
n In the immediate postoperative recovery phase, it is important that nurses
ensure that patients’ pain is well controlled so that early mobilization can
take place.
n Patients having total hip replacement (THR) or total knee replacement (TKR)
surgery are at high risk of venous thromboembolism, and appropriate
assessment and interventions need to be in place.
n Patients take several months to recover completely from the surgery,
although they will be mobile from the day after their operation.
n At 10 years after surgery, approximately 90–95% of patients with a THR
or TKR are still pain free and functioning well.
n Some THRs/TKRs will require removal and a replacement prosthesis inserted;
this is known as revision surgery. The most common indications for revision
surgery are aseptic loosening and infection. Nurses should be aware of the
symptoms associated with these complications.
1414
survivorship of two thousand consecutive primary Charnley total hip
replacements. J Bone Joint Surg Am 84-A(2): 171–7
British Orthopaedic Association (2007) Total Hip Replacement: A Guide to Best
Practice. British Orthopaedic Association, London
Chow WH (2001) An investigation of carers’ burden: before and after a total
hip replacement. Br J Occup Ther 64(10): 503–8
Cullinane M, Findlay G, Hargraves C, Lucas S (2005) An Acute Problem? A
report of the National Confidential Enquiry into Patient Outcome and
Death (NCEPOD), London
Della V, Zuckerman J, Di C (2004) Periprosthetic sepsis. Clin Orthop Rel Res
420: 26-31
Fischer H, Simanski C (2005) A procedure-specific systematic review and
consensus recommendations for analgesia after total hip replacement.
Anaesthesia 60(12): 1189–202
Flynn S (2005) Nursing effectiveness: an evaluation of patient satisfaction with
a nurse-led orthopaedic joint replacement review clinic. J Orthop Nurs 9(3):
156-65
Harwin S (2002) The diagnosis and management of the infected total knee
replacement. Semin Arthroplasty 13(1): 9–22
Haynes S, Torella F, Smith J, McCollum C (2003) Post-operative red cell salvage
in total knee replacement. J Orthop Nurs 7(1): 15–17
Hill S, Flynn J, Crawford E (2000) Early discharge following total knee
replacement – a trial of patient satisfaction and outcomes using an
orthopaedic outreach team. J Orthop Nurs 4(3): 121–6
Jackson R (2003) Advancing nursing practice for orthopaedic outpatients.
J Orthop Nurs 7(1): 10–14
Jester R (2003) Early discharge to hospital at home: should it be a matter of
choice? J Orthop Nurs 7(2): 64–9
Jester R, Russell L, Fell S, Williams S, Prest C (2000) A one hospital study of
the effect of wound dressings and other related factors on skin blistering
following total hip and knee arthroplasty. J Orthop Nurs 4(2): 71–7
Khan R, Fick D, Yao F et al (2006) A comparison of three methods of wound
closure following arthroplasty: a prospective randomised controlled trial.
J Bone Joint Surg Br 88(2): 238–42
Lucas B (2006) Through the keyhole: an examination of minimally invasive hip
surgery. J Orthop Nurs 10(1): 38–48
Lucas B (2008) Total hip and total knee replacement: preoperative nursing
management. Br J Nurs 17(21): 1346–51
Mahomed N, Liang M, Cook E et al (2002) The importance of patient
expectations in predicting functional outcomes after total joint arthroplasty.
J Rheumatol 29(6): 1273–9
Mancuso C, Graziano S, Briskie L et al (2008) Randomized trials to modify
patients’ preoperative expectations of hip and knee arthroplasties. Clin
Orthop Rel Res 466(2): 424–31
National Collaborating Centre for Acute Care (2007) Reducing the Risk of
Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in
Inpatients Undergoing Surgery. Commissioned by the National Institute for
Health and Clinical Excellence. Royal College of Surgeons of England and
National Collaborating Centre for Acute Care, London
National Joint Registry (2006) National Joint Registry for England and Wales: 3rd
Annual Report. National Joint Registry, Hemel Hempstead
Noble P, Conditt M, Cook K, Mathis K (2006) The John Insall Award. Patient
expectations affect satisfaction with total knee arthroplasty. Clin Orthop Rel
Res 452: 35–44
O’Brien S, Gallagher P, Engela D et al (1997) The use of wound drains in total
hip replacement surgery. J Orthop Nurs 1(2): 77–83
Peak EL, Parvizi J, Ciminiello M et al (2005) The role of patient restrictions in
reducing the prevalence of early dislocation following total hip arthroplasty.
A randomized, prospective study. J Bone Joint Surg Am 87(2): 247–53
Phillips C, Barrett J, Losina E et al (2003) Incidence rates of dislocation,
pulmonary embolism, and deep infection during the first six months after
elective total hip replacement. J Bone Joint Surg Am 85(1): 20–6
Royal College of Anaesthetists (2004) Risks Associated With Your Anaesthetic.
RCA, London
Royal College of Anaesthetists (2008) Anaesthetic Choices for Hip or Knee
Replacement. RCA London
Scuderi GR, Tenholder M, Capeci MS (2004) Surgical approaches in mini-
incision total knee arthroplasty. Clin Orthop Rel Res 428: 61–7
Sharkey P, Hozack W, Rothman R, Shastri S, Jacoby S (2002) Insall Award
paper. Why are total knee arthroplasties failing today? Clin Orthop Rel Res
404: 7–13
Showalter A, Burger S, Salyer J (2000) Patients’ and their spouses’ needs after
total joint arthroplasty: a pilot study. Orthop Nurs 19(1): 49–62
Talbot N, Brown J, Treble N (2002) Early dislocation after total hip arthroplasty:
are postoperative restrictions necessary? J Arthroplasty 17(8): 1006–8
Vazquez-Vela Johnson, Worland R, Keenan J, Norambuena N (2003) Patient
demographics as a predictor of the ten-year survival rate in primary total
knee replacement. J Bone Joint Surg Br 85(1): 52–6
Wimhurst J (2003) The pathogenesis of aseptic loosening. Curr Orthop 16(6):
407–10
Woolson S, Adler N (2002) The effect of partial or full weight bearing
ambulation after cementless total hip arthroplasty. J Arthroplasty 17(7):
820–5
Wright J, Crockett H, Delgado S, Lyman S, Madsen M, Sculco TP
(2004) Mini-incision for total hip arthroplasty: a prospective, controlled
investigation with 5-year follow-up evaluation. J Arthroplasty 19(5):
538–45
British Journal of Nursing, 2008, Vol 17, No 22
Downloaded from magonlinelibrary.com by 137.154.019.149 on August 2, 2018.