Introduction

Total Knee Replacement (TKR) surgery or Total Knee Arthroplasty (TKA) is an excellent medical option for the restoration of knee function.

Though total knee replacement procedures are carried out with standard surgical protocols, restoration of near normal function in patients with extra-articular deformities, varus and valgus deformities, and posttraumatic arthrosis pose severe challenges.

Restoration of motion to near normal levels in such cases requires skilled nursing care (Lucas, 2009) to provide positive surgical outcomes.

The key issues that mandate skilled nursing care include intra-operative and post-operative anaesthetic complications, postoperative pain management, perioperative cardiopulmonary complications, infection and rehabilitation.

Anaesthetic Complications

Most knee replacement surgeries are performed under regional anesthesia.

This is because of the fact that the regional techniques offer several benefits compared with traditional general anesthesia like elimination of airway manipulation complications and scope for continuous communication with the patient.

At the same time, regional anesthesia, does give rise to some complications that demand prompt nurse interventions. The hemodynamic period during tourniquet release, when, the blood pressure falls suddenly within minutes and subsequent reduction in heart rate deserves a special mention (Lucas, 2009).

Nurse care also includes limiting the level of pre-block sedation, prompt perception of paresthesias and pain during injection of the regional anesthetic.

This is especially true in neuraxial anesthesia where, a benign, short-term backache and post dural puncture headache is a common occurrence.

Post-operative Pain Management

Post-operative pain management in total knee replacement surgeries is complex for the single reason that the post operative pain is intensely severe immediate to the surgery.

Thus, nurse care in the pain management during this immediate post -operative period involves aggressive analgesic therapy (Karlsson et.al, 2012). Post-operative pain management has serious implications in the surgical outcomes and patient rehabilitation.

A nurse has to effectively address the triple challenge of maximizing the pain relief, minimizing the side effects and maintenance of effective rehabilitation regimens. Post-operative anticoagulation is a serious issue and modification of the analgesic protocol according to the anticoagulation regimen is a very important aspect of the nurse care.

Patient Controlled Epidural Anesthesia (PCEA) has been an effective pain relief regimen. The infusion is tapered gradually and oral pain medication initiated based on the patient response. Acute pain care complications include respiratory depression, epidural hematoma, and side effects of PCEA like pruritis, nausea, and vomiting (Karlsson et.al, 2012).

Single shot peripheral nerve or plexus blocks offer excellent analgesia. Femoral nerve blocks have been shown to provide excellent supplemental analgesia in TKA.

Inadvertent perioperative hypothermia is a risk in Total knee Arthroplasty (TKA) procedure and hypothermia has significant effect on the postoperative pain.

Recent findings indicate that patient-controlled, forced-air warming gowns enhance perioperative body temperature and reduce post operative pain (Benson et.al, 2012).

A retrospective study to study various regional anesthetics used for control of postoperative pain in TKAs with fewer side effects has shown that patients who are given intrathecal morphine sulfate, single-shot femoral nerve block and wound catheter have better pain control and request less opioids (Otten and Dunn, 2011).

Strong pain assessment and reassessment skills and an understanding of multimodal pain management are mandatory skills for an evidence based nurse care (Parker, 2011).

A recent study to investigate the efficacy of patient-controlled oral analgesia (PCOA) and extended release epidural morphine (EREM) to reduce pain (Smith-Miller et.al, 2009) and opioid use has shown that traditional nurse (RN)-administered analgesia is superior in pain reduction (Kastanias et.al, 2010).

Infection after Total Knee Surgery

Infection after total knee surgery remains a difficult complication and infection is one of the most common reasons for TKA failure.

Septic Total Knee Arthroplasty requires staged reimplantation and subsequent repeat infections pose serious treatment challenges (Maheshwari et.al, 2010).

Superficial, deep, hematogenous infections and periprosthetic joint infections (PJIs) cause major complications (Renaud et.al, 2013).

Wound ooze is common following total knee arthroplasty and often leads to infection (Butt et.al, 2011).

Nurse care can prevent onset of infections and minimize the risk of infection. Screening every patient with a painful TKA for infection by standard laboratory screening tests and synovial fluid aspiration are excellent diagnostic tools available for early detection of infection (Springer, 2013).

The main risk factors distinctly associated with infection after TKA are BMI, diabetes mellitus, hypertension, steroid therapy and rheumatoid arthritis (Chen et.al, 2013).

Recent studies have shown that screening methods that use automated data can streamline surgical site infection (SSI) surveillance and improve treatment outcomes.

The use of automated inpatient diagnosis codes and pharmacy data in coherence with a medical record review to identify SSIs after arthroplasty has been successfully evaluated.

These studies have shown that an inpatient diagnosis code for infection allotted within a year after the operation has substantial surveillance accuracy and additional data coding on antimicrobial therapy in the first week after the procedure further improves the outcomes (Bolon et.al, 2009).

Nurse role in infection control can be more effective with a thorough knowledge of the pathogens, the preferred antibiotic therapy, their drug resistance and sensitivity profile (Joulie et.al, 2011).

Cardiopulmonary complications

Perioperative cardiopulmonary complications are common in total knee surgeries and studies have shown that patients receiving reinfused shed blood are more prone to cardiopulmonary complications. Higher incidence of cardiopulmonary complication rates have been reported in patients using the reinfusion device (Hanlon et.al, 2011).

Conclusion

The nurse has an important role in the preparation, care and support of the patient throughout the surgical process (Walker, 2012).

Patient education by the nurses at the bed side on various aspects of the surgery, anesthesia, analgesia and rehabilitation is an essential ingredient of nursing care that has a positive impact on surgical outcomes (Montin et.al, 2010).

There are significant relationships between patient trust on nurses, level of care, patient satisfaction and discharge functional outcome.

References

•Benson EE, McMillan DE, Ong B. The effects of active warming on patient temperature and pain after total knee arthroplasty. Am J Nurs. 2012 May; 112(5):26-33; quiz 34, 42.

•Bolon MK, Hooper D, Stevenson KB, Greenbaum M, Olsen MA, Herwaldt L, Noskin GA, Fraser VJ, Climo M, Khan Y, Vostok J, Yokoe DS. Improved surveillance for surgical site infections after orthopedic implantation procedures: extending applications for automated data. Clin Infect Dis. 2009 May 1; 48(9):1223-9.

•Butt U, Ahmad R, Aspros D, Bannister GC. Factors affecting wound ooze in total knee replacement. Ann R Coll Surg Engl. 2011 Jan; 93(1):54-6.Epub 2010 Sep 10.

•Chen J, Cui Y, Li X, Miao X, Wen Z, Xue Y, Tian J. Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2013 May; 133(5):675-87.Epub 2013 Apr 5.

•Hanlon L, Punzo A, Jones RA, Speroni KG. Comparison of cardiopulmonary complication rates in patients undergoing total knee arthroplasty and reinfusion of shed blood. Orthop Nurs. 2011 Sep-Oct; 30(5):307-11.

•Joulie D, Girard J, Mares O, Beltrand E, Legout L, Dezèque H, Migaud H, Senneville E. Factors governing the healing of Staphylococcus aureus infections following hip and knee prosthesis implantation: a retrospective study of 95 patients. Orthop Traumatol Surg Res. 2011 Nov; 97(7):685-92. Epub 2011 Oct 13.

•Karlsson AC, Ekebergh M, Mauléon AL, Almerud Österberg S. "Is that my leg?" patients' experiences of being awake during regional anesthesia and surgery. J Perianesth Nurs. 2012 Jun; 27(3):155-64.

•Kastanias P, Gowans S, Tumber PS, Snaith K, Robinson S. Patient-controlled oral analgesia for postoperative pain management following total knee replacement. Pain Res Manag. 2010 Jan-Feb; 15(1):11-6.

•Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010 Jan; 468(1):52-6.Epub 2009 Aug 8.

•Lucas B. Total hip and total knee replacement: postoperative nursing management.Br J Nurs. 2008 Dec 11-2009 Jan 7; 17(22):1410-4.

•Maheshwari AV, Gioe TJ, Kalore NV, Cheng EY. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty. 2010 Sep; 25(6 Suppl):92-7.

•Parker RJ. Evidence-based practice: caring for a patient undergoing total knee arthroplasty. Orthop Nurs. 2011 Jan-Feb; 30(1):4-8; quiz 9-10.

•Renaud A, Lavigne M, Vendittoli PA. Periprosthetic joint infections at a teaching hospital in 1990-2007.Can J Surg. 2012 Dec; 55(6):394-400.

•Smith-Miller CA, Harlos L, Roszell SS, Bechtel GA.A comparison of patient pain responses and medication regimens after hip/knee replacement. Orthop Nurs. 2009 Sep-Oct; 28(5):242-9.

•Springer BD, Scuderi GR. Evaluation and management of the infected total knee arthroplasty.Instr Course Lect. 2013; 62:349-61.

•Walker J. Care of patients undergoing joint replacement. Nurs Older People. 2012