MSK: PART 6 - Orthopedic Surgeries

The video introduces orthopedic surgeries, focusing on lower extremity amputation and total knee replacement, as the final topic for the semifinals. Post-operative care includes pain management, mobility support, and preventing complications like DVT and infection. Orthopedic surgery is a major risk factor for DVT and pulmonary embolism due to vascular damage and immobility. Post-op priorities include monitoring neurovascular status of the operative limb, assessing for compartment syndrome (six Ps: pain, paresthesia, paralysis, pallor, pulselessness, poikilothermia), and preventing DVTs through early ambulation, sequential compression devices, prophylactic anticoagulants, and monitoring for signs of DVT.

Pain management involves multimodal analgesia (non-pharmacological and pharmacological interventions) and pre-medication before physical therapy. Mobility precautions are crucial to prevent dislocation and contractures, such as avoiding adducting legs after hip arthroplasty by placing a pillow between the legs. Patients should use raised toilet seats and be taught safe use of assistive devices like crutches and walkers, including techniques for climbing stairs (up with the good, down with the bad).

Lower extremity amputation is a surgical limb removal, usually for complications of peripheral artery disease or diabetes when other treatments fail. It can be performed at various levels. Major risks include hemorrhage, infection, flexion contracture, and phantom limb pain. Post-op nursing care focuses on three areas: residual limb wrapping and stump care, mobility and rehabilitation support, and discharge education.

Residual limb compression is essential after amputation to decrease edema and shape the limb for prosthesis fitting. The compression bandage should be snug but not impede circulation and needs to be re-wrapped multiple times daily or when loose. Nurses must prevent dangling the residual limb to avoid edema, monitor the stump for hemorrhage, infection, and pressure injury, and keep a tourniquet at the bedside in case of active bleeding. Patients are taught daily stump inspection, continued compression bandage use, and washing with mild soap and water while avoiding lotions or alcohol.

To prevent hip flexion contractures, clients should be placed in a prone position for 20-30 minutes several times daily, and the residual limb kept flat when supine. Early ambulation is encouraged to prevent pneumonia and DVT. Physical and occupational therapy consultations are crucial for rehabilitation and learning to use prosthetics. Prosthesis fitting occurs after incision heals and edema resolves. Pain, including residual limb pain (managed with analgesics) and phantom limb pain (managed with neuropathic pain medications like gabapentin, TCAs, or mirror therapy), must be addressed. Mirror therapy helps rewire neural pathways. Support groups are recommended for coping with limb loss and altered body image.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) involve surgical implantation of joint prostheses to treat pain and immobility from arthritis or repair hip fractures. Post-op care focuses on managing pain, supporting mobility, and preventing DVT and infection. Pain is managed with nerve blocks, patient-controlled analgesia (PCA), and NSAIDs, with pre-medication before painful procedures.

Early ambulation within 24 hours using assistive devices like walkers and crutches is vital to prevent joint stiffness and DVTs. For knee replacement, a continuous passive motion (CPM) machine improves circulation and knee flexion. For hip replacement, preventing hip dislocation is critical, especially with a posterior approach. This includes keeping hips abducted in a neutral position, avoiding hip flexion greater than 90 degrees (using elevated toilet seats/chairs), avoiding adduction (using an abduction pillow), and not crossing legs. Signs of hip dislocation (sudden pain, shortened limb, external rotation) should be reported immediately. Activity modification should be taught for discharge.

DVT prevention remains a priority through early ambulation, anticoagulants (heparin, enoxaparin), and sequential compression devices or stockings. Signs of DVT (calf pain, redness, swelling) should be monitored. Elevation is only recommended to prevent DVT, not if DVT is already present, as it can facilitate clot travel. Infection prevention involves keeping dressings clean and dry and monitoring for signs like fever, drainage, warmth, and redness. Discharge teaching after hip arthroplasty stresses avoiding excessive hip flexion (low chairs, deep bending) using elevated seating, long-handled assistive devices (shoe horn), and removing household hazards like rugs and cords to prevent falls.