1. Total Joint Replacement
While many surgeons and bioengineers contributed to the concepts, techniques and designs of implants for total hip replacement, one pioneer stands out, Sir John Charnley. He reported his experience with a steel femoral component and a plastic socket cup in He also revolutionized the field with the use of the self-curing acrylic cement used to fix the implants into the bone. These advances greatly improved the success rate of total hip replacement. The Charnley concepts of the hip implants are still in use today in large measure.
First, it is important to bear in mind that an artificial hip joint is not a normal hip. This is because a total hip replacement (you will see it referred to as THR) is not able to withstand repeated heavy impact, such as jumping and long-distance running. Tennis--singles, at least--jogging, and volleyball are not recommended. Swimming, golf and bike riding are safe.

2. Agenda Time Topic Speaker 0700-0730 Introduction
Total Joint Replacement in Chinook Health
TJR: What is it?
TJR: Indications
Kathy Sassa, Educator- Surgery
Preop Assessment Total Joint Clinic
Susan Folkerson, UM Unit 3B
The Surgical Process
Gail Kiefuik, OR RN
Break
Post-Op Care
Post-Op Orders
Tracey Kusk
Role of Physiotherapy & Occupational Therapy
OT/PT
Complications
Kathy Sassa
Lunch
Role of Pharmacy
Anticoagulation
Sheila Seely, Pharmacist
Discharge Planning
Kevin Elder, Charge RN Unit 4A
4A Mass Casualty Response Plan: Burns

3. INCIDENCE OF POST-OP COAGULATION COMPLICATIONS WITHOUT PROPHYLAXIS
THR DVT becomes symptomatic av. 17 days post-op
TKR DVT becomes symptomatic av. 6.7 days post-op
Incidence of DVT
Incidence of Fatal PE
Elective Knee Surgery
61%
5-12%
Elective Hip Surgery
51%
2.4%
Hip Fracture
44%
5.9%
General Surgery
25%
0.9%

4. Post-Operative Anticoagulation Therapy

5. Anticoagulation Therapy
The purpose of anticoagulant therapy is prevention & treatment of thromboembolic disorders
Anticoagulants DO NOT dissolve clots
Anticoagulants affect the balance between coagulation and fibrinolysis

6. Virchow’s Triad Identifies the three primary components
that contribute to pathological clot formation (i.e. DVT and PE)
TKR and THR pts
automatically have 2 of the 3 risks

7. CH Anticoagulation Guidelines
Based on CHEST Evidence-based guidelines
Reviewed periodically & approved by P&T (last revision 2001, currently under review)
Risk Assessment Tool
Prophylaxis Guidelines
Treatment Guidelines

8. CH Anti-coagulation Guidelines
Risk Assessment (Value Noted in Brackets):
Major orthopedic surgery of lower limbs:
total knee arthroplasty [ 5 ]
hip fracture [ 5 ]
total hip arthroplasty [ 4 ]
Extensive abdominal or pelvic surgery for malignancy [ 4 ]
Multiple trauma [ 4 ].
Acute spinal cord injury with paralysis [ 4 ]
History of DVT/PE [ 3 ]
Advanced age:
age over 70 years [ 3 ]
age 61 to 70 years [ 2 ]
age 41 to 60 years [ 1 ]
Stroke [ 1 ]
CHF [ 1 ]
MI [ 1 ]
Varicose Veins [ 1 ]
Obesity (greater than 20% of IBW) [ 1 ]
Congenital and acquired aberrations in hemostatic mechanisms [ 1 ]
General surgery lasting more than 30 minutes [ 1 ]
History of pelvic or long bone fracture [ 1 ]
Leg edema, ulcers, stasis [ 1 ]
Pregnancy or postpartum <1 month [ 1 ]
Inflammatory bowel disease [ 1 ]
Severe infection [ 1 ]
High dose estrogen use [ 1 ]
Other

9. Recommendations:
Low Risk [ 1 ]:
Early ambulation
Moderate Risk [ 2 to 3 ]:
Low Dose Unfractionated Heparin at 5000 IU sc bid OR
Intermittent pneumatic compression
Low Molecular Weight Heparin – Tinzaparin (Innohep) 3500 IU sc qd until patient is mobilized. Start 6 hours post-op.
High Risk [ 4 or more ]:
Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op.
If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg
Low intensity oral anticoagulation -- INR
Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

10. Guidelines for Treatment of Venous Thrombosis/Pulmonary Embolism:
Intravenous Unfractionated Heparin as per Weight Adjusted PE/DVT Heparin Protocol. OR
LMWH: Tinzaparin (Innohep) 175 iu/kg body weight sc q24h.or
Enoxaparin (Lovenox) 1mg/kg (max.100mg) sc q12h or
1.5mg/kg sc qd (max.180mg)
Pulmonary Embolism:
Intravenous unfractionated Heparin as per PE/DVT Heparin Protocol
LMWH: Tinzaparin 175iu/kg body weight sc q24H
Warfarin (Coumadin):
Should be started within 24 hours after initiation of Heparin or Low Molecular Weight Heparin and the dose adjusted in the usual manner.
Heparin or Low Molecular Weight Heparin should be continued for a minimum of five days.
INR should be in the therapeutic range (2 to 3) for two consecutive days prior to discontinuing heparin or Low Molecular Weight Heparin

11. High Risk (4 or more):
Low Molecular Weight Heparin -- Tinzaparin (Innohep) 4500 IU sc qd until patient is mobilized. Start 12 hours post-op.
If patient is less than 55kg use 3500 iu. If patient is greater than 70kg consider dosing at 75iu/kg
Low intensity oral anticoagulation -- INR OR
Intermittent pneumatic compression plus Low Molecular Weight Heparin or Low Dose Unfractionated Heparin.

12. Clotting Cascade Warfarin affects Factors II, VII, IX, X,
the factors involved in Vitamin K metabolism
Low Molecular Weight
Heparins (eg Tinzaparin)
inhibit Factor Xa and inactivate thrombin

13. Anticoagulant Example: Warfarin
Classification:
Vitamin K Antagonist
Monitoring:
INR, goal range
Indications:
Prophylaxis & treatment of:
Venous thrombosis
Pulmonary embolism
Atrial fibrillation with embolization
Embolization after MI, including stroke
Adverse Reactions:
Bleeding
Cramps & nausea
Dermal necrosis
Fever

14. Anticoagulant Example: Tinzaparin
Adverse Reactions:
Bleeding, anemia, rash, thrombocytopenia, ecchymosis
Dizziness, headache, insomnia
Edema
Constipation, vomiting, nausea, reversible increase in liver enzymes
Urinary retention
Heparin-Induced Thrombocytopenia (HIT)
Erythema at injection site, hematoma, pain, irritation
Fever
Classification:
Low Molecular weight Heparin
Monitoring: CBC and Creatinine baseline and twice weekly
Indications:
Prevention of DVT & PE after:
Abdominal surgery
Hip/knee surgery or replacement