The Perioperative Nurses Role in Table-Enhanced Anterior Total Hip Arthroplasty 3.

7
CASSENDRA A. MUNRO, RN, MSN, CNOR
New! Complete this CE activity online at aorn.org/CE

ursing care of the patient in surgery has naturally evolved along the same trajectory as the development of the technology used in the OR. Today, most surgical services use computer technology and an increasing amount of specialized equipment, making cross-training of personnel more challenging. With the addition of such technology comes the need for perioperative nurses to be more educated and knowledgeable about new equipment so they can effectively participate in caring for their patients. Orthopedics is no exception as advances in equipment and techniques change rapidly for many types of orthopedic surgical procedures (eg, new approaches for traditional joint replacement procedures). Performing the anterior approach for total hip arthroplasty (THA) with the patient in a supine position on an orthopedic OR table requires exposure, dislocation, and reduction of the hip joint. As with any surgical procedure, the circulating nurse is directly involved and an integral member of the surgical team. The nurse must have an understanding of the surgical intervention and a willingness to participate in this innovative approach.

There are distinct advantages to the anterior approach. The orthopedic table promotes ease of THA by increasing femoral access with adduction, extension, and proximal femoral hook placement. Improved exposure of the femur limits soft tissue trauma. The supine position and use of a radiolucent orthopedic table facilitates use of fluoroscopy. Patient selection criteria are not limited as they may be with the conventional lateral approach.1

HISTORY

OF

ANTERIOR APPROACH THA

Traditionally, most THAs have been performed with the patient in the lateral position and the use of the lateral or posterior approach on a standard OR bed. In 1947, Robert Judet, MD, performed the first anterior-approach THA in France using the Judet-Tasserit orthopedic table.2,3 This table provided unique ways to position a patient for

ABSTRACT
The anterior approach to total hip arthroplasty (THA), when performed with the patient in the supine position, is enhanced by the use of a radiolucent, orthopedic table. This technique has numerous advantages: enhanced intraoperative fluoroscopy because of the patients supine position on a radiolucent table, improved femoral exposure, and reduced soft tissue trauma. Criteria for patient selection is not limited as it may be for other arthroplasty techniques. The role of the perioperative nurse during an anterior THA is to ensure optimal function of the orthopedic table and provide safe patient care. A clear understanding of the surgical techniques used and the functions of the table are imperative. Key words: anterior total hip arthroplasty, anterior approach THA, radiolucent orthopedic table-enhanced THA. AORN J 90 (July 2009) 53-68. AORN, Inc, 2009.

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 69-70 and then completing the answer sheet and learner evaluation on pages 71-72. The contact hours for this article expire July 31, 2012.

AORN, Inc, 2009

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orthopedic procedures rather than having to place the patient in the standard lateral position. During a visit to France in 1981, Joel Matta, MD, of Los Angeles, California, observed this surgical technique as performed by Emil Letournel, MD, a former resident under Dr Judet. Dr Matta began to perform the technique in the United States in 1996 using the Judet-Tasserit orthopedic table. When production of this orthopedic table was discontinued in 2003, Dr Matta began to use the ProFX and Hana radiolucent orthopedic tables. With the advent of new, American-made tables, courses teaching the anterior technique for THA began to be offered to orthopedic surgeons in the United States, and interest in the procedure has grown (J. Matta, MD, founder and director, Hip and Pelvis Institute, St Johns Health Center; verbal communication; June 9, 2008). From November 1996 to November 2008, Dr Matta performed 1,723 primary, anterior-

approach THAs. According to Dr Mattas patient data, a mean time of 64 minutes and a median time of 85 minutes was required to perform the surgical procedure. Average blood loss has been estimated to be approximately 400 mL. Patients have had an average (ie, mode) length of stay (LOS) in the hospital of three days. The length of the incision is almost always 10 cm (Figure 1). Only three patients have experienced dislocation of their prostheses. The hip prostheses implanted included cemented, uncemented, and surface replacement THA (J. Matta, MD; unpublished data, August 2007). Among the 1,723 THAs, 494 consecutive, single-incision, anterior-approach THAs on an orthopedic table were performed by Dr Matta and several surgical fellows from September 1996 to September 2004. The surgical time of these 494 procedures averaged 90 minutes with an average LOS of four days. The majority of

Surgical Approaches for Total Hip Arthroplasty (THA)

he approaches for THA vary in the invasiveness of the hip musculature: (a) the posterior approach, (b) the lateral or tansgluteal approach, (c) the anterolateral approach, and (d) the anterior approach. a. The posterior approach (ie, Kocher-Langenbeck approach) splits the gluteus maximus muscle and detaches the posterior external rotator muscles (ie, the piriformis, obturator internus and externus, superior and inferior gemellus). b. The lateral or transgluteal approach (ie, Harding approach) splits the gluteus medius muscle and detaches the gluteus minimus and the anterior third of the gluteus medius muscles from the femur. c. The anterolateral approach (ie, Watson-Jones approach) is performed posterior to the tensor fascia lata and anterior to the gluteus medius and splits the hip deltoid muscle, which consists of the gluteus maximus and tensor fascia lata muscles. d. The anterior approach (ie, short Smith-Petersen and Hueter approach) does not split or detach muscles. This approach is performed over the tensor fascia lata, inside the tensor sheath, anterior and medial to the tensor fascia lata and lateral to the sartorius and rectus femoris muscles.

gluteus medius the gluteus minimus is under the gluteus medius gluteus maximus the obturator externus is under the inferior gemellus, which is under the obturator internus, which is under the superior gemellus, which is under the piriformis, which is under the gluteus maximus c a

tensor fascia lata the tensor fascia lata is under the tensor sheath sartorius the rectus femoris is under the sartorius

d
b

vastus lateralus biceps femoris

ilio tibial band patella

Illustration by Kurt Jones

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these patients were walking postoperatively without external support by 10 days. The postoperative complications reported included one infection, three dislocations, and one temporary nerve palsy.4 In general, other surgeons report that the muscle-sparing, anterior approach is versatile and has favorable long-term outcomes with minimal complications.5 In a study of 1,037 THAs, there were only 10 hip dislocations. The authors of that study corroborate that the procedure is safe with a low dislocation rate.6 Another study of 100 consecutive THAs concluded that this technique was safe and advantageous beFigure 1 Typical 10-cm incision for an orthopedic table-enhanced anteriorcause of reduced approach total hip arthroplasty procedure. blood loss, postoperative pain, and osteoarthritis, rheumatoid arthritis, traumatic LOS with more rapid rehabilitation.7 In a study of 195 THAs, a mini-posterior arthritis, and avascular necrosis. Furthermore, approach (MPA) performed on 96 patients there is less subcutaneous and deep fat to diswas compared to a direct, anterior approach sect over the hip joint using this approach. Pa(DAA) performed on 99 patients.8 The results tients requiring a revision whose hips were showed that patients who underwent the previously replaced using the lateral or posteDAA had a more rapid recovery of hip funcrior approach or who previously had posttion and gait ability. The average surgical time traumatic hip or pelvic surgery are not excludfor MPA was 100.4 minutes and for DAA was ed. This technique also is suitable for patients 104.7 minutes. The LOS was 30.4 days for who need bilateral hip replacements.4 MPA patients and 22.2 days for DAA patients. Patient advantages with the anterior apBlood loss averaged 426.9 mL during MPA proach include: procedures and 526.1 mL during DAA proce less postoperative pain;7 dures. There was one dislocation experienced shorter hospitalization;7 by a patient who had undergone MPA and a single, small incision;4 none reported for patients who had under no postoperative dislocation precautions gone DAA. According to the researchers, the and very low risk of postoperative dislocablood loss during DAA was greater because of tion;2,4,5,7 and technical difficulty with femoral preparation. immediate weight bearing on the surgical leg.2 A comparison of this study and Mattas statis- The procedure offers better access to the hip tics is shown in Table 1. because the hip is superficial in the supine position and subcutaneous fat is thinner at the PATIENT SELECTION AND ADVANTAGES incision site. Placing the patient supine also The anterior approach is a treatment option allows for better control of pelvic position. In for all patients requiring hip arthroplasty inaddition, the anterior approach preserves cluding patients suffering from the effects of pelvic and femoral muscle attachments, thus
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TABLE 1

Data for Different Approaches to Total Hip Arthroplasty

Table-enhanced anterior1 (N = 1,723) Surgical time
Mean Median 64 minutes 85 minutes 10 cm 104.7 minutes Not reported (NR) NR NR 22.2 days 526.1 mL 100.4 minutes NR NR NR 30.4 days 426.9 mL

Direct anterior2 (N = 99)

Mini-posterior2 (N = 96)

Length of incision Length of stay

Mode Mean 3 days NR 400 mL

Blood loss
Average

Number of dislocations
3 hips 0 hips 1 hip 1. J Matta, MD, Founder and Director, Hip and Pelvis Institute, St Johns Health Center, Santa Monica, CA; unpublished data; June 9, 2008. 2. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior approach with mini-posterior approach two consecutive series. J Arthroplasty. 2008 Jun 12. [Epub ahead of print].

reducing the risk for dislocation and allowing for a more rapid recovery.4

PREPARATION

FOR

THA

The circulating nurse assesses the function of the orthopedic table (Figure 2) before each procedure to ensure that it is working properly. This includes pressing the return to level button, which returns the base of the table to a neutral position and lowers the height of the table when the leveling process is complete. After testing both femoral lifts for function, the circulating nurse lowers the lifts and secures them in a locked position at the base of the lift where it attaches to the table. The nurse checks the femoral lift switch to ensure that the table has been lowered and leveled and confirms that both spars of the table are tightly locked. A spar is a radiolucent extension from the table base. The patients foot is placed in a secured boot that is locked with a swivel joint to a mount on the spar to allow mobility of the leg. Lowering the table and locking both

femoral lifts facilitates safe transfer of the patient to the table. Other procedure preparation responsibilities of the circulating nurse include ensuring that all necessary equipment is in the room and functioning properly. As with any orthopedic surgical procedure, in addition to the orthopedic table, a mobile x-ray viewing box is used. The nurse places the viewing box on the patients surgical side. When performing bilateral THAs, the perioperative nurse moves the viewing box to the opposite side after the first hip procedure is complete. The radiology technologist places the fluoroscopy unit (ie, C-arm) on the opposite side of the surgical site and situates the C-arm monitor on the opposite side but distal to the C-arm. The nurse ensures that an upper-body warming blanket, which is used for thermoregulation, is available and functioning, and that the warming unit is near the head of the OR bed. The autotransfusion device, which may be used particularly during bilateral THAs, and the electrosurgery unit (ESU) are

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hand control

femoral hook

perineal post

leg support

boot lock

fine traction handle

spar handle

lateral traction bar rotation lock

femoral lift spar femoral lift foot control gross traction lock spar lock

rotation handle

Figure 2 Orthopedic table used to place patients in the supine position for anterior-approach total hip arthroplasty. The model is seen with the right leg in flexion and external rotation. The purpose of this photograph is to identify the intricate table parts but does not necessarily reflect best practices in patient positioning. Photograph courtesy of Mizuho OSI, Union City, CA.

also positioned near the head of the bed. The room layout for a left THA is shown in Figure 3.

PREOPERATIVE ASSESSMENT
As part of performing a routine systematic and thorough review of the surgical patient, the perioperative nurse meets the patient and his or her family members in the preoperative holding area, verifies the patients identity, and performs an assessment. Preoperative assessment and physical findings provide an important baseline with which to compare postoperative assessment data. The nurses physical assessment of the patient scheduled for anterior THA includes assessing the patients current level of pain using a rating scale of zero to 10, identifying prior orthopedic injuries or mobility issues, identifying prior orthopedic procedures, and performing a skin assessment. The perioperative nurse also confirms the availability of blood products (eg, autologous or direct donor blood) and the completion of blood typing and cross-matching. He or she then verifies allergies and NPO status. To protect the patient during transfer and positioning, the nurse may need additional padding to support the patients arms. The

nurse alerts perioperative team members if the patient has any limited range of motion, previous injuries, mobility issues, or any other restrictions. This information alerts surgical team members to use caution when manipulating the table during the procedure or while rotating the patients leg. The nurse notes whether the patient has an ankle injury on the surgical side or has any implanted hardware so that he or she knows to take care when placing the ESU grounding pad and avoid placement areas that would allow electrical current to pass through that area. The perioperative nurse notes and documents any altered skin integrity. The perioperative nurse reviews the medical record for pertinent laboratory values and diagnostic studies (eg, chest x-ray, complete blood count) and ensures the presence of proper documentation. The anesthesia care provider meets the patient and obtains informed consent for anesthesia before transporting the patient to the surgical suite. After the patient and surgeon have initiated verification of the hip to be replaced, the circulating nurse confirms this information by reviewing the surgical consent, checking how the procedure is scheduled, conferring with the surgeon, and confirming all the information with the patient.
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anesthesia cart autotransfusion device

anesthesia care provider forced-air warming unit electrosurgical unit

radiology technologist

fluoroscopy unit

x-ray viewing box scrub person back table

assistant
flu o m ros on co ito py r

surgeon

Mayo stand

assistant

circulating nurse

second circulating nurse

Figure 3 Setup of the OR for a left anterior approach total hip arthroplasty. Scrubbed personnel are in sterile blue scrub gowns; unscrubbed personnel are in green scrub attire.

After identifying the correct surgical site, the nurse compares that information with the surgical site marking performed by the surgeon. The nurse resolves discrepancies in this information before leaving the preoperative holding area with the patient. Patient education, which is provided by the perioperative nurses working in the preoperative admissions area and in the OR, includes care that will be provided during surgery, postoperative pain management, signs and symptoms of infection, and the recovery process (see Patient Education Sheet). The nurse explains the intraoperative and immediate postoperative periods and assesses the patients level of understanding. The nurse

gives the patient and family members an opportunity to ask questions and express fears or concerns before transporting the patient from the preoperative holding area to the OR. The nurse then develops a plan of care specific for this patient and the proposed procedure (Table 2).

INTRAOPERATIVE CARE
When the circulating nurse, surgeon, and anesthesia care provider have completed their patient assessments, the circulating nurse transports the patient to the OR and assists the anesthesia care provider in applying monitoring equipment. The anesthesia care provider anesthetizes the patient on the transport cart before the patient is moved to the orthopedic table. Before transfer, the perioperative nurse places the

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Patient Education

Anterior-Approach Total Hip Replacement1

Overview The hip is a ball-and-socket joint made up of the ball (femoral head) and socket (acetabulum). As you get older, you may suffer from diseases of the hip (arthritis) or injuries (broken hip). If you suffer from pain and poor hip movement, it may be difficult for you to perform normal activities of daily living and physical exercise. You may need a total hip replacement (THR), which is also called total hip arthroplasty. Advantages to the anterior approach Traditionally, THR surgery is performed with the patient in the lateral (side-lying) position. A newer approach is to perform the procedure with the patient supine (lying on his or her back). There are numerous advantages to surgery in this position, such as spending less time in the hospital and recovering faster because the hip is replaced without taking the muscles off the pelvis or femur; less risk of the hip dislocating (coming out of the socket) after surgery and no limit to hip movement; being able to have both hips replaced at one time, if needed, instead of having to undergo two surgeries because you do not have to be turned over to get to the second hip; having a smaller incision; and being able to have x-rays taken during surgery to make sure the artifical hip is in the correct position rather than waiting to have x-rays taken after surgery. Risks of undergoing a hip replacement As with any THR surgery, there are risks. Possible complications of anterior THR surgery include hip dislocation, infection, injury to nerves or blood vessels, and need for the surgery to be redone. How is anterior approach THR performed? Your surgeon, anesthesia care provider, and OR nurse will meet you in the preoperative area to make sure you are ready for surgery and to answer any questions. You will then be taken to the OR on a stretcher. After you go to sleep with anesthesia, the OR team will put you into the supine position on the special orthopedic OR bed. This bed allows the OR nurse to move your leg during the surgery, which helps the surgeon remove your old hip and put in the new hip implants. After surgery, the OR team will move you to your recovery bed and take you to the recovery room. Postoperative care Typically, patients stay in the hospital 1 to 3 days after undergoing anterior THR of one hip or 2 to 5 days after having both hips replaced. While you are recovering from surgery, you may feel tired or uncomfortable, not have a bowel movement for several days, or lose your appetite or have nausea or vomiting. You will have no hip movement restrictions and will have physical therapy several times a day. What happens after I go home? When you are discharged from the health care facility, you will continue with physical therapy to regain mobility and normal activity; may shower but should not immerse the incision in water (bath, pool) until two weeks after surgery; may have some thigh soreness, swelling, or bruising but these should gradually improve; and may have clicking in your new hip that will go away as the swelling decreases and your muscles tighten. Call your physician immediately if you experience any of the following postoperative complications: swelling or excessive bleeding from the surgical site; coldness or numbness in your legs; sudden weakness or dizziness; or back, chest, abdominal, or groin pain.
1. Matta J. Hip replacement surgerythe anterior approach: what you need to know. Hip & Pelvis Institute, Saint Johns Health Center. Santa Monica, CA. http://www.hipandpelvis.com. Accessed May 28, 2009. Revised with permission. artificial joint

normal hip joint

hip joint affected by osteoarthritis

Illustration by Kurt Jones

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TABLE 2

Nursing Care Plan for a Patient Undergoing Anterior-Approach Total Hip Arthroplasty
Diagnosis
Risk for impaired skin integrity

Nursing interventions

Interim outcome statement

The patient is free from signs and symptoms of injury related to transfer/ transport on discharge from the OR.

Outcome statement
The patient is free from signs and symptoms of injury related to transfer/ transport. The patient is free from signs and symptoms of injury related to positioning. The patient is free from signs and symptoms of injury caused by extraneous objects.

Transports according to individual needs. Evaluates for signs and symptoms of skin and tissue injury as a result of transfer or transport.

Risk for perioperative positioning injury

Identifies physical alterations that require additional precautions for procedure-specific positioning. Verifies presence of prosthetics or corrective devices. Positions the patient. Evaluates for signs and symptoms of injury as a result of positioning. Confirms identity before the operative or invasive procedure and verifies operative procedure, surgical site, and laterality. Implements protective measures before the operative or invasive procedure. Applies safety devices. Implements protective measures to prevent skin/tissue injury due to mechanical sources. Performs required counts. Uses supplies and equipment within safe parameters. Records devices implanted during the operative or invasive procedure. Maintains continuous surveillance. Evaluates for signs and symptoms of physical injury to skin and tissue. Assesses susceptibility for infection. Implements aseptic technique. Classifies surgical wound. Performs skin preparations. Protects from cross-contamination. Minimizes the length of invasive procedure by planning care. Initiates traffic control. Administers prescribed prophylactic treatments. Encourages deep breathing and coughing exercises. Administers care to wound site. Monitors for signs and symptoms of infection. Assesses knowledge regarding wound care and

The patients peripheral tissue perfusion is consistent with preoperative status at discharge from the OR. The patients skin condition, other than incision, is unchanged between admission and discharge from the OR. The patient is free from unplanned retained objects after surgery.

Risk for injury

Risk for infection and knowledge deficit regarding wound care

The patient is afebrile and free from signs and symptoms of infection. At the time of discharge, the patient verbalizes signs and symptoms of wound infection to report immediately to the surgeon. The patient and family members

The patient is free from signs and symptoms of infection. The patient demonstrates knowledge of wound management.

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TABLE 2 (CONTINUED)

Nursing Care Plan for a Patient Undergoing Anterior-Approach Total Hip Arthroplasty
Diagnosis Nursing interventions Interim outcome statement
demonstrate correct technique for applying a wound dressing at time of discharge. The patient verbalizes control of pain. The patient participates in management of pain control before and immediately after surgery. The patient and family members verbalize realistic expectations regarding discomfort after surgery. The patient verbalizes the sequence of events to expect before and immediately after surgery and states realistic expectations regarding recovery from procedure. The patient demonstrates and/or reports adequate pain control throughout the perioperative period and demonstrates knowledge of pain management.

Outcome statement

Acute pain

phases of wound healing. Provides instruction about wound care and phases of wound healing. Evaluates responses to instruction about wound care and phases of wound healing. Assesses pain control. Identifies cultural and value components related to pain. Implements pain guidelines. Collaborates in initiating patient-controlled analgesia. Implements alternative methods of pain control. Provides pain management instruction. Evaluates response to pain management interventions and instruction.

Anxiety and compromised family coping

Notes sensory impairments. Identifies barriers to communication. Determines knowledge level. Assess readiness to learn, identifies psychosocial status, and assesses coping mechanisms. Explains expected sequence of events. Implements measures to provide psychological support. Provides status reports to family members. Elicits perceptions of surgery. Evaluates psychosocial response to plan of care and to instructions. Provides instruction based on age and identified need. Identifies expectations of home care. Evaluates environment for home care. Evaluates response to instruction.

The patient demonstrates knowledge of the expected responses to the operative or invasive procedure.

Impaired physical mobility, ineffective therapeutic regimen management, and knowledge deficit regarding the rehabilitation process

The patient and family members verbalize realistic expectations regarding rehabilitation after surgery. The patient describes the prescribed rehabilitation regimen to follow immediately after discharge from the facility.

The patient participates in the rehabilitation process.

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patients feet into boots that will be fastened to the table spars. The nurse may apply pneumatic compression sleeves to both of the patients legs to reduce the risk of deep vein thrombosis. All surgical team members actively participate in a surgical time out to verify the correct patient, correct site and laterality, and correct surgery and also ensure that all equipment and supplies, including implants, are immediately available. POSITIONING. Surgical team members (eg, surgeon, fellow, resident, assistant, circulating nurses) help transfer the patient to the orthopedic table and assist with positioning. If the team members are temporarily unavailable, the circulating nurse recruits assistive personnel and, with the help of the anesthesia care provider, transfers the patient to the orthopedic table and positions him or her, assessing for pressure points and body alignment. The surgeon ultimately is responsible for checking the final position and ensuring that it is acceptable. Team members position the patient close to the perineal post, which is used to accommodate traction on the leg. The nurse places both the patients arms on arm boards extended at less than 90-degree angles to the bed. After placing a support under the patients nonsurgical leg, the nurse places both of the patients legs in slight internal rotation (Figure 4). The nurse then assesses the patient for possible pressure points and places additional padding to support the patient or relieve pressure as needed. SURGICAL SKIN PREP. The surgical prep site for a THA spans from the patients midline abdomen laterally to the level of the bed, distal to the middle of the thigh, and proximal to the navel (Figure 5). The surgeon may want the circulating nurse to expand proximal exposure above the patients navel to ensure that the anterior superior iliac spine is included in the prep. This surgical approach allows bilateral THA preps to be conveniently performed with a single preparation and draping of both hips. After the prep, the nurse applies a small amount of gross traction, as well as a mild amount of abduction, before locking the table in position. This position enhances the landmarks of the hip for surgical exposure (Figure 6). The nurse positions both of the patients legs similarly, as the nonsurgical side will be

Figure 4 The nurse attaches the boots on the patients legs in slight internal rotation to the table spar.

Figure 5 Typically, the patient is prepped from the midline abdomen laterally to the level of the bed, distally to the middle of the thigh, and proximally to the navel.

Figure 6 Hip landmarks are identified for surgical exposure.

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used as a radiographic reference. The circulating nurse confirms correct positioning with the physician before the scrub person applies the surgical drapes because variations of anatomy and physique may require alterations. It is also important that the circulating nurse ensure that each table control has been locked (ie, the boots at the junction of the attachment to the bed, the swivel joint, the rotation of the legs, the gross traction for both spars). FLUOROSCOPY. Anterior to posterior x-rays are hard to obtain when the patient is in the lateral position because hip alignment may not be symmetric. Most traditional THAs are performed in the lateral position; therefore, the surgeon orders x-ray films to be obtained after surgery in the postanesthesia care unit (PACU) to confirm component placement. The patients supine position on the radiolucent orthopedic table during an anterior approach THA facilitates the use of fluoroscopy during the surgery. Intraoperative use of fluoroscopy not only facilitates accurate component position, but also greatly reduces the risk of a second procedure for exchange of implants when postoperative x-rays are taken after the patient has left the surgical suite. The surgeon compares radiographic landmarks to confirm equal leg length and correct offset during surgery before wound closure. Dr Matta calculated an average fluoroscopy time of 24.9 seconds on 102 of his most recent arthroplasties (J. Matta, MD; unpublished data, August 2007).5 Published reports of fluoroscopy time for these procedures are not available currently, and not all surgeons use fluoroscopy during these procedures. Annual radiation exposure limits established by the Nuclear Regulatory Commission are set at a total effective dose equivalent of 5 roentgen equivalent units (REMs) for radiation workers and 0.1 REMs for members of the public.9 As with any procedure in which fluoroscopy is used, the surgical team should adhere to recommended safety measures to reduce their exposure to ionizing radiation. AORNs Recommended practices for reducing radiologic exposure in the perioperative practice setting, states, The greater the dis-

Surgical team members should adhere to recommended safety measures to reduce their exposure to ionizing radiation, such as using distance and shielding to decrease the amount of radiation exposure and consistently using dosimeters to monitor radiation risks.

tance an individual or target is from the source of radiation, the less the amount of radiation exposure.10(p1000) Radiation exposure can be reduced by one-quarter when the distance from the source is doubled.10 Radiation exposure time is minimal but the use of distance and shielding and the consistent use of dosimeters can reduce radiation risks. The radiology technologist positions the fluoroscopy unit on the opposite side of the surgical team next to the nonsurgical hip and perpendicular to the patient. The circulating nurse also places a thyroid shield on the patients neck for radiation exposure protection. According to Dr Mattas data, the ionizing radiation exposure for both the patient and surgical team during the procedure is minimal (J. Matta, MD; unpublished data, August 2007). Use of the fluoroscopy unit and the orthopedic table are based on the surgeons preference. The surgeon may choose not to use fluoroscopy or may limit its use throughout the procedure. The surgeon may also decide to perform the surgery without the use of the orthopedic table. The anterior approach to THA performed without the use of the orthopedic table increases the difficulty of access to the femur, and patient selection is more limited because surgeons must avoid operating on
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heavy and/or muscular patients because of the difficulty of accessing the femur.

SURGICAL PROCEDURE

AND TABLE

OPERATION

To better anticipate the circulating role during an orthopedic table-enhanced procedure, the nurse must have a thorough understanding of what occurs (Table 3). Understanding and using proper body mechanics during table manipulation is essential to prevent injury to both the patient and the circulating nurse. More than one circulating nurse is required during this procedure. One nurse stands at the foot of the orthopedic table throughout the procedure to perform needed table operations, always giving direct attention to the surgeon and to the progress of the procedure. Another circulating nurse is required to provide direct patient care and meet all additional circulating responsibilities during the procedure. The circulating nurse operating the table provides individualized care to ensure safety of the patient during orthopedic table-enhanced THA. For instance, osteopenic bone is at higher risk of fracture and the force of external rotation may lead to a tibial or ankle fracture. The force used on a patient with osteopenia, therefore, is more gentle. The nurse assigned to assist the surgical team performs all table operations under the direction of the surgeon throughout the procedure using the table controls (eg, fine traction, gross traction, rotation) on the foot of the orthopedic table, which are not within the sterile field (Figure 7). The nurse does not rotate the patients leg to the extent of his or her range of motion, but rather stops rotation when resistance is met. The surgeon directs the circulating nurse regarding the amount of rotation to apply based on the amount of resistance met and will direct the nurse if further rotation is indicated. This rotation can be applied safely with clear communication and direction from the surgeon combined with careful consideration of the patients physical status. The nurses preoperative assessment plays a large role in this aspect of the procedure. Before the beginning of the procedure, the surgeon and the circulating nurse who performed the preoperative physical assess-

ment on the patient discuss the patients condition and the individualized plan of care, including the degree of rotation anticipated. As table movements are being performed, the nurse communicates with the surgeon regarding the extent of force being used and, if additional exposure is requested, the nurse describes the force being used and resistance, if any, that he or she feels. The surgeon removes the femoral head with assistance from the nurse, who uses the table controls at the foot of the table to manipulate the degree of fine traction and external rotation. Several turns of fine traction control while the gross traction mechanism is still locked creates a space between the femoral head and the acetabulum where the surgeon inserts a bone skid (ie, flat instrument with a dip/scoop on the distal ends in which to distract the femoral head from the acetabulum). The circulating nurse then releases the fine traction almost entirely by reversing the turns. For example, if three turns of traction were initially applied, then two turns in reverse may be sufficient. The circulating nurse then externally rotates the hip approximately 20 degrees to allow the surgeon to insert a corkscrew, after which both the surgeon and circulating nurse apply further external rotation to dislocate the hip. The circulating nurse may apply fine traction to distract the neck osteotomy and facilitate the surgeons extraction of the femoral head. The surgeon may cut the femoral head in situ without dislocation, but this may make extraction more difficult. While the surgeon prepares the acetabulum, the circulating nurse externally rotates the leg approximately 45 degrees and maintains a slight amount (ie, one turn) of fine traction to provide better exposure. The surgeon may initiate fluoroscopy at this point to confirm depth of reaming and prosthesis insertion. After the acetabular components have been inserted, the circulating nurse must position the patient for femoral preparation. After unlocking the gross traction on the spar, the circulating nurse applies some internal rotation to assist the surgeon in posterior placement of the femoral hook. The circulating nurse then

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TABLE 3

Surgeon Preference Card for Orthopedic Table-Enhanced Total Hip Arthroplasty

Medications
Preoperative antibiotic: 1 g vancomycin IV Irrigation and glove-rinse solution: 1 L normal saline with 50,000 units bacitracin and 500,000 units polymyxin but before transferring patient to table.

Place patient in supine position on the

Prep

orthopedic table with padded arm boards

Instruments
Total hip arthroplasty sets Acetabular reamers and osteotome set Power drill and battery Anterior traction set

2% chlorhexidine gluconate/70% isopropyl alcohol solution

Draping
Benzoin Hand towels U-shaped, antimicrobial surgical drape Incise drapes 4 3/4 sheets (x 2 distal, x 2 proximal) Full sheet x 2 1 x-large and 1 regular Mayo cover Plastic split sheet x 2: 1 proximal, 1 distal Paper split sheet x 2: 1 proximal, 1 distal

Sterile supplies
Selected implants and trial sizers Total hip arthroplasty pack #1 polyglycolic acid suture CT-2 (anterior capsule) #1 polyglycolic acid suture CT-1 (deep fascia) 2-0 polyglycolic acid suture CT-2 (fascia) 3-0 poliglecaprone 25 suture PS-1 (subcutaneous closure)

Dressings
Liquid skin adhesive Self-adhesive wound approximating strips Nonadherent dressing pad and 4 x 4 gauze Soft, cloth surgical tape

Room setup and equipment settings

Electrocautery machine (settings: 60/60) x-ray view box Fluoroscopy unit and monitor Sequential compression device (SCD) leggings and unit Forced-air warming unit (109.4 F/43 C) and upper-body blanket Autotransfusion device (bilateral THAs only) Room furniture Double-decker back table Small back table Double ring stand x 1 Single ring stands x 4 1 jumbo and 1 regular Mayo stand Steps: place 1 under the OR bed, 1 near arm board on surgical side if observer present

Terms for using the orthopedic table

Traction on

Hair removal
Remove patients hair at surgical site, only if necessary. Perform hair removal in preoperative area, if at all possible, using tape to contain hair.

Position
induction of anesthesia but before patient is transferred onto orthopedic table Wrap perineal post with soft roll Wrap patients feet with soft roll, if he or she is not wearing socks Apply SCDs after putting on the table boots

Insert indwelling urinary catheter after

3 turns of fine traction (more if requested); count out loud. Traction off 2 turns of fine traction; count out loud. External and internal rotation Used for femoral head removal and acetabular reaming. Twist knob once to lock and unlock. Unlock rotation Allows surgeon to guide the foot position. Lock when the surgeon lets go of the foot. Keep holding the rotation handle while the surgeon is positioning, but allow him to move the patients leg. Externally rotate, unlock the gross traction, extend and adduct the patients leg Used for femoral broaching. Place leg under nonsurgical leg on the floor. No need to lock spar when extended. Flex the hip Bring leg up level with the nonsurgical leg. Reduce the hip Internally rotate the leg at the same time as pulling gross traction. Dislocate the hip Externally rotate the leg at the same time as pulling gross traction.

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Figure 8 The surgeon compares fluoroscopic views of both hips and with printed images on transparency film of the replaced total hip.

Figure 7 Table controls on the foot of the orthopedic table are not within the sterile field.

externally rotates the patients leg approximately 90 degrees, to the extent of the patients maximum range of motion as directed by the surgeon. The circulating nurse then extends the patients hip with the table spar positioned to the floor and adducted so the patients leg is crossed under the other spar. The circulating nurse must ensure that the gross traction mechanism is unlocked before extending the hip to prevent stretching of the femoral nerve. To further expose the femur, the surgeon raises the femoral lift after he or she has placed the femoral hook into position. After the surgeon inserts the trial components and removes the femoral hook, the circulating nurse flexes the hip and returns it to its original neutral position. The circulating nurse reduces the hip with simultaneous application of internal rotation and gross traction by manually pulling and rotating the gross traction handle of the table. The amount of pulling should be just enough to accommodate reducing the hip. A gentle push of the gross traction handle after reduction is achieved ensures that no traction tension remains.

The surgeon obtains fluoroscopic views of both hips and compares them with printed images on transparency film (Figure 8). If needed, the surgeon may request abduction and adduction of the spars to match the alignment of both hips. The circulating nurse should identify the last position of the spars placement so he or she can readjust the spars to this position when the hip is returned to a neutral position. To dislocate the hip for removal of the trial components, the circulating nurse externally rotates the hip and applies gross traction. This is done simultaneously and similarly to the reduction of the hip. The surgeon reinserts the femoral hook, after which the circulating nurse externally rotates the leg and extends and adducts the patients hip. Reduction and dislocation occurs as often as is necessary for the surgeon to insert trial components and determine the best component sizes for the patient. After the surgeon inserts the components (Figure 9), the circulating nurse performs a reduction of the hip (ie, adjusts the spars to the desired position) and ensures that flexion and rotation are the same for both of the patients hips. The radiology technologist takes and prints final views via fluoroscopy.

POSTOPERATIVE CARE
The circulating nurse reassesses the circulation of both of the patients feet and the condition of the skin around the perineal area after the procedure to ensure that no injury has occurred

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Figure 9 The surgeon inserts the femoral hook and retractors to insert the components during a resurfacing total hip arthroplasty (ie, surface replacement). The femoral head shown is larger than the implant for a total hip replacement.

seven to 10 days after surgery. For those patients who continue to use aids beyond the seven- to 10-day period, use of these aids is usually discontinued after two to three weeks (J. Matta, MD, e-mail communication, June 10, 2008). There are no dislocation precautions for the patient who has undergone an anterior THA. This eliminates the postoperative need for an abduction pillow, a traction sling, a raised toilet seat, or a hip cushion. The use of sequential compression devices on both legs during the postoperative period helps prevent deep vein thrombosis. Typically, a patient is discharged home from one to three days after undergoing a unilateral anterior THA and two to five days after a bilateral procedure.

CONCLUSION
before helping to transport the patient to the PACU. If the patient has not been given a regional anesthetic and is able to obey commands, the nurse assesses the mobility of the patients lower extremities through passive range of motion. The circulating nurses handoff communication includes the surgery performed, outcomes related to the procedure, the patients allergies, and the patients current condition. The PACU receiving nurse verifies the information received and asks the circulating nurse questions as needed. The location of the incision and lack of muscle dissection in a patient who has undergone anterior THA decrease the patients postoperative pain, allow for early ambulation, and reduce the risk of dislocation. Proper postoperative wound care reduces the risk of infection. Physical therapy begins within hours after surgery. Activity is not restricted because the patient can bear weight immediately, and activity is increased according to the patients tolerance level. Many patients use a walker to begin ambulating with assistance on the same day of their surgical procedure or the following day, depending on the time of day that the surgery was performed, and most patients can walk with a cane by the time they are discharged. Some patients may use an assistive device, such as a walker or crutches, while others do not require any assistance at discharge. Generally, most patients are walking without aids within The use of an orthopedic table enhances the surgeons ability to perform an anterior approach for THA. The supine position of the patient and the radiolucency of the orthopedic table create ideal conditions for the use of fluoroscopy, which increases accuracy of component placement and ensures matching leg length. The perioperative nurse plays a vital role in the successful execution of the orthopedic tableenhanced, anterior-approach THA in the supine position. Under the direction of the surgeon, the circulating nurse is responsible for maneuvering the orthopedic table to provide acetabular and femoral exposure to accommodate hip replacement. These table functions have multiple benefits that appeal to surgeons and patients, including decreased soft tissue trauma; less pain after surgery; shorter hospitalization; a single, smaller incision; and a very low risk of postoperative hip dislocation. An understanding of the complete anterior approach procedure, proper technique while operating the orthopedic table, and clear communication between members of the surgical team help minimize complications. Coordination between the surgeon and perioperative nurse, as always, is imperative. Acknowledgement: The author thanks Joel Matta, MD; Founder and Director, Hip and Pelvis Institute, Saint Johns Health Center, Santa Monica, CA, for allowing use of his data and consulting on the article.
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Editors note: ProFX and Hana are registered trademarks of Misuho OSI, Union City, CA. Publication of this article does not imply AORN endorsement of companies or products mentioned herein.

REFERENCES 1. Matta JM, Ferguson TA. The anterior approach for hip replacement. Orthop. 2005;28(9):927-928. 2. Matta JM. The anterior approach for total hip arthroplasty: background and operative technique. August 2005. Hip and Pelvis Institute. http://www. hipandpelvis.com/patient_education/totalhip/index .html. Accessed April 28, 2008. 3. Matta JM. The anterior approach for total hip arthroplasty: background and operative technique. In: MIS Techniques in Orthopedics. Scuderi GR, Tria AJ, Berger RA, eds. New York, NY: Springer; 2007:121-140. 4. Matta JM, Shahrdar C, Ferguson TA. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. December 2005;441:115-124. 5. Kennon RE, Keggie JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85-A(Suppl 4):39-48. 6. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: a

study of 1037 total hip replacements. Clin Orthop Relat Res. September 2004;426:164-173. 7. Rachbauer F. Minimally invasive total hip arthroplasty via direct anterior approach [In German]. Orthopade. 2005;34(11):1103-1110. 8. Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior approach with mini-posterior approach two consecutive series. J Arthroplasty. 2008 Jun 12. [Epub ahead of print]. 9. Part 20standards for protection against radiation. United States Nuclear Regulatory Commission. http://www.nrc.gov/reading-rm/doc-collec tions/cfr/part020/. Accessed May 19, 2009. 10. Recommended practices for reducing radiological exposure in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:455-466.

Cassendra A. Munro, RN, MSN, CNOR, is a perioperative clinical nurse specialist at Saint Johns Health Center, Santa Monica, CA. Ms Munro has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

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Examination
PURPOSE/GOAL

3.7

The Perioperative Nurses Role in Table-Enhanced Anterior Total Hip Arthroplasty

To educate perioperative nurses about caring for patients undergoing orthopedic table-enhanced anterior-approach total hip arthroplasty (THA).

BEHAVIORAL OBJECTIVES
After reading and studying the article on anterior-approach THA, nurses will be able to

1. identify advantages of performing THA using the anterior approach with a radiolucent
orthopedic table,

2. discuss nursing care of a patient who is undergoing anterior THA, 3. describe the anterior THA procedure, and 4. explain the nurses role in operating the orthopedic table used for anterior THA. QUESTIONS
1. Advantages to the orthopedic tableenhanced anterior approach for performing THA include 1. improved ability to use fluoroscopy. 2. limited soft tissue trauma. 3. improved exposure of the femur. 4. increased femoral access. a. 1 and 4 b. 2 and 3 c. 1, 3, and 4 d. 1, 2, 3, and 4 2. One advantage for patients who undergo THA using the anterior approach is immediate weight bearing on the surgical leg. a. true b. false 3. The perineal post is used to a. prevent perineal nerve injury. b. accommodate traction on the leg c. provide a landmark during fluoroscopy. d. prevent exposure of patients genitals. 4. Intraoperative use of fluoroscopy 1. facilitates accurate component position. 2. reduces the risk of a second procedure for implant exchange. 3. unnecessarily exposes the patient to large quantities of ionizing radiation. a. 1 and 2 b. 1 and 3 b. 2 and 3 c. 1, 2, and 3 5. More than one circulating nurse is required during table-enhanced THA. a. true b. false 6. The nurses preoperative assessment helps determine the degree of hip rotation anticipated. a. true b. false 7. The circulating nurse uses the table controls at the foot of the table to 1. manipulate the degree of fine traction and external rotation to create a space between the femoral head and the acetabulum. 2. release the fine traction to create the space to insert the skid. 3. externally rotate the hip to allow the surgeon to insert a corkscrew.

AORN, Inc, 2009

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Examination

4. apply further external rotation to dislocate the hip. 5. apply fine traction to distract the neck osteotomy and facilitate the surgeons extraction of the femoral head. 6. externally rotate the leg and maintain a slight amount of fine traction to provide better exposure. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 8. The location of the incision and lack of muscle dissection in a patient who has undergone anterior THA 1. allows for early ambulation. 2. decreases the patients postoperative pain. 3. necessitates use of an adduction pillow. 4. reduces the risk of dislocation. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 9. Generally, most patients are walking with-

out aids within _________________ days after surgery. a. one to two b. two to three c. five to seven d. seven to 10 10. When discharging a patient who has undergone THA from the health care facility, the nurse should instruct the patient that he or she 1. may have some thigh soreness, swelling, or bruising, which is normal and will gradually improve. 2. may shower but should not immerse the incision in water until two weeks after surgery. 3. should call the surgeon if there is clicking in the new hip, which is not normal. 4. will continue with physical therapy to regain mobility and normal activity. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

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Answer Sheet
The Perioperative Nurses Role in TableEnhanced Anterior Total Hip Arthroplasty
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

3.7
Event #09112 Session #1087

AORN Customer Service

c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212.
Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 3.7 continuing education contact hour (222-minute) program. ______ 4. Enclose fee if information is mailed.
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A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion.

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3.7

Learner Evaluation

The Perioperative Nurses Role in Table-Enhanced Anterior Total Hip Arthroplasty

his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

PURPOSE/GOAL
To educate perioperative nurses about caring for patients undergoing orthopedic tableenhanced anterior-approach total hip arthroplasty (THA).

OBJECTIVES
To what extent were the following objectives of this continuing education program achieved? 1. Identify advantages of performing THA using the anterior approach with a radiolucent orthopedic table, 2. Discuss nursing care of a patient who is undergoing anterior THA. 3. Describe the anterior THA procedure. 4. Explain the nurses role in operating the orthopedic table used for anterior THA.

CONTENT
To what extent 5. did this article increase your knowledge of the subject matter? 6. was the content clear and organized? 7. did this article facilitate learning? 8. were your individual objectives met? 9. did the objectives relate to the overall purpose/goal? c. the AORN Journal web site. 15. What factor most affects whether you take an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________ __________________________________________
AORN, Inc, 2009

TEST QUESTIONS/ANSWERS
To what extent 10. were they reflective of the content? 11. were they easy to understand? 12. did they address important points?

LEARNER INPUT
13. Will you be able to use the information from this article in your work setting? a. yes b. no 14. I learned of this article via a. the AORN Journal I receive as an AORN member. b. an AORN Journal I obtained elsewhere.

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