“It’s not the plan that is important, it’s the planning”
– Dr. Graeme Edwards

The goal of preoperative planning is to outline the projected path of your care. This should not be looked at as an absolute but instead as a guide. The human body is unpredictable and you may deviate from this path, but by understanding the overall process you will never lose your way.

 

Coaches

The process of planning for and recovering from a joint replacement can be complex. There is lots of information given to you in a short amount of time and we expect that you digest all of it. You will also need some encouragement and physical assistance during the recovery. It is for all these reasons that you need a coach. It can be a spouse, friend or other family member. They just need to be reliable and trustworthy. Your coach will be asked to come with you to your preoperative class, be with you part of the time in the hospital, and stay at your house when you return after surgery for three days. Your coach is your advocate and should act in that fashion. They need to understand the process as well.

 

Preoperative Medical Evaluation

I want to be sure you are as healthy as possible for your surgery. To do this, I will send you to your primary doctor, any relevant specialists (i.e. cardiologist), and your dentist. I will give you medical clearance forms for each doctor and you need to see them in person to be evaluated. I will have you get some standard lab tests done, as a matter of routine, before your surgery.

We want your primary doctors to give us an estimate of your risk for joint replacement surgery. If they believe the surgery would be prohibitively dangerous for you then we will not proceed any further in the process. Otherwise, they will be sure to provide us with any pertinent suggestions regarding how to care for you during and after your joint replacement.

Your dentist is being asked to evaluate your gums and your teeth. There is a link between infections in the mouth and bacteria in the bloodstream. There is also a link between bacteria in your blood stream and infections in joint replacements. So we want to lower you risk of infection by identifying and treating any gum/tooth infections at least three weeks before surgery.

Once my office has received all of your medical clearance forms back, we will contact you to schedule a date for your surgery. Please feel free to contact us once your preoperative work is done so we can be sure the materials are sent to us in a timely fashion by your doctors and dentist.

 

Insurance

There are many different types of insurance these days and with all the recent changes it is very important for YOU to verify what the coverage is for your joint replacement surgery. We will get authorization from your insurance company if necessary but it will be up to you to confirm what share of the total cost you will need to pay.

 

Preparing for Home Care

We want your transition to home to be a smooth one. We contract with specific home health agencies and hand pick our physical therapists. We notify the home health agencies weeks in advance of your surgery so they have you on their list. When you go home after your surgery, the agency will be notified and you will see a nurse either the day you return home or the next morning. After your visit with the nurse, you will start working with the physical therapist at home.

 

Continuity of Care

It is important that your health information is accurate and complete both in our office and at the surgical facility where you will have your joint replacement performed. Expect to get a phone call from a nurse at the facility to discuss the details of your medical history (medications, allergies, etc…). This information will be shared with the anesthesiologist who will take care of you during surgery. You may also be seen in the preoperative clinic.

 

Infection Prevention

We take all reasonable precautions to reduce your infections risk. Part of this process is to have you wash with an antibacterial soap called Hibiclens. You will be given a prescription for this wash and asked to use it for three days prior to your surgery. It has been shown to reduce surgical infection rates.

 

The Night Before Your Surgery

Surgery is anxiety provoking and it is normal to feel nervous. Do your best to get plenty of sleep the night before your surgery. Be sure to shower the morning of your surgery but do not shave the surgical area. It is better, and cleaner, to let us shave the area with special clippers the day of your surgery.

 

Preference Card

Many patients will have special requests for food, medications, and more. It is impossible for us to remember these details for all our patients. This is why I ask you provide me with a preference card (a note card with your name and preferences on it) the morning of surgery. This way I will be sure to incorporate all of your special requests when entering your postoperative orders.

 

Medical Jargon

Frequently in medicine we forget that the words we use on a daily basis are not common to our patients. In order to understand the process, you will need to know those terms. One very important term is “catheter”. A catheter, by definition, is a flexible tube. We use lots of catheters in medicine and I want to describe a few you will be seeing during your joint replacement experience.

• Epidural Catheter – this is a very small, flexible tube that is placed by the anesthesiologist in your back and left in for a few days. Pain medications are given through this tube.
• Foley Catheter – this is a soft, flexible tube that is place through your urethra and into your bladder once you are numb or asleep for your surgery. It drains urine from your bladder so there is not any back up and possible damage to your kidneys.
• Intravenous (IV) Catheter – This is a thin flexible tube place in a vein of your arm through which medications are given during surgery and afterwards as needed.
• Drainage Catheter (hemovac) – This is a slightly more rigid but flexible tube that is inserted in your knee joint and exits the side of your knee to drain blood from your joint. It is removed about a day or two from your surgery.

 

The Day Of Surgery

Once you arrive at the facility a nurse will help you get into a gown and special cap. You will have an IV placed in your arm and you will talk to your anesthesiologist. Many people will ask you what surgery you are having and on what side. Don’t let this worry you. It is a way of preventing wrong side surgery. I will also ask you to show me the surgical site and I will sign that area. Once signed, that will be the side and site that is operated on. As the surgical time draws closer, you may be given some medications to help you relax.

 

In the Operating Room

You will be taken to the operating room on a wheeled bed by your nurse. You will be introduced to the surgical team and they may ask you again what you are having surgery on. You will have sticky EKG pads placed on your chest and a small clip placed on your finger:

You will also have placed on your arm a blood pressure cuff. When the blood pressure cuff first inflates it will squeeze your arm very tightly but then it learns your blood pressure and the squeezing is much reduced. After the anesthesiologist determines that your vitals are stable and they will give you some medications to relax and give you your spinal/epidural.

 

Anesthesia for Your Surgery

In general, if you are having a hip replacement the typical anesthesia is a spinal injection and medicine to make you sleep. The anesthesia for a knee replacement is typically a spinal injection with an epidural catheter or a spinal injection with a femoral nerve block. In both cases, you also get medicine to make you sleep.

Spinal Anesthesia – this procedure is performed by your anesthesiologist by having you sit on the edge of the operating room table and lean forward. They will place a small needle into the fluid around your spinal nerves and inject a numbing medication and a small amount of narcotic medication. This will give you excellent pain relief for about 12 to 24 hours.

Epidural Anesthesia – after the spinal injection is given a small catheter is threaded through the needle and into the epidural space in your back. This catheter is typically left in place for two days. Pain medications are dripped through the catheter to bathe your nerves and reduce your sensation of pain.

Femoral Nerve Block/Catheter – sometimes an injection is given to the top of your thigh on the front to numb the femoral nerve. This is called a femoral nerve block and it helps relieve pain in the front part of your knee. If a catheter is left in place where the injection was given, numbing medications can be dripped through the catheter and provide pain relief for up to three days.

After your spinal/epidural are administered, you will lie down on the operating room table and medications will be given to you to make you sleep. Next thing you know, you will be waking up in the recovery room.

 

Post Anesthesia Care Unit (PACU)

After completing your surgery on the operating room table, you will be moved to your bed and wheeled to the recovery room or PACU. You will be there for about one hour and then be transported to your room. The nursed in the PACU are very sensitive to changes in your vital signs. If you have any fluctuations in your blood pressure, heart rate or oxygen saturation they will keep you there longer.

 

The Orthopedic Floor

Once you are stable you will be taken to the orthopedic floor. The nurse will take your vitals assess your pain and administer medications as needed. You will have a small tube blowing oxygen gently into your nose to keep the amount of oxygen in your blood high as you completely recover from anesthesia. There will be tight stockings on both legs that are meant to prevent blood clots. There will also be wraps on your legs that will periodically, gently squeeze to help keep blood from settling in your legs. This helps reduce the chance of blood clots. You will also be asked to take deep breaths and cough to help improve your lung function.

You will remain on Main East until you leave the hospital. You will be provided a Patient Checklist by the nurse. If you don’t have one please ask your nurse to get you one and go over it with you. The post op check lists are meant to be a guide for both you and your nurse to be sure your care remains consistent regardless of the nurse taking care of you. If you find a deviation from the list that is not explained to your satisfaction, please call my office right away so I can clarify the situation.

The nurse will ask you to rate your pain on a scale from one to ten. Depending on your answer, they will give you a specific type and strength of pain medication. You must ask for your pain medications to get them. I typically use the following pain medications post-operatively:

• Intravenous (IV) Medications
• Fentanyl (narcotic)
• Morphine (narcotic)
• Oral Pain Medications
• Celebrex (anti-inflammatory)
• Lyrica (nerve pain medication)
• Oxcodone (narcotic- long and quick acting)
• Tylenol (non-narcotic)
• Tramadol/Ultram (non-narcotic)

 

Physical Therapy

There are few things more important in your recovery than physical therapy. Remember you are not sick after surgery. You need pain relief and physical therapy. The majority of your recovery time is spent not lying in bed but with a physical therapist. In the hospital the therapy is focused on performing functional activities so you can go home. They want to be sure you can safely get out of bed, to the bathroom, and into the shower. If you have stairs at home, they will work on stair climbing as well.

It is very important to time your pain medications for physical therapy. We would like to see you get your oral pain medications about one hour before physical therapy, if needed. This will allow you to get the maximal benefit from your therapy sessions. Please work with your nurse in the hospital to arrange the proper timing of your medications.

Please keep in mind that spinal and epidural anesthesia is very effective at relieving your pain but they do wear off eventually. You will notice that the first twenty-four hours after your surgery you will get very good pain relief from your spinal anesthetic. When it starts to wear off your pain will increase some so be sure to ask for pain medications. This same increase in pain for a short period of time (a few hours) also occurs when the epidural catheter is removed.

 

Possible Complications

Every surgical intervention has risks and a joint replacement is no exception. The four main complications we worry about are blood clots, urinary tract infections, constipation and infections:

• Blood Clots – the chance of getting a blood clot in the lower extremities is relatively high if you are not given preventative medications. These blood clots can also form in the lungs which is a potentially fatal complication. You will be treated for two weeks with a blood thinner called xarelto for hip replacement surgery and with aspirin for knee replacement surgery. There are exceptions to these rules that will be discussed on an individual basis. The symptoms of blood clots in the legs are pain and excessive swelling of the leg, ankle and foot. If the clot is in the lungs, you may experience chest pain, shortness of breath and/or a rapid heart rate. Please report any of these symptoms immediately.
• Urinary Tract Infections – the earlier we remove your foley catheter the lower your risk of having a urinary tract infection. We have to leave the Foley catheter in place when you have an epidural catheter in place. If you have a hip replacement then you can ask the nurse to remove the Foley catheter the day after surgery. We worry about urinary tract infections traveling through the blood to your replaced joint so we want to catch these infections early and give antibiotics as soon as possible. Some symptoms to watch out for with a urinary tract infection is burning with urination, four smelling urine and cloudy urine.
• Constipation – you are more likely to get constipated around the time of surgery. The anesthesia slows your bowels down and you are taking narcotics which do the same. The best way to prevent constipation is to judiciously use your narcotic pain medications, get out of bed and ambulate as much as possible, drink lots of water, and take the routine anti-constipation meds provided to you at the hospital.
• Infection – this is everyone’s concern and everyone’s responsibility. We will provide you with twenty-four hours of intravenous antibiotics which is the standard of care. Keep unwashed hands off your incision. Vigilance is often the best approach treating infections. If you notice increasing redness around your incision, drainage or other wound changes please contact us right away. Many superficial infections can be eliminated with a quick diagnosis and immediate antibiotics. If the infection goes deep into the joint, and if it is within six weeks of surgery, we will need to go back to surgery and wash out the joint replacing all the plastic parts. If it is after six weeks then it is necessary to remove the entire prosthesis, place an antibiotic spacer into the joint and then give six weeks of intravenous antibiotics. It is after the six weeks of antibiotics that we can consider going back to surgery and placing an revision stem.

 

Transition to Home

You will have a home health agency already assigned and ready to see you the day after you return home. You will be given their phone number so feel free to call them and ask for help that you might need. If you think you need a nurse to come out to your house and check on something, just call your home health agency. Once you are settled at home, you will have a physical therapist coming to work with you three times per week. Don’t forget to time your pain medications about one hour prior to physical therapy.
When you leave the hospital please be sure to take your belonging with you. This will include an ice machine and your white compression stockings. The stockings are to be worn while out of bed for two weeks after surgery.

You will need to have your Coach at home with you for three days straight. They can help you focus on your physical therapy, make meals, and help keep you safe at home. Please make use of your coach as long as you have them.

Once you have improved with home physical therapy to the point that the therapist deems you safe for outpatient care, please notify me and we will fax over a request to a facility of your choosing so you can start the outpatient portion of your rehabilitation. You will be in physical therapy for about six to twelve weeks following your surgery.

Your pain will reduce and your function will improve steadily through this process. I will want to check on you at two weeks and then six weeks after surgery. Depending on how you are doing, I will then see you at three months, six months and a year after surgery.

 

Life With Your New Joint Replacement

The activities that are encouraged after joint replacement are hiking, biking, swimming, doubles tennis and golf. We do not recommend that you try and run as it is not good for the prosthesis. Expect to have some mild, occasional pain in your joint for up to one year from surgery. Most people will forget they had the joint replaced between six months to a year after surgery.

 

Tips For Your New Knee Joint

We do not recommend kneeling on hard surfaces as it is bad for the prosthesis. If you enjoy gardening or need to work on your knees, you must buy a knee protector that has a hard outer shell and a thick inner lining to adequately protect your knee. Expect to hear some clicking (like a dime tapping on a marble surface) in your knee replacement. You should also expect to have occasional swelling in the replaced knee for up to one year from surgery.

 

Tips For Your New Hip Joint

Avoid excessive hip flexion exercises as you will strain the muscles in the front of your hip that are already sore from surgery. Also, I do not recommend doing straight leg raises with weights or against gravity for the first six weeks after surgery. You may have some numbness on the side of your thigh. This typically will improve over the first year after surgery. Also, please avoid any undergarments from running over your incision for the first six weeks after surgery.

 

Dental Appointments

I do not want you to go to the dentist, unless it is an urgent issue, for six months after your joint replacement surgery. It is my current recommendation that for the first two years after joint replacement surgery that you take one dose of an oral antibiotic before every dental procedure and/or cleaning. After the first two years, I allow each patient to decide whether they want to continue this practice or not. The most recent recommendations from a workgroup of the American Academy of Orthopedic Surgeons and the American Dental Association made vague recommendations regarding antibiotics before dental work and I believe this is a reasonable compromise.

 

Final Thoughts

It is very important to establish informed expectations for the process of recovery from a total joint replacement. By reading this article, you now know what to expect and what it takes to achieve an excellent outcome. Remember, you aren’t sick after a joint replacement surgery; you just need some pain medications and lots of physical therapy. You have more control over your outcome than you may think, take advantage of it.