Joint Academy - North Star Orthopaedics

Joint Academy - North Star Orthopaedics

Joint Academy

Patient Education

(330) 971-7258 | westernreservehospital.org

Dear Patient;

Thank you for choosing Western Reserve Hospital (WRH). Our goal is to provide you with expert care, a safe experience and to prepare you for your return home.

This book is provided as a resource for you and your family. It will guide you through your joint replacement. It is yours to keep, please bring it to the hospital when you have your surgery.

We have included information about preparing your home, what to expect from Pre-surgical testing through discharge and even what to expect at home after your surgery.

You can expect to stay with us for 2-3 days after your surgery. While with us, we ask that you work with your team of health care professionals to make your stay as comfortable and safe as possible. You will see your surgical team on a daily basis, work with the nursing staff, physical therapists, and occupational therapist.

In turn, you should expect compassion and respect for all of our staff at WRH. We will do everything possible to provide the services to meet your needs and increase your comfort. If you feel that we are not meeting your needs, please notify us immediately. We are all here to help you with your recovery and help prepare you for your transition home.

Again, thank you for selecting us; we are privileged to have you as one of our patients.

Douglas J. Chonko, DO

Orthopaedic Surgery

Western Reserve Hospital

Steven B. Jackson, DO

Orthopaedic Surgery & Adult

Reconstruction

Western Reserve Hospital

Carrie Gallo, RN, BSN, MBA

CNO, Vice President, Patient Care Services

Western Reserve Hospital

Abi Morrison, MSN, BSN, RN

3 West Unit Manager

Western Reserve Hospital

Suzanne Yee, BSN, RN, RN-BC, NE-BC

Director, Medical/Surgical Services

Western Reserve Hospital

“To provide the highest quality, compassionate care to our patients and members and to contribute to a healthier community”

Table of Contents

Introduction:

Pocket: My Surgery

Medication Checklist

Map

Chapter 1 - Page 5: Preparing for Surgery

1. Medication Caution

2. Guide to Herbal Medications and Dietary

Supplements

3. A Positive Approach

4. Observations to Report Prior to Surgery and

Cessation

5. Pre Surgical Testing

6. Patient Surgical Check List

7. Preparing Your Home for Your Return

8. Adaptive Equipment

Chapter 2 - Page 12: Surgery and your team

1. The Team

2. Total Hip Arthroplasty

3. Total Knee Arthroplasty

4. Minimally Invasive Total Knee Arthroplasty (MIS)

Chapter 3 - Page 18: Day of Surgery

1. Pre-hospital Patient Education for Prevention of

Surgical Infection-using Chlorhexidine

2. What to Bring to the Hospital

3. What to Expect at the Hospital a. Surgery b. Pain and Medication c. Prevention: Constipation, Infection,

Blood Clots, Pneumonia d. Drainage Tubes e. Therapy f. Pre-surgical Experience

4.

Recovery (PACU)

5.

Transfer to Your Room

Chapter 4 - Page 25: What to Expect after Surgery:

1. Day of Surgery

2. Post-op Day 1

3. Post-op Day 2

4. Post-op Day 3

5. Exercises

Chapter 5 - Page 28: Your Transition Home

1. Discharge

2. Pain Medication

3. Around the House: Staying Safe

4. Lifetime Visits

5. Home Care Instructions

6. Prevention of Surgical Site Infections

7. Managing swelling

Chapter 6 - Page 33: Do’s and Don’ts

1. Hip Precautions

2. General Guidelines for Activities of Daily Living

3. Problems You May Encounter at Home

4. Post-replacement Prevention

Chapter 7 - Page 45: FAQs

Chapter 8 - Page 48: Possible Complications

Chapter 9 - Page 50: Conservative treatments to

Osteoarthritis

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My Surgery

Date of Surgery: _______________________________________________ Time of Surgery: __________________________

Date and Time of Joint Academy ___________________________________________________________________________

Location:

Western Reserve Hospital

1900 23rd St., Cuyahoga Falls, OH 44223

Date of Pre-surgical Testing: ___________________________________ Time of Pre-surgical Testing: ______________

My Notes:

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_______________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________

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For nursing questions call (330) 971-7476. For therapy questions call (330) 971-7287.

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My Medication Checklist

Fill in with information on all the medications you are currently taking. This includes medications ordered by your doctor as well as over the counter medications including pain relievers, vitamins, herbal supplements, etc.Use an additional sheet of paper as necessary.

Medication Name Dose Frequency

Route

(oral, shot)

Notes

- 3 -

Map

FIRST FLOOR

1 AUDITORIUM

Parking Lot Entrance

• Auditorium

• Falls Family Practice

• Medical Education

2 MAIN

ENTRANCE

Parking Lot Entrance

• Main Lobby

• New Choice Pharmacy

• Outpatient Surgery

• Patient Rooms

• Sleep Medicine Center

• Surgery

• Visitor Entrance

- Direct Admits 7 a.m. - 5 p.m.

3 EASY STREET

ENTRANCE

PHYSICIAN

OFFICE

BUILDING

ENTRANCE

Parking Lot Entrance

• Easy Street Therapy

• Endoscopy

• ICU

• Center for Pain Medicine

• Rehabilitation

• Physician Office

Building

4 EMERGENCY

Parking Lot Entrance

•Emergency Department

5 OUTPATIENT

ENTRANCE

Parking Lot Entrance

• Cardiopulmonary

• Infusion Center /

Chemotherapy

• Laboratory

• Nuclear Medicine

• Outpatient Registration

• Radiology

• Suite 1000

P

Public Parking

V

Valet Parking

Free Monday-

Friday 6 a.m.-5 p.m.

6 MATERIALS

ENTRANCE

• Receiving Dock

ICU

Endoscopy

P

Center for Pain

Medicine

PHONE NUMBERS

General Information................................................... (330) 971-7000

Patient Information .....................................................(330) 971-7410

Security (for directions)..............................................(330) 971-7412

VISITING HOURS

Our Hospital has unlimited business hours, please use the main entrance. Guests visiting between 9:00 p.m. and 6:00 a.m. please enter through the Emergency Department entrance.

V

5

Nuclear

Medicine

Emergency

Entrance

4

Emergency

Department

Radiology

A

Lab

Cardiopulmonary

SECOND FLOOR

Center for Pain

Medicine

Procedure

Area

A

Physical

Therapy

Easy

Street

Therapy

3

LEGEND

Elevators Telephones Restrooms Dining

Employee

Only

?

Information Waiting Area Vending

Stairs Free Valet Parking

All entrances and restrooms are accessible to the physically challenged

If you get lost please call 7410 from any house phone for assistance.

Infusion Center/

Chemotherapy/

Outpatient Registration

Suite 1000

P

South

Courtyard

23rd Street

P

Cafeteria

M

North

Courtyard

H

6

Library

P

Receiving Dock

Falls Family Practice

Graduate

Medical

Education

Department

Auditorium

1 2

NORTH

1

South

Courtyard

2 West

Chapel

M

2 West/Nurses

Station

North

Courtyard

P

Volunteer Services/Pre-Surgical Testing

P

Medical Records

Human

Resources

23rd Street

Lobby

?

2

Main

Entrance

V

Retail Pharmacy

H

Surgery

Outpatient

Surgery

Administration

Medical Staff

Services

NORTH

P

DRIVING DIRECTIONS:

From the North: Take Route 8 South to the Broad Blvd Exit. Turn right onto Broad Blvd and follow the signs to the hospital.

From the East: Take I-76 West to Route 8 North. Exit at Broad Blvd. Turn left onto Broad

Blvd and follow the signs to the hospital.

From the West: Take I-77 South to the Central Interchange. From the Interchange take

Route 8 North to the Broad Blvd Exit. Turn left onto Broad Blvd and follow the signs to the hospital.

From the Southwest: Take State Route 224/I-76 East to I-77 North. Follow I-77 North to

Route 8 North to the Broad Blvd Exit. Turn left onto Broad Blvd and follow the signs to the hospital.

From the South: Take I-77 North to Route 8 North. Exit at Broad Blvd. Turn left onto

Broad Blvd and follow the signs to the hospital.

- 4 -

Chapter 1: Preparing for Surgery

Medication Caution

Always consult with your doctor first in regard to any medication

Many medications are discontinued before surgery. The time frame to stop these medications may vary, so always consult your doctor. Below is a general guideline:

Medication

Herbal Supplements

Aspirin

Coumadin

Plavix

Ticlid

Pletal

Trental

NSAIDS (see list below)

Plaquenil

Celexa

Stopping time frame

Stop 14 days prior to surgery

325 mg - stop 7 days prior to surgery

81 mg - stop 3 days prior to surgery

Stop 5 days prior to surgery

Stop 5-7 days prior to surgery

Stop 10-14 days prior to surgery

Stop 2-4 days prior to surgery

Stop 8 hours prior to surgery

Stop 3-5 days prior to surgery

Stop 1 day prior to surgery

Stop 7 days prior to surgery

Some commonly prescribed or over the counter Non-Sterodial Anti-inflammatory Drugs (NSAIDS) are:

Advil

Arava

Daypro

Lodine

Naprosyn

Aleve

Arthotec

Feldene

Mobic

Oruvail

AGAIN: Always double check with your doctor BEFORE stopping any medications

Anaprox

Cataflam

Ibuprofen

Motrin

Relafen

Ansaid

Clinoril

Indocin

Naprelan

- 5 -

Supplement

Bromelain

Chondroitin

Chromium

Cysteine

Echinacea

Ephedra

Garlic

Ginkgo

Ginseng

Glucosamine

5-hydroxytryptophan

Kava

Omega-3 fatty acids

Phenylalanine

S-Adenosylmethionine

St. John’s Wort

Valerian

Vanadium

Vitamin A

Vitamin C

Vitamin D

Vitamin E

Zinc

Guide to herbal medications and Dietary Supplements

Stop taking all herbal medications 14 days prior to surgery. Inform your physician if you have been taking any

herbal preparations or dietary supplements. They may cause complications if taken before surgery.

Complication

Increased risk for bleeding, excessive menstrual bleeding

Irregular heart beat, increased risk for bleeding

Enhanced effectiveness of insulin and oral sulfonylurea agents

Interaction with ACE inhibitors, nitroglycerin, or isosorbide, can result in abnormally low blood sugar

Immunosuppressant, poor wound healing

Increased heart rate and blood pressure

Increased risk for bleeding

Increased risk for bleeding

Increased risk for bleeding

Reduced effectiveness of insulin, hyperglycemia

Interaction with antidepressants and Tramadol, can results in life-threatening

“Serotonin Syndrome”

Increased risk for sedation

Increased risk for bleeding, hemorrhagic stroke

Reduced effectiveness of Baclofen and Levodopa

Interaction with antidepressants, can results in irregular or accelerated heartbeat.

Multiple herbal and drug interactions

Increased risk for bleeding

Increased risk for bleeding

Increased risk for bleeding and liver damage

Dehydration, increased blood levels of NSAIDS

Toxic reaction if taking Digoxin

Increased risk for bleeding, reduced effectiveness of Beta-Blockers taken for hypertension

Reduced effectiveness of NSAIDS

- 6 -

A Positive Approach

Preparing for surgery is important for your recovery. Because of medical advancements, total joint replacement surgery is possible to relieve your pain and discomfort and improve your activity level. The pain and activity limitations after surgery will be different and short term. An important part of the recovery process is using your new joint by walking and doing the exercises that your doctor orders.

Depending on you condition, your recovery and exercise plan will be tailored to meet your needs. Each patient recovers differently and joint replacement revisions often progress slower than the initial surgery.

Your stay at the hospital will be short and your recovery will be continued after discharge in your home or at an extended care facility/rehab center. It is important for you to make a commitment to follow your doctor’s instructions and work on your exercise plan after surgery in order to benefit most from the joint replacement. If you need support, either physically or emotionally coping with the surgery and recovery, please talk to the staff.

Pre-operative Office Visit:

You may wish to see your surgeon one to two weeks prior to your surgery to make sure everything is in order.

This is an optional appointment but it is recommended for those patients going through the surgery that have additional questions.

During this visit you will have the opportunity to ask any questions that you may have regarding your surgery. As you read about your surgery, be sure to write down the questions and concerns as they arise. Bring these with you and discuss them with the surgeon. If you choose not to have this appointment, yet still have questions, please call your surgeon’s office. It is important to have all of your concerns addressed prior to surgery as it is an vital part in order to plan for your surgery and recovery.

Important Observations to Report before Surgery:

If your physical condition changes before surgery (cold, persistent cough or fever, infections), or there is an important change to your skin where the surgery is to be performed, notify your surgeon as soon as possible.

An important change would be a draining wound or a localized area with swelling, redness, heat, tenderness to touch or pain.

Smokers should know:

Smoking shrinks the arteries, decreases blood flow, speeds your heart rate, raises blood pressure and increases fluid production in your lungs. You will recover faster is you stop smoking before your surgery. Smoking is not permitted anywhere on hospital property.

Pre-Surgical Testing:

- 7 -

What to Expect:

After your surgeon’s office has scheduled your surgery, the registration department will contact you to schedule an appointment for pre-surgical testing (PST). If you are not home, they will leave a message. Please return their call at (330) 971-7682 or (330) 971-7309 to register and make your appointment. We require this appointment for an anesthesia evaluation even if you have already been seen by your private physician.

All patients require PST. The amount of testing and length of your appointment will vary based upon your age, health, medication, and type of anesthesia. Plan on being here for 45-90 minutes. Bring your medication bottles, including all over the counter medications, listed on prior page, and a list of your previous surgeries. You may eat as usual before this appointment.

During your visit a Certified Nurse Practitioner (CNP) will obtain a detailed health history, review your medications and allergies, and take your vital signs. Then the CNP will perform a physical exam.

There may be testing such as blood work, EKG, or chest x-ray. If you have had blood work performed elsewhere within the past 30 days of your planned surgery date, or an EKG and chest x-ray within the past 6 months, bringing a copy of those results may save us from having to repeat these tests.

Our Pre-Surgical Testing department works closely with the anesthesiologists to ensure your safety during surgery. In a few cases, the CNP may ask the anesthesiologist to see you during your Pre-Surgical Testing appointment, otherwise you will meet him the day of your surgery. If you have had complications with anesthesia in the past, please mention it at this appointment.

Patient education and pre-operative instructions are an important part of your pre-surgical testing. We will do our best to answer any of your questions or concerns. Our highly skilled professional staff will ensure you receive the safest and highest quality confidential care during your surgical experience. It is our goal to make your visit as pleasant and convenient as possible.

Patient Checklist for Surgery:

This checklist should be used as a guide to follow in the time leading up to your surgery.

You should: p

Receive an explanation of the surgery by your surgeon p

Receive a patient education book p

Schedule a date for your surgery p

Schedule an appointment with your Primary Care Physician for medical clearance if needed.

p

Schedule any dental check-up or dental care prior to you total joint replacement surgery p

Read your Joint Academy Patient Education Book p

Prepare your home for convenience upon your return from the hospital p

Discuss discharge planning/ transportation with your care givers p

Arrange for caregivers for the first couple of weeks if you are planning on returning home p

Schedule Pre-Surgical Testing p

Decrease smoking and alcohol consumption (if you need assistance, please inquire about our smoking cessation classes).

- 8 -

p

Do not eat or drink after midnight the night before surgery p

Use Chlorohexidine wipes (provided in class) to cleanse surgical area the morning of surgery.

p

You may take your approved medications on the morning of surgery with sips of water.

p

Report to Western Reserve Hospital at the designated day and time of your surgery.

Please pull to the front of the hospital and use our free valet services. p

Bring your patient education book with you.

Please contact your orthopaedic surgeon’s office with any questions.

Prepare Your Home

Follow this checklist to help get your house ready for your return home.

p

Clean, do the laundry and put it away. Put clean linens on your bed. p

Perform any yard work or arrange to have it done. p

Set up for someone to collect your mail and take care of your pets or loved ones, if needed. p

Move furniture as needed to provide easy access to the bedroom, bathroom and kitchen with a walker. You may need to ask someone to help you. p

Make sure all walkways are free of clutter. Pick up all throw rugs and tack down any loose carpeting. p

Remove electric/phone cords from walkways or tape them to the floor. p

Consider having nightlights in the bedroom, bathrooms and hallways. p

Your mattress should be firm. You may need to place a piece of plywood between the box spring and mattress to make your bed firmer. This is recommended for those having their hip replaced. p

Prepare meals ahead of time; freeze them in single-serving containers. p

Put cooking supplies and utensils in a place that is easy to reach. p

If you have a tub/shower combo in your bathroom, consider taking off the doors and using a tension rod with a shower curtain. This will make it easier to get in and out of the shower. p

Find a chair in your home that will allow you to sit down comfortably and stand up easily (dining room chairs with arms are ideal). Avoid a recliner as they are difficult to get out of and they can place your hips at a greater than 90 degree angle. p

Anticipate other needs you may have. For example, if your bedroom is on the upper level of your house, you may wish to prepare a sleeping area on the main level to use when you first come home.

Even if you plan to stay with someone or go somewhere else instead of your own home when you are discharged, you will eventually be returning to your house, so plan ahead. If you need any other equipment for your home, we can help you locate and learn how to use them while you are in the

hospital.

- 9 -

Precautions for Returning Home:

Do not use the towel rack in the bathroom for support.

They are not anchored into the wall and are not safe.

Be aware of pets, they will be happy to see you and can cause you to fall.

You may want to sit in a chair with arms as they are easier to get out of.

Consider installing grab bars in the shower/tub, they can be very helpful.

Review the list of adaptive/assistive equipment. You may want to purchase before your surgery, but do not open and save your receipt. Frequently utilized items follow with a brief description. Unfortunately, most of these items are self pay and not covered by insurance. They can make your recovery much easier though.

1. Raised toilet seat (3-in-1 bed side commode will be needed if you do not have a bathroom on the first floor, this can be ordered while you are in the hospital)

2. Reacher/Grabber

3. Sock aid

4. Leg lifter

5. Shower chair/ bench

6. Long handled shoe horn

7. Long handled sponge

8. Elastic shoe laces

9. Walker bag

- 10 -

Adaptive Equipment Options to assist post operatively

Toilet Seat Riser: Available in a variety of forms. Place over or on your toilet to raise the level of the seat. Has grab bars to assist in sitting and standing.

Long Handled Shoe Horn: The handle should extend on this shoe horn to avoid unnecessary bending when putting on shoes. Place the horn inside the back of the shoe and push heel down into the shoe.

Long Handled Bath Sponge: To assist in bathing, especially those hard to reach places. Wrap a towel around the sponge to help with drying. Rinse the sponge thoroughly after washing and let air dry for longer use.

Bath Seat: Good for tub or shower. Place seat in the tub and elevate to the appropriate height. Bath seat will elevate to 21”.

Grabber/ Reacher: Assists in picking items off of the floor or for taking items out of cabinets. Squeeze the handle to close/open the claws on the end. Helps to avoid unnecessary bending.

Sock Aid: Used to help don socks to prevent unnecessary bending.

Leg Lifter: Used to lift your leg when your muscles are not strong enough to lift the leg independently.

- 11 -

Chapter 2: Surgery and your team

Chapter 2: Surgery and Your Team

Your Total Joint Replacement Team

The better prepared you are for surgery, the easier your recovery program will be.

Our orthopaedic joint replacement specialists are dedicated to performing state-of-art hip and knee replacement procedures to improve function and eliminate pain in patient’s diseased joints. Nationally, more than ½ million total joint replacements are performed each year, with hip and knee procedures accounting for the majority of operations.

The orthopaedic specialists at Western Reserve Hospital (WRH) work with a team of medical professionals to assist you throughout your surgery and recovery. You will be seeing many team members while you are a patient at WRH and they may include the following:

Orthopaedic Surgeon:

Your surgeon will perform the surgery and direct your care throughput your hospital stay.

Anesthesiologist and Certified Registered Nurse Anesthetist (CRNA):

The anesthesia staff will greet you during the pre-surgical phase of your surgery. They will provide education about the medication and process used during your surgery. Anesthesia is also responsible for your care during the recovery phase in the Post Anesthesia Care Unit (PACU). It is your responsibility to ask questions, voice concerns, discuss any past complications with anesthesia.

Consultants:

Your surgeon may ask other physicians to assist in your care. They may evaluate your medical condition and manage another aspect of your care throughout your stay and through the discharge process.

Orthopaedic Residents:

They will assist in your surgery and follow your progress closely. You will see them in the early morning. They will work with your surgeon and nursing staff to promote a rapid recovery.

Case Manager and /or Social Work:

They will meet with you and assess your situation for discharge. They will assist with your discharge process and arrange for homecare or transfer arrangements to a rehab facility. If you have any concerns about your discharge, please share them with the staff.

Staff Nurses and Clinical Technical Assistants (CTA):

They will see to your daily needs. The nurses will assess your physical conditions and provide medications and treatments as ordered by your doctors. They will assist with bathing, dressing, mobility, education and communicate closely with your surgeon on an ongoing basis.

Physical Therapists:

They will evaluate your physical capabilities and instruct you on an exercise program after your surgery. They will work with you on a daily basis while you are in the hospital and communicate your progress to the surgeon and case manager to ensure you are discharged to the safest place for your recovery.

Occupational Therapist:

They will evaluate your needs for any equipment or devices to help you with self-care. The therapist will teach you how to perform daily activities safely and easily within your new restrictions.

Pharmacist:

Our pharmacy staff work closely with your physicians and nurses to ensure that you are taking the best medicine for your condition. They are available to review your medications and the interactions they have with each other. We also offer a concierge service through our retail pharmacy that can deliver your homegoing medications directly to your room.

- 12 -

Your Role:

Your role is very important in your recovery. We need you to work with the staff at WRH and ask any questions to ensure you fully understand your instructions. Make time each day for the exercises you have been taught.

Follow your surgeons and therapist’s instructions and restrictions. Please report any problems or concerns to your staff. Assist in maintaining your safety through use of your call light, participating in the “Call, Don’t Fall

Program”, prompting your staff to wash their hands and taking only the medications as ordered while at WRH.

Total Hip Replacement

Healthy Hip:

Your hip joint is the largest weight bearing joint in your body.

It is considered a “ball in socket” joint because, in a healthy hip, the smooth ball at the end of the thigh bone fits easily in the end of the hip socket. The layer of cartilage covers the ends of these bones, serving as a cushion while allowing the ball to glide within the socket.

Problem Hip:

Severe pain and deceased movement can result as the cushion of cartilage wears away in a hip joint affected by osteoarthritis or other diseases. The joint surfaces rub against each other, becoming rough, pitted and irritated.

Replacing Worn Joints:

Joint replacement procedures (also called arthroplasties) involve replacing a painful joint with a new mechanical joint, called a prosthesis. The procedure is appropriate when a patient experiences severe, incapacitating hip pain due to conditions such as osteoarthritis, rheumatoid arthritis or injury.

Hip Prosthesis:

The hip prosthesis consists of a specially designed ball and socket that replace your worn hip joint. The ball and stem replace the worn ball of your thigh bone. A cup replaces the rough socket. The prosthesis has smooth surfaces that fit together and allow the ball to move easily and painlessly within the socket, much like a healthy hip.

- 13 -

Total Knee Replacement

Healthy Knee:

In a healthy knee, the bones are smooth and glide together easily in the knee joint, allowing you to walk without pain.

The cartilage between the knee joint serves as a cushion, permitting the bones to rotate, glide and roll upon each other while you walk.

Problem Knee:

With certain conditions such as osteoarthritis, rheumatoid arthritis or injury, the knee’s cartilage slowly wears away.

The bones rub against each other, causing pain and difficulty walking. The knee cap may move and allow the knee to feel unstable.

Replacing Worn Joints:

Joint replacement procedures (also called arthroplasties) involve replacing a painful joint, with a mechanical joint, called a prosthesis. The procedure is appropriate when a patient experiences severe, incapacitating knee pain due to conditions such as osteoarthritis, rheumatoid arthritis or injury.

Knee Prosthesis:

A knee prosthesis is comprised of smooth surfaces, much like a healthy knee, The femoral component caps the end of the thigh bone; the tibial component covers the underside of the knee joint surfaces. This allows you to move and walk easily without pain.

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Minimally Invasive (MIS) Total Knee Arthroplasty (TKA) - an alternative to a traditional TKA

What does this mean?

MIS is a newer method of performing total knee replacement, and entails replacing the knee joint surfaces with cobalt chrome and plastic components. Although, the knee components are the same as those used in the traditional surgery, the procedure differs from the traditional procedure in two major respects.

1) The operative procedure is done through an incision that is less than half the length of the standard

total knee incision, yet the same result is accomplished—knee pain from disabling arthritis is gone.

2) The MIS approach allows your surgeon to avoid muscle and tendon cutting, thereby minimizing

trauma to the knee. As a result, there is much less post-operative pain and patients are routinely able

to begin walking and exercising the day of surgery. This accelerated rehabilitation enables patients to

go home from the hospital earlier (usually after 2 days) and return to a normal lifestyle much earlier

than with traditional surgery.

What are the Details of the Minimally Invasive (MIS) Procedure?

MIS total knee arthroplasty is usually accomplished through an approximately 4-inch incision. The development of new instruments has made this surgery possible. The components are the same as those used in traditional

TKA, but the degree of surgical exposure is minimized. The quadriceps tendon and muscle are not cut and the kneecap is not dislocated. Special retractors and guides are used to accomplish the replacement. This less invasive approach dramatically minimizes the discomfort after surgery.

Minimally Invasive (MIS) Total Knee Arthroplasty (TKA)?

Most patients with painful disabling arthritis are candidates for this surgery. Exceptions are patients with very large legs due to obesity or heavy muscles. However, even these patients can benefit from many of the techniques used in MIS surgery and realize a decrease in post¬operative pain and disability.

Can Both Knees be done at the Same Time?

Bilateral knee replacements may be appropriate for a select group of patients. However, certain patients may have a slightly higher risk; therefore this option should be discussed with your physician. We recommend 12 weeks between knee replacements.

What Can I Expect On the Day of Surgery?

You will arrive at the hospital about two hours before the surgery. You will be given an oral anti-inflammatory/ pain medicine, and you will meet with your surgeon and the anesthesiologist. Usually, the MIS TKA is performed under spinal anesthetic. This enables the nurses to administer oral pain medicine after the surgery, but before the spinal anesthetic has “worn off.” This effectively treats pain before it is felt. A long acting Novocain type drug is also injected into and around? the knee during surgery. However, while this will help with post-operative pain, it also may cause a temporary numbness in the foot that can last as long as 24 hours. If needed, the nurses will administer additional intramuscular (IM) pain medication.

This pain management protocol allows the patient to stay alert, yet comfortable. It also enables the physical therapist to begin treatment on the day of surgery. Therapy includes light muscle exercises, and walking in your room. IM and oral pain medications are continued overnight and the next day as needed.

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How Long Will I Be In the Hospital?

Most patients spend two nights in the hospital, however, if you are doing well and your pain is controlled you may go home the following day. Patients that have been weakened as a result of their arthritis and require more postoperative therapy will be discharged to a skilled nursing facility or rehabilitation center for more aggressive therapy.

What Can I Expect When I Go home?

You will be sent home with a prescription for an oral pain medication (usually Percocet) to be taken as needed and an anti-inflammatory medication to be taken for about two weeks. In addition, most patients will be instructed to take 325-milligram enteric coated aspirin twice daily to minimize the risk of blood clots. White surgical stockings should be worn during the day until your surgeon or his assistant tells you to discontinue them.

Your incision requires little care. You may shower. However, don’t soak the incision in the bath or a hot tub. There will be skin tapes, called steri-strips on your incision. Leave these on for two weeks. They may begin to dry up and fall off, this is acceptable. Don’t apply any oils or creams to the incision until after the steri-strips come off. If there is any significant change in the status of the incision, call your doctor. When you are two weeks post-op you may gently remove the steri-strips.

You should avoid prolonged sitting, walk comfortable distances, and do your exercises as directed upon discharge. Before discharge from the hospital, the physical therapist will make any necessary recommendations for outpatient therapy, though many patients will only need home exercises.

A common mistake is to “over-do it” after surgery because you will feel so good. Activities like mowing the lawn, working around the house, and excessive walking can cause discoloration and swelling for at least two weeks after the surgery. This will only prolong your full recovery. Any dental work and long trips should also be avoided for six weeks after surgery.

The discomfort in your knee should lessen daily, though occasional mild set backs are normal. Any excessive increase in pain, swelling, temperature (oral temp over 102°) or pain in the calf area of either leg should be reported immediately to your surgeon. Normal occurrences after surgery include an increase in warmth in the operative knee, clicking in the knee, stiffness after sitting, and mild pain in the shin or thigh areas. These normal symptoms will eventually disappear, but may last for 6 to 12 months in some patients. Applying ice to your knee twice a day for 30 minutes will help control swelling and pain. You will notice numbness on the outside of your knee. This area of numbness will decrease in size with time, but a small area of decreased feeling maybe permanent.

What Are the Potential Complications of Minimally Invasive (MIS)

Total Knee Arthroplasty (TKA)?

The complications of MIS TKA are the same as for standard TKA. The most devastating complications are infection and blood clots. The frequency of each of these is less than 1 percent but, unfortunately, potential for risk cannot be eliminated. We minimize the likelihood of infection by giving antibiotics during and after the surgery. Blood clots are prevented by early mobilization (walking the day of surgery) and the use of blood thinners (usually aspirin) immediately after surgery. Other potential complications include, but are not limited to, stiffness of the knee, injuries to the blood vessels and nerves, failure or loosening of the prosthesis and instability of the knee or the knee cap.

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How Long is the Healing Process and When Can I Return to Normal

Function?

When discharged home, most people use a cane, crutches or a walker for approximately one to four weeks.

As soon as your balance and strength return you may walk independently without the use of an aid. Driving is allowed when you are no longer taking narcotic pain medications—usually in 2 weeks if the surgery was on your left leg. If the surgery was on your right leg, you may drive in 6 weeks if no longer taking narcotics. You may return to a desk job in 3 to 4 weeks and more vigorous labor in 2 to 3 months. These are only guidelines, however, and may vary considerably from individual to individual. Your doctor will advise you of your limitations as you progress with your recovery and therapy. Permanent limitations include running and jumping, full squatting and kneeling (possible for only short periods of time).

What Are the Long-term Expectations of Minimally Invasive (MIS)

Total Knee Arthroplasty (TKA)?

The life expectancy of the knee replacement is, on average, approximately 20 years. If necessary, revision of your knee replacement can then be done. Factors that accelerate wear of the components include heavyweight, young age, and impact loading of the prosthesis. We recommend that patients avoid running and jumping and control their weight through a walking program and diet. You will be required to take antibiotics for all dental procedures for at least two years after surgery. Your prosthesis will probably set off the metal detector at the airport. We will give you a card that will inform the security personnel that you have a joint replacement, but expect screening anyway.

Routine follow up of your TKA should be every 3 years. You are responsible for making an appointment with your doctor at that time. If you have any unusual symptoms in the interim, contact your surgeon immediately. Most importantly, enjoy your knee replacement and many years of pain free function.

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Chapter 3: Day of Surgery

Prevention of Surgical Site Infections

A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Most patients who have surgery do not develop an infection but sometimes it does happen.

Some of the common symptoms of a surgical site infection are:

• Redness and pain around the area where you had surgery.

• Drainage of cloudy fluid from your surgical wound.

• Fever.

Before surgery – what you can do:

• Tell your physician about other medical problems. Allergies, diabetes and obesity can affect your surgery and treatment.

• Quit smoking. Patients who smoke get more infections.

• Do not shave near where you will have surgery as it will irritate the skin making it easier to develop an infection.

• Use chlorhexidine wash as directed on next page.

After surgery:

To prevent surgical site infections, doctors, nurses, other healthcare providers and visitors are asked to:

Clean their hands with soap and water or an alcohol-based hand rub before and after touching the patient or the dressing. This is one of the most important measures we can all take to prevent the spread of infection.

Visitors might also observe the following actions by healthcare providers that have been shown to help in reducing the incidence of surgical site infections:

• Cleaning their hands and arms up to their elbows with an antiseptic agent just before surgery.

• Removing some of your hair immediately before your surgery using electric clippers if the hair is in the same area where the surgery will occur.

• Wear special hair covers, masks, gowns and gloves during surgery.

• You will receive antibiotics before your surgery starts.

• Application of special soap to kill germs on your skin at the site of your surgery.

Visitors can help by:

• Washing their hands.

• Not touching the wound or dressing.

At home:

Make sure you know how to care for your wound before you leave the hospital. Always clean your hands before and after caring for your wound. Make sure you know who to contact if you have questions or problems after you get home.

• Call your healthcare provider immediately if you develop:

• Redness and pain at the surgery site.

• Drainage at the surgery site.

• Fever

This worksheet is intended as a guide only. Each patient is an individual and responses may vary. If you have any questions or concerns please consult your healthcare provider.

Reference: CDC.Gov//TakingCare.htm

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Pre-hospital Patient Education for Prevention of Surgical Infection -

Using Chlorhexidine

There are steps you can take to help prevent infection

SKIN CARE

• The following outline guides you on what you should do to prep (prepare) your skin.

• If you wish to shower, bathe or shampoo your hair, this should be done two hours before you prep your skin. Use warm water only.

• Do not shave the surgical site for 2 days prior to surgery.

General Skin Cleansing Instructions for Bathing or Showers

Before you bathe or shower:

- Read the instructions given to you by your healthcare practitioner, and begin your general skin cleansing protocol as directed.

- Carefully read all directions on the product label.

- Chlorhexidine in not to be used on the head or face, keep out of eyes, ears and mouth.

- Chlorhexidine is not to be used in the genital area.

- Chlorhexidine should not be used if you are allergic to chlorhexidine gluconate or any other ingredients in this preparation.

* See Chlorhexidine label for full product information and precautions.

When you bathe or shower:

- If you plan to wash your hair, do so with your regular shampoo. Then rinse hair and body thoroughly to remove any shampoo residue.

- Wash your face with your regular soap or water only.

- Thoroughly rinse your body with warm water from the neck down.

- Apply the minimum amount of Chlorhexidine necessary to cover the skin.

- Use Chlorhexidine as you would any other liquid soap. You can apply Hibiclens directly to the skin and wash gently.

- Rinse thoroughly with warm water.

- Do not use your regular soap after applying and rinsing Hibiclens

When using Chlorhexidine for a second day in a row:

- Shower/bathe again using Chlorhexidine in the same method as described above.

- Do not apply any lotions, deodorants, powders or perfumes to the body areas that have been cleaned with chlorhexidine.

MOUTH CARE

It is known there is a great link between germs in the mouth and the rest of the body. To help prevent germs from traveling to other areas of the body you should:

The morning of surgery

• Take any pre-op medications (as directed by physician) with sips of water

• Brush your teeth

• Do not eat or drink

This material is intended to provide general educational information to help you make informed decisions about your care.Your healthcare provider may have additional instructions.

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What to Bring to the Hospital

Follow this checklist to pack for the Hospital.

Please bring:

p

Your smile, patience, and determination p

A positive attitude p

One set of loose clothing for the day of discharge p

Comfortable slip-on or walking shoes (make sure they are wide enough to allow for some swelling on your operative leg and are not too loose). No flip-flop, sandals or Crocs, please. p

Personal hygiene products (soap, shampoo, toothbrush, toothpaste, ) p

Your insurance card, prescription card (if you have one), and a photo ID p

Your Joint Academy Surgery Book

If you have them, please bring the following, as well:

p

Case for dentures and denture adhesive (if applicable) p

Walker, if adjustable p

Eyeglasses/contact lenses and case p

CPAP or breathing machine, with settings p

Copies of your living will and/or medical power of attorney

Please leave at home:

p

Jewelry and valuables p

Underwear p

Credit cards, cash and purse p

All medications, especially pain medications p

Any valuables that you bring may be locked up by protective services.

What to Expect In the Hospital:

Surgery:

Patients are admitted to the hospital the same day as their surgery. Pull your car to the front door and please take advantage of our free valet parking. You will be greeted at the front desk by a member of our concierge staff and escorted to the surgical area by one of our numerous volunteers.

Upon your arrival at the same day surgery area, the receptionist will orient you and your guests to the process of your surgery. You will then be seated and your nurse will call your name when it is time for your preparation to begin. At this point, your guests will be asked to remain in the waiting area until the surgical staff has completed some personal and time sensitive tasks. Be assured though, your guests will be able to join you again before your surgery begins. You will be asked to change into a warming gown, your medical history and medications will be reviewed. An IV will be started and blood may be drawn.

You will see your surgeon and the surgical staff prior to surgery. They will verify the surgical site and sign the operative limb. They will answer any questions that you or your guests may have.

The anesthesia staff will meet with you to discuss your options for anesthesia and also to review a brief history, medications and allergies. You may feel that several of our staff are asking the same questions, this is because we want to provide you with the safest of experiences. We double check and cross check each other as it is easy for patients to forget something at this highly stressful time. Please remember, this is a great time to ask any questions or voice any concerns.

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If you have had any problems with anesthesia, nausea, or vommiting in the past please discuss it at this time.The anesthesiologist will discuss your options for anesthesia based upon your medical history and surgery. Although the choice is yours, they will have a preference based upon their years of education and knowledge.

Before going into the operating room, you will be given a sedative that may make you feel a little sleepy. This is the time to say good bye to your guests. You will be taken into the operating room about an hour before your surgery actually begins and the surgical staff will prepare you for your surgery. When the operation is over, the surgeon will notify your guests and give them a progress report.

After surgery, you will be placed in your bed which has been prepared and brought into the operating room for you. You will then be taken to the Post Anesthesia Care Unit (PACU) for recovery until your sedation wears off.

Staff in the PACU will monitor and medicate you until you are ready to move to your room.

After Surgery:

You will wake up in the recovery room. Many people feel cold when they wake up so warm blankets are available, if you need them. Monitors will measure your blood pressure, heart rate and breathing. While you are in the recovery area, a sample of your blood may be drawn to check your blood count and an X-ray may be taken to check your surgery. You will remain in the recovery room for about 2-3 hours.

Patients are usually moved to the surgical unit after their surgery. On occasion, some patients are transferred to ICU for monitoring before being transferred to the surgical unit. This does not mean that their condition is critical, but that the surgeon feels the need for closer monitoring because of age or preoperative medical conditions that increase risk.

Once you arrive in your room, you will be greeted by the nursing staff. You will be oriented to the room, vital signs will be taken, and an assessment and your medical history will be reviewed and completed. Your pain and nausea will be assessed and a clear liquid tray will be delivered shortly after your arrival. Please communicate any questions, concerns, or increases in pain/nausea to your nursing staff.

At WRH we try to place all of our patients in a private room, however at times of increased patient census, we may place two patients in a room. Your bed is assigned by the location of your surgery. For the ease and safety of getting out of bed, your operative leg is placed closer to the wall.

Medications:

Pain:

Your physicians and nurses are committed to developing a pain management plan for you that works well with the rehabilitation of your new joint. The pain you experience after surgery is usually different from the kind you felt before surgery (your arthritic pain will be replaced by surgical pain). The difference is that the arthritic pain was chronic or long lasting, while the surgical pain will be acute and shorter in duration.

To help control your pain after surgery, you will be given strong pain medications while in the PACU, or recovery area. These will make you very sleepy and at times, possibly nauseous. There is medication available to aid with the nausea.

Once transferred to the surgical unit, your pain will be controlled with intramuscular (IM) or oral pain medication.

Your pain medication will not be scheduled, it will be ordered, “as needed”, which means that you need to request your medication. Throughout your stay with us at WRH, you will be asked to assess your pain level before medication and after medication. You will continue to be asked to rate your pain on the 0-10 pain scale.

To remain as comfortable as possible, it is important to request pain medication before your pain level gets too high. It is also important to let your nurse know if your pain medicine is not working so changes can be made that will help you feel better.

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There are many types of pain medicines and a variety of ways to administer them. You may have just one kind of medicine or you may be given a combination of medicines to control your pain. Your nurse will work closely with you to determine what “recipe” works best. Your nurse and surgeon will teach you how to use pain medicine effectively. Keep in mind that everyone feels and responds to pain differently. It is important to keep your pain at a controlled level. By doing this, you will be able to complete your therapy goals (both in the hospital and at home).

The following techniques will help you manage your pain after surgery:

• Activity: It is important to start moving as soon as possible after surgery. Moving helps your breathing and digestion, and will help you heal faster. It may hurt to move, but moving and being active will help lessen pain over time. On the day of surgery, your nurse or physical therapist will help you sit up, or get out of bed, when you are ready – do not try doing this without someone present and the physical therapist tells you that you are ready to do this by yourself. You will start walking and exercising after the therapy team works with you the morning after surgery. Please note, you are expected to spend most of the daytime hours out of bed and in a chair.

• Distraction: By focusing your attention on something other than your pain, you can relax and stop thinking about it. Playing cards or games, visiting with friends and family, watching television, reading or listening to music are some of the ways you can distract yourself.

• Ice/Cold Therapy: Some swelling is expected after surgery. Using ice or cold therapy will help keep the swelling under control; it will also help control your pain.

• Elevation: By raising your incision higher than your heart, you will improve blood flow and reduce swelling. It may also provide some pain relief. Your nurse will help you adjust your body or bed as needed. While elevating your leg, be sure not to place a pillow directly under the knee. This can inhibit blood flow and increase the risk of a blood clot forming. Instead, place a pillow under your

ankle.

• Comfort: Get as comfortable as possible while you are in bed. Ask your nurse for more pillows or blankets if you need them. Make sure your room temperature is not too hot or too cold. Other things that may improve your comfort include having your family rub your back, applying a cool cloth to your face or hands, and keeping light and sound to a minimum.

Constipation:

Anesthesia, pain medications and lack of activity can all lead to constipation. Your surgeon has prescribed medication to help prevent this and your nursing staff will be giving this to you daily.

Antibiotics:

After your surgery you will be given two to three doses of intravenous antibiotics to help prevent infection. This is the recommended practice throughout the country for total hip and total knee replacement surgery. It is only a preventative measure therefore it is not recommended to continue past the first 24 postoperative hours.

Home Medications:

Your home medications have been reviewed with you at several points on this journey. Your surgical staff will order the medications necessary and safe for you to take during your hospital stay. Your nurse will give them to you at pre-established times. If these times do not coincide with the times you take your medications at home, feel free to discuss with your nurse. Your recovery is a partnership between you and the staff at WRH, we all work together. Please DO NOT take any medications unless your nurse gives them to you.

Blood Transfusions:

On a rare occasion you may require a blood transfusion if your blood count drops below an acceptable range. All of our blood products are screened, tested and considered safe.

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Your Diet:

Your diet will be restricted the day you have surgery. We realize you will have had nothing to eat since midnight the night before; however, it is important for your digestive system to “wake up” after anesthesia. Usually, patients are able to have clear liquids the night of surgery and resume eating solid food the next morning, providing you do not experience any postoperative nausea or vomiting. While staying with us, you will be using our room service system, which allows you to order from a menu between 6:30 a.m. and 6:00 p.m. Meals arrive within one hour, or at the requested time. Nursing staff will make sure you order and receive your meals.

Preventing Blood Clots:

Having a joint replaced puts you at risk for developing a blood clot. There are a number of ways you and your nurse will help minimize these risks:

• The evening of your surgery, your nurse will help you get up and sit on the side of the bed. This may be combined with toileting.

• You will be encouraged to be up and around every day during the classes. This helps promote movement and exercise of your lungs.

• Your nurse will remind you to do ankle pumps at least 10 times every hour while you are awake. This promotes the return of your blood from your legs back up toward your heart.

• Arterial/Venous Impulse (AVI) boots will be on your feet or Sequential Compression Device(SCD) leggings will be applied to your calves. These help the blood circulate well in your legs and throughout your body.

• Your surgeon may be prescribing a blood-thinning medicine for you while you are in the hospital.

This medicine will be continued for a short time after you go home.

Pneumonia Prevention

Surgeries using general anesthesia will increase the risk of developing pneumonia. Your lungs consist of many air sacs which get larger when you breathe. When awake, we periodically take a deep breath and blow off extra fluid from these tiny air sacs. When you are sleeping you do not take deep breaths causing fluid and mucous to build up in the air sacs. If allowed to collect, pneumonia can develop and slow down your recovery.

• After surgery, make a conscious effort to deep breathe and cough.

• You nurse will also bring you an incentive spirometer (IS) and instruct you on the use.

• Use the IS at least 10 times every hour while you are awake. This device will help us assess the amount of air you are using with each breath.

• Every patient will have an incentive spirometer to help prevent the risk of pneumonia.

• If you qualify, your nurse will offer you a pneumonia vaccine. It would be given before you leave the hospital. Talk to your nurse to see if you qualify for this vaccine (there are certain age and medical requirements).

• Elevate the head of your bed.

• During the flu season, we will offer you the influenza vaccination (flu shot).

• Pneumonia vaccine will be offered if you qualify.

Drainage Tubes:

Without a tube in the bladder, some patients may have difficulty passing urine right after surgery. To avoid the consequences of an overextended bladder, a catheter may be inserted during the operation and is typically removed on the first post operative day. The nursing staff will monitor your urine output closely, but please notify them of any complications.

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Operative Wounds and Dressings:

Your incision dressing will be changed on the second postoperative day. It is common to have some seepage from the wound during the first week. A waterproof dressing will be applied to the hip incision and you may remove it in one week as directed on your discharge instructions. You are permitted to shower with this dressing on as it is waterproof. Steri-strips will be applied to the knee incision (and covered with an Ace Wrap) and will remain in place until you follow up with your surgeon. Often, they begin to dry and peel off and that is acceptable.

Physical Therapy:

Typically, the physical therapist will get you out of the bed on the day of, or the first day following your surgery.

They will also remind you about the amount of weight to put on your operative leg. If you have an early morning surgery, you may be seen by a therapist the same day. Usually, you can put as much weight as you can tolerate. If your weight-bearing is limited, your surgeon will instruct you when you can advance the amount of weight your can bear. Generally, this decision is made after the follow up x-rays and evaluations.

Occupational Therapy:

The occupational therapist will meet with you before you are discharged from the hospital. They will assess your need for assistive/adaptive equipment (as discussed earlier) and instruct you on the proper use.

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Chapter 4: What to Expect after Surgery

Day 1:

• Arrival at hospital

• Surgery - your new journey begins

• Transferred to the surgical floor

- Your blood pressure, pulse and temperature will be taken frequently; ice will be applied to your

new joint

- First meal is clear liquids, can be advanced if tolerated

- Will be assisted to edge of bed, chair and bedside commode

- IV will be infusing until you can tolerate food and beverage

- Intramuscular or oral pain and nausea medication will be given as needed and per your request

Post op day 1 (Day 2 of hospital stay):

• Good Morning, time to get up and out of bed

• Blood will be drawn in the early morning

• The surgical team will see you very early this morning and every morning

• Stool softeners will begin to prevent constipation

• Vital signs will be less frequent

• Bathe in chair

• Case manager will meet with you to discuss discharge plan

• Physical Therapy (PT) will begin if not started on the day of surgery. Therapist will see you twice on this day

• Pain medications will be transitioned to oral medications and medication for nausea is available upon request

• IV will remain intact but fluid will no longer be infusing

• If you have a catheter draining your bladder it will typically be removed on this day

Post op day 2 (Day 3 of hospital stay):

• Blood may be drawn in the early morning

• Medications will be oral

• You will be able to shower

• PT returns twice this day

• Case manager will meet with you if unable on previous day

• Most likely discharged today

Post op day 3 (Day four of hospital stay):

• Blood may be drawn in the early morning

• PT will visit again before you go home

• If unable to be discharged on post-op day 2, you will be discharged to the most appropriate place for recovery

* Occupational Therapist will visit prior to discharge to assess your self-care needs.

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Exercises

Your physical therapist will instruct you as to which of the following exercises and how many repetitions of each you are to perform, and how many times a day you should repeat them.

Ankle Pumps:

p

Lie on back. Move foot up toward the shin, then downward. p

Lie on back. Switch legs and repeat.

Repeat ankle pumps _________ times

_________ times a day

Quad Sets:

p

Lie on back. Lie down with leg extended. p

Lie on back. Tighten muscles on front of leg. p

Lie on back. Push back of knee into bed. p

Lie on back. Hold for 10 seconds.

Repeat quad sets _________ times

_________ times a day

Gluteal Squeeze:

p

Lie on back. p

Legs straight. p

Squeeze buttocks together as tightly as possible. p

Hold for 10 seconds.

Repeat gluteal squeeze _________ times

_________ times a day

Heel Slides:

p

Lie on back. p

Bend knee. p

Pull heel toward buttocks. p

Hold for _________ seconds.

p

Repeat with other knee.

Repeat heel slides _________ times

_________ times a day

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Exercises

Your physical therapist will instruct you as to which of the following exercises and how many repetitions of each you are to perform, and how many times a day you should repeat them.

Terminal Knee Extension:

p

When in bed, your leg should be supported with a rolled towel (about 6” wide). p

Straighten leg at knee by lifting the heel only off the bed. p

Hold for 5 seconds. p

Return to start position.

Repeat terminal knee extensions _________ times

_________ times a day

Out to the side:

p

Lie on back with legs straight and together. p

Slide operative leg out to the side. p

Keep knees straight and toes pointed up. p

Slide leg back to starting position.

Repeat out to the side _________ times

_________ times a day

Straight leg raises:

p

Bend one leg. p

Raise other leg 6-8 inches, with knee locked. p

Exhale and tighten muscles while raising leg. p

Lower leg, and repeat using opposite leg.

Repeat straight leg raises _________ times

_________ times a day

Sitting quad sets:

p

Sit with back against chair. p

Tighten thigh muscle and straighten knee. p

Hold for 10 seconds. p

Repeat using other leg.

Repeat sitting quad sets _________ times

_________ times a day

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Chapter 5: Your Transition Home

An Extended Stay

Patients who progress at a slower pace or have no one to help them once they get home, may qualify to go to a rehabilitation unit, a sub acute unit, or a skilled nursing facility for additional therapy and general care.

If you do not have a caregiver that can stay with you, your surgeon will request that you transfer to an extended care facility before you return home. This is for your safety and assists with your recovery. If this is your situation, the length of time for an extended stay depends on your rate of recovery. Members of your healthcare team

(physical therapist, nurse, occupational therapist and case manager) will help you and your family decide which of these choices is best for you after surgery. If you have an idea of where you want to stay, you may want to visit that facility before your surgery

Some insurance companies have preferred rehabilitation facilities that must be used for full coverage. If you have private insurance and are thinking that you will need to go to an extended care facility, our case managers and social workers will assist you with this after your surgery.

Transportation Home from the Hospital:

Insurance will not usually cover the transportation to home or a rehabilitation facility from the hospital. Most patients are able to go home in their family car with some assistance getting in and out of the car. If you are traveling by car, it is helpful to use a midsize car or minivan. Small cars or cars with low bucket seats will be difficult for you to travel in safely. Have the driver bring one or two pillows to sit on and a blanket in case you are chilled. We can help arrange wheel chair ambulette transportation to your home or a facility. The cost will depend on the distance to your home or facility. The ambulette company will bill you for the service. Again, our case managers can help assist with this prior to your discharge.

Once you get home you are not expected to stay in bed. You should be up and about on your walker or crutches most of the time, but rest as much as needed. You should also do the exercises you have been taught and that you can do on your own

Driving

You may drive in two weeks if you are no longer taking narcotic pain medications and your surgery was on your left side. If your surgery was on the right side, you need to wait for 6 weeks, and also be off of all narcotics, before you can resume driving.

Returning to Work

You may not return to work for eight to twelve weeks after the operation. Quite a few patients do return earlier, depending on the nature of their work and how flexible their workplace is for returning on a part-time basis initially. We generally tell employers 8 to 12 weeks, but you may return sooner if you are physically ready. It is easier to return to work sooner than to request more time off. Discuss this with your surgeon if you need to be back at work sooner.

Going Home

Your hospitalization will likely last two to three days, after which our goal is for you to go home. By coming to Joint Academy classes and participating in the exercises, you will have become stronger. You also will have learned about the important skills to ensure your safety and aid your recovery.

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Pain and Medication:

• Make a schedule to take your pain medicine regularly. Be sure to take pain medicine at least 30 minutes before physical therapy and planned exercises.

• You can start taking pain medicine less often when your pain subsides. Gradually, you will wean yourself off the prescription pain medicine and take Tylenol (acetaminophen) instead.

• Time your pain medicine so you take a dose before you go to bed. This will help keep you comfortable through the night while you sleep. If you awaken in the middle of the night, you may need to repeat the dose. Try not to sleep or nap too much during the day.

• Keep taking your blood-thinning medicine as prescribed to prevent blood clots from forming.

• Try to change your position at least once every hour while you are awake.

• Use an ice pack (or a bag of frozen peas wrapped in a kitchen towel). Ice helps with pain and swelling, and may feel especially good before and after your exercise program. Use a barrier like a towel or pillowcase between the ice and your skin. A good rule of thumb is to use ice 20-30 minutes at a time.

• Taking pain medicine and not being at a normal activity level increases the risk of constipation. Use stool softeners as recommended by your physician or pharmacist (usually two to three times a day).

Be sure to eat plenty of fruits and vegetables; this will help normalize your bowel movements. Also, drink six to eight glasses of water each day. You may need to take a laxative periodically.

Around the House: Saving Energy and Protecting your Joints

Stay Healthy

• Eat a well-balanced diet

• Maintain a healthy weight

• Exercise

Whether you have reached all the recommended goals in three months or not, you should have an exercise program in place. By exercising, you can help maintain healthy muscles around your new joint. With the permission from your surgeon and family doctor, try to exercise routinely: three to four times per week, each session lasting 20-30 minutes. Remember, low impact activities are recommended. These include one to three mile walks, using a treadmill, stationery bike, an exercise program at a fitness center, or a home program.

Stay Safe and Avoid Falls

• If not done already, pick up throw rugs and tack down loose carpeting. Cover slippery surfaces with carpets that are firmly anchored to the floor or that have non-skid backs.

• Be aware of all floor hazards such as pets, small objects, or uneven surfaces.

• Provide good lighting throughout the home. If not already done, consider installing nightlights in the bathrooms, bedrooms, and hallways.

• Keep extension cords and telephone cords out of pathways. DO NOT run wires under rugs, this is a fire hazard.

• DO NOT wear open-toe slippers or shoes without backs. They do not provide adequate support and can lead to slips and falls.

• Sit in chairs with arms. It makes it easier to get up.

• Rise slowly from either a sitting or lying position. This helps prevent feeling dizzy or light-headed.

• Do not lift heavy objects for the first few months, and then only do so with your surgeon’s permission.

• Plan ahead. Gather all your supplies at one time. Put them within reach.

- 29 -

• Continue to avoid tobacco products as they hinder the healing process.

• Utilize your incentive spirometer during any extended periods of rest.

• Stop and think… use good judgment.

The Importance of Lifetime Visits

WRH has discovered that many people are not following up with their orthopedic surgeon on a regular basis.

The reason for this may be that they do not realize they are supposed to, or they do not understand why it is important. So, when should you follow-up? These are some general rules:

• Periodic visits as instructed by your surgeon

• Anytime you have mild pain for more than a week

• Anytime you have moderate or severe pain that requires medication.

• Anytime that you notice signs or symptoms of infection

There are two good reasons for follow-up visits with your orthopedic surgeon:

• If you have a cemented hip or knee, we need to evaluate the integrity of the cement. With time and stress, cement may crack. You probably would be unaware of this happening, because it usually happens slowly over time. This typically does not occur in the first 10 years, but it occasionally can.

After 10 years of use, the incidence is greater. Seeing a crack in cement does not necessarily mean you need another surgery, but it does mean we need to follow things more closely. Why? Two things could happen. Your hip or knee could become loose and this might lead to pain. Or, the cracked cement could cause a reaction in the bone, called “osteolysis”, which may cause the bone to thin out. In both cases, you might not know this for years. Orthopedists are constantly learning more about how to deal with both of these problems. The sooner we know about potential problems, the better chance we have of avoiding problems that are more serious.

• The second reason for follow-up is that the plastic liner in your knee or hip may wear. Little wear particles may get in the bone and cause osteolysis, similar to what can happen with cement. (Again, this may cause the bone to thin out). Replacing a worn liner early can keep this from happening.

X-rays will be taken at your follow-up visits, which will help detect these potential problems. New

X-rays will be compared with your older films to make these determinations.

We are happy that most patients do so well that they do not think of us often. However, we enjoy seeing you and want to continue to provide you with the best care and advice. If you are unsure how long it has been or when your next visit should be scheduled, call your surgeon. He or she will be delighted to hear from you.

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Total Knee Home Care Instructions

Activity

• Refer to your Joint Academy book

• Perform your exercises three times each day

• Walk with your walker (or crutches) at all times

• Progress to use of cane at 2 to 3 weeks if able, or as directed by your therapist or physician

• Walk 3 or 4 times a day, gradually increase the distance

• Get up and move about frequently throughout the day to avoid stiffness

• You may climb stairs as tolerated

• You may ride in a car

• You may drive in two weeks if off narcotic pain medication and your surgery was on the left leg

• You may drive in six weeks if off narcotic pain medication and your surgery was on the right leg

• For swelling of the lower legs, elevate your leg while in bed. Elevate the leg on 2-3 pillows turned lengthwise under your leg for 40 minutes, 2 or 3 times a day, “toes above your heart” (refer to patient education book). You may bear weight on your surgical leg

Wound Care

• Gently clean the entire length of the incision with soap and water daily, pat dry

• No lotions, creams powders on the incision until after three weeks and/or the staples are removed

• Use ice on the wound area as needed, 20-30 minutes at a time for pain and swelling

Preventing Blood Clots

• Wear your support hose during the day for the first two weeks

• Perform your exercises faithfully

Special Instructions

• Notify your surgeon if you have a temperature above 102°

• Notify your surgeon if you have drainage from your incision

• Notify your surgeon of swelling of the lower leg that does not improve with elevation and there is warmth and pain in the calf area

• Seek immediate attention at an emergency room with shortness of breath and/or chest pain

• For any other questions about your knee surgery contact your surgeons office

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Total Hip Home Care Instructions

Activity

• Refer to your Joint Academy Surgery book

• Total Hip Precautions for 6 weeks: No hip flexion past 90°, no twisting/turning, no crossing legs; chair, bed and toilet seat height must be 20 to 21 inches high, use a reacher and elevated toilet seat

• Perform your exercises three times each day

• Walk with your walker (or crutches) at all times

• Progress to use of cane at 2 to 3 weeks if able, or as directed by your therapist or physician

• Walk 3 or 4 times a day, gradually increase the distance

• Get up and move about frequently throughout the day to avoid stiffness

• You may climb stairs as tolerated

• You may ride in a car

• You may drive in two weeks if off narcotic pain medication and your surgery was on the left hip

• You may drive in six weeks if off narcotic pain medication and your surgery was on the right hip

• For swelling of the lower legs, elevate your leg while in bed. Elevate the leg on 2 to 3 pillows turned lengthwise under your leg for 40 minutes, 2 or 3 times a day, “toes above your heart”

(refer to the patient education book) p

You may bear ____________ weight on your surgical leg

Wound Care

• Gently clean the entire length of the incision with soap and water daily, pat dry

• No lotions, creams powders on the incision until after three weeks

• Use ice on the wound area as needed, 20-30 minutes at a time for pain and swelling

Preventing Blood Clots

• Wear your support hose during the day for the first two weeks (you will need assistance to apply)

• Perform your exercises faithfully

Special Instructions

• Notify your surgeon if you have a temperature above 102°

• Notify your surgeon if you have drainage from your incision

• Notify your surgeon of swelling of the lower leg that does not improve with elevation and there is warmth and pain in the calf area

• Seek immediate attention at an emergency room with shortness of breath and/or chest pain

• For any other questions about your hip surgery contact your surgeons office

For any other questions about your hip surgery, contact your surgeons’ office

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Chapter 6: Do’s and Don’ts

The Three Hip Precautions

You will be in danger of dislocating your hip if you do not follow the precautions below:

1. Never bend beyond a right angle. This means you may not lift your knee higher than your hip or lean forward with your body. Never sit in a chair with your knee higher than your hip.

Example: never bend down to put on a shoe or lean forward when you are sitting.

2. Do not combine flexion and internal rotation of your operated leg. Example: never place your foot out to the side while sitting. Do not internally rotate your leg.

3. Do not cross your leg over the midline of your body If lying on your unoperative (good) side when in bed always support the operative leg with pillows to avoid crossing the midline and to maintain the leg in a neutral position.

Example: do not cross your legs or ankles.

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General Guidelines

As you recover from your hip replacement surgery, please remember the following:

• Follow the hip precautions.

• Follow your exercise program given to you by your physical therapist or occupational therapist.

• Gradually, you will be able to increase your activity level as your endurance increases. This will take several months.

• Avoid any sudden jarring or twisting motion of your hip.

• Use the recommended adaptive equipment to help with self-care while adhering to your hip replacement program.

• Do not lean forward from the back of your chair.

• Do not flex your hip beyond a right, or 90 degree, angle.

• Never sit in a low chair or sofa.

• If a chair is too low, place several firm pillows on the seat to avoid sitting at a right angle.

• Always keep needed objects within reach to avoid bending, use reacher if needed.

• Turn on lights to see where you are going

• Always wear rubber-soled shoes when walking to avoid slipping.

Dressing:

Note: when undressing, remove clothing from non-operative leg first for increased ease of movement.

Pants and underwear:

1 Sit on the edge of the bed or chair with the adaptive equipment within reach. Hook the waist of the underwear or pants with the dressing stick and lower it down to the operated leg first. Then, slip pant leg over the operated leg, followed by the non-operated leg.

2 Pull the pants up over your knees.

3 Stand up with the walker and pull the pants up.

Socks and stockings:

1 Slide the sock or stocking over the sock aid. Make sure the toe is tight against the aid.

2 Drop the sock to the operated leg holding on to the cords.

3 Slip your foot into the sock and slide it on.

4 You may put the sock on your non-operated leg by bringing your leg up. If you are unable to, you may use the sock aid for this leg also.

Shoes:

1 Slip on shoes, or shoes with elastic laces, are recommended.

2 Use a long handled shoe horn to put your shoes on and off.

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Positioning in Bed:

Lying on your back:

1 Keep a pillow, or abduction pillow (large blue wedge) between your legs when lying on your back to prevent legs from crossing.

2 Do not cross your legs.

Lying on your side:

1 You should get approval from your surgeon to lie on your side.

2 Once cleared by your surgeon, you should always keep a pillow between your legs. This should be done for approximately six weeks.

3 Do not allow your operative leg to fall off the pillow and cross your bottom leg.

Getting In and Out of Bed

Getting in to bed:

1 Sit down on the edge of the bed the same way you would sit in a chair.

2 Push your buttocks back on the bed as far as you can angling toward the head of the bed with the operated leg going into bed first on the same side you had surgery.

3 Once the operated leg is lifted onto the bed then lift the non-surgical leg into the bed while lying flat on your back.

Getting out of bed:

1 When getting out of bed, slide your legs over the edge of the bed leading with your non-operated

leg.

2 Push yourself to sitting using your arms, remember the 90 degree rule when sitting, avoid rolling on your side.

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Positioning in a Chair

Always keep your hip at an angle less than 90 degrees. When your knees are above your hips, the angle is

GREATER than 90 degrees. This can occur when you sit in a low chair/toilet, or when you bend forward.

1 When sitting, your knees must be below your hips.

2 Use an abduction pillow between the legs for several days after the operation. Keep the operated leg elevated to control swelling.

3 Always sit in a chair with armrests to assist with sitting and standing.

4 If the chair is too low, place several pillows on the chair to avoid sitting at an angle greater than 90

degrees.

5 To raise your toilet seat height at home you will need a commode seat/chair.

6 Keep objects within reach to avoid bending forward.

Sitting and Rising from a Chair

Do not sit in a chair that does not have arms. Select an armchair with a firm and fairly high seat - a “captain’s” or dining room chair are good choices.

To sit down in a chair:

1 When you have approached the chair, turn and back up until you feel the chair with the back of your legs.

2 Place the operated leg far out in front of you. This is very important.

3 Place the two crutches/or walker in the hand of the non-operated side, and place the free hand on the arm of the chair.

4 Gently ease down into the chair.

5 Once you are seated, you may bring your operated leg back so your foot is under your knee.

6 The ankle and knee should be exercised while sitting to avoid stiffness.

7 In the early stages avoid sitting for long periods of time. Get up every 20 to 30 minutes to stretch up and down on your tiptoes or take a walk before sitting

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To rise up from a chair:

1 Place the foot of the operated leg as far out in front of you as possible.

2 Bring your hips forward to the edge of the seat. Keep your hip positioned at less than 90 degrees.

3 Again, place the operated leg out as far as possible.

4 Push up with both hands on the arms of the chair and rise on your non-operated leg.

5 Do not try to use your operated leg in standing up.

6 Transfer your hands to the handles of the walker

7. Never pull up on the walker

If using crutches, stand by pushing up from the chair with one hand and pushing up from the grips of the crutches held in the other hand. Once standing, place one crutch under each arm.

Gait Training (Using a Walker, Crutches, and Canes)

Gait training means learning to walk after you have had hip surgery. You will begin by using a walker until you are steady on your feet. You may then progress to using crutches and then a cane.

Walkers, crutches, and canes:

These devices provide support through your arms to limit the amount of weight on your operated hip. Initially, after a total hip replacement you will use a walker to get around. Your therapist may advance you to crutches when you are ready. Eventually, you can advance to a cane when your surgeon clears you to put more weight on your leg. The amount of weight bearing on your leg ordered by your surgeon can be:

Touch down weight bearing: almost no body weight should be placed on the operated leg; just touch the foot to the floor for balance.

Partial weight bearing: 20%-50% of your weight can be placed on the operated leg.

Weight bearing as tolerated: as much body weight as you are able to put on the operated leg.

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Gait pattern for using a walker:

1. Place the walker one step ahead of you.

2. Lean into it and pick up the operated leg, bend the knee and step forward, planting the heel down first.

3. Do not turn your knee inward or outward.

4. Bring the non-operated (good) leg up in front of the operated leg.

5. Repeat the process.

6. Remember: Put only the amount of weight on your operated hip that was specified by your doctor or therapist. Always use caution!

7. Place all four legs of the walker flat on the floor before taking a step.

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Gait pattern for using crutches:

1 Place the two crutches one step ahead of you and slightly to the side.

2 Place weight on your good leg and bring the operated leg up between the crutches.

3 Bring the non-operated (good) leg up beyond the crutches.

4 Example: if your right hip was operated on, the sequence is crutches, right foot, left foot.

As you gain strength and endurance, you will advance to a three-point gait pattern. This means you will move the crutches and the operated leg at the same time, and then move the non-operated leg beyond the crutches.

It is important to remember that while standing still, the crutches should always be kept in front of you and slightly out to the side. If the crutches are even with your body when you are standing still, they will not keep you from falling. Also, do not carry your weight on the armpits when using crutches. This can cause permanent nerve damage. The weight should be taken on your hands and your non-operated leg. The physical therapist will instruct you in proper gait training with crutches and how much weight is allowed on your operative leg.

Climbing and Descending Stairs

If the banister is secure and sturdy, hold both crutches under the arm opposite the banister and use the banister when you climb and descend the stairs.

If you are not using a banister, place one crutch under each arm and follow the instructions below.

Climbing stairs:

1. Stand close to the bottom step.

2. Step onto the first step with the non-operated (good) leg.

3. Bring the crutches on to the same step.

4. Bring the operated (bad) leg to the same step.

5. Make sure your feet and the crutches are completely on each step.

6. If someone is with you, have them follow you.

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Descending stairs:

1. Stand on the top step with your toes just over the edge of the step.

2. Bring the crutches down onto the first step.

3. Bring the operated (bad) foot onto the same step.

4. Step down with the non-operated (good) leg onto the same step.

5. Make sure your feet and crutches are completely on each step.

6. If someone is with you, have them in front of you, facing you.

Getting In and Out of a Shower

Use a stall shower if you have one. It will be easier to get in and out of. It is okay to use a tub shower, but follow the directions below:

To get in the stall shower:

1. Walk into the shower with your walker.

2. First, place the walker in the stall.

3. Follow with your operated leg then your non-operated leg.

4. You can either stand up to shower or sit in a chair.

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To get into a tub shower (do not take a bath):

1.

2.

3.

4.

5.

Use a tub bench. Do not sit in the bottom of the tub.

Walk to the tub seat with your walker and face away from the tub.

Keep one hand on the walker and reach behind with the other hand for the back of the chair.

Gently sit down on the chair with your operated leg out straight.

Lift your legs into the tub helping your operated leg with your hands.

How to get in and out of a car:

Before entering a car, have someone slide the passenger seat all the way back and recline it slightly to create more leg room. For cloth seats, placing a plastic garbage bag over the seat makes it easier to slide.

Note: please do not drive until your doctor tells you to.

Front seat:

1 Open the front door and back up to the front seat all the way.

2 Place one hand on the dashboard and the other hand on the back of the front seat. Roll down the window and place your hand on the windowsill.

3 From a position of standing on the pavement sit down on the front seat.

4 Slide back into the seat as far as possible in a semi-reclining position.

5 Then bring each leg into the car, helping the operated leg into the car with your hands.

6 Keep the operative leg straight (seat should be pushed back as far as possible so leg can be straight).

7 Reverse the procedure to get out of the car.

Back seat:

Enter the car from the side that allows your operated leg to be supported by the car seat. Example:

You would enter from the driver’s side if you had a left hip replacement or from the passenger side if you had a right total hip replacement.

1 Slide back into the seat as explained above.

2 Reverse the procedure to get out of the car.

Common obstacles to car travel:

1. Seats do not recline: Use the backseat method, if possible.

2. Patient is over 6’2” tall Sit in the back seat.

3. Own a van or SUV: Use a sturdy step stool to get in.

4. Difficulty sliding onto seat: Place a garbage bag on seat before sitting down.

Problems You May Encounter at Home

Excessive swelling of your leg and foot. Many people do develop some swelling in the first few weeks after surgery.

If this occurs, you should elevate your leg whenever you are not up walking. However, excessive swelling of the foot and lower leg can be due to thrombosis (blood clots) in the veins in the leg. We should be notified if swelling is associated with pain or tenderness in the calf muscles, if it seems excessive, if it doesn‘t respond to elevation, or you are just as swollen in the morning as the night before.

Chest pain or shortness of breath may be signs of embolism. Please do not ignore these symptoms. Seek medical attention right away.

Drainage from the wound, or increasing redness around the wound, could signify impending infection. Your surgeon‘s office should be notified, and in most instances you will need to come in and have it checked. Your dressing change routine and medications may need to be adjusted. In the meantime, clean with soap and water and cover with dry sterile gauze twice a day or as needed. If you have drainage, do not shower and notify your surgeon.

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Occasionally a pocket of fluid [a hematoma if bloody fluid; a seroma if clear fluid] develops under the closed incision. This collection of fluid can give a hardness to the skin over this area. As the surgical wound heals, the body reabsorbs this fluid most of the time and the area softens. Occasionally this fluid finds an opening in the incision and drains out. Hematomas drain dark maroon colored fluid and seromas drain a clear yellowish fluid. If a hematoma happens to drain while you are still on the anticoagulant [that is within the first 2 weeks after your surgery] the initial darkish fluid may be followed by bright red bleeding. This occurrence can be startling if you are caught by total surprise. The majority of fluid that has collected can drain out in a short time and it may seem like it is an endless amount of fluid that is coming out. If the drainage continues, notify your surgeon.

High fever could also be a sign of impending infection. If you feel you have a fever, take your temperature. If you get two readings, at least three hours apart, of 102 degrees or more, you need to notify your surgeon. Your pain medication may have acetaminophen in it that helps keep your fever down. If you need to call, we will want to know when you last took your medication and what it is you are taking.

Increasing joint pain. Pain should be decreasing from day to day. If it seems to be steadily increasing, let your surgeon know.

Staples and Subcutaneous Stitches

Staples hold the outer skin edges together. Your surgeon leaves them in place for 10- 14 days. Toward the end of this time period you may notice some redness in the skin around each staple. This is common and considered a normal reaction. If the redness should extend beyond a half inch from the staple and there is increased tenderness, rather than decreased, then you should report it. The occurrence of drainage from the incision does not change when the staples are removed. Underneath the skin the tissue is held together with a dissolvable stitch material. This material doesn‘t start to dissolve or liquefy until around 4 weeks from surgery. So when the staples are removed from the skin, the surgical wound is still held together by this suturing underneath. At each end and sometimes in the middle of the incision there is a knot of this dissolvable stitch material. If this dissolves and a bubble of liquid ends up close to the surface of the skin as the surgical wound is healing, a bump forms and it may become tender. Usually the liquid gets absorbed and the tenderness goes away. Occasionally the skin opens a little and the liquid drains out. This liquid is white from the dissolved material and has startled some to think that it is pus. If this occurs, keep the area clean and covered. At times there is a piece of stitch material or thread that is visible. If any thread can be seen it needs to be removed. Once this material is exposed to the air it stops dissolving. It will act as an obstruction for the skin to close. Once removed, the area can resume its healing process.

Managing Leg Swelling After a Total Joint Replacement Surgery

Leg swelling is a common occurrence following joint replacement surgery. Excessive swelling may interfere with your return to normal activity and could lead to more serious complications. By understanding the dynamics of leg swelling and following the steps below, most of the swelling can be eliminated.

Arteries carry blood away from the heart to the outer areas of the body including the hip, knee and lower leg area. Blood is returned to the heart through the venous system. Proper venous return from the lower extremities depends on the integrity of the valves within the veins and is assisted by muscle contraction during activity. The valves allow blood to pass through going toward the heart, but keep it from flowing back down with the force of gravity. Following a joint replacement operation muscle contracture is decreased because of low activity level.

The veins become distended and the valves become less effective. When the legs are continuously in a hanging down position with little activity, such as a sitting position, swelling occurs.

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Leg swelling occurs most frequently after a patient leaves the hospital. During the early postoperative period, a patient may be up and about but his or her activity level is still curtailed. Without regular walking and normal activity, blood remains trapped in the ankle or foot. Recognition of swelling is an important consideration.

Effective management is needed or correction of the problem. Think of swelling as a glass full of liquid, it is easy to see that position changes can make a radical difference. When the glass is tipped up, fluid pours out. Without activity related muscle contracture to act as a pump, we need to take advantage of gravity to remove fluid.

The position changes must involve a complete horizontal lying down with the legs elevated higher than the level of the heart. This should be done for an hour in the morning, and afternoon. The position is easily accomplished by lying on a sofa or bed, putting a pillow under the involved knee and calf, and raising the leg high above the level of your heart.

Raise Your Legs Higher than Your Heart

In this position, excess fluid is drained from the leg by force of gravity.

*Hip replacement patients just coming home from the hospital should lie on a high surface, such as a bed, and have pillows supporting the entire length for the leg.

Drainage by gravity cannot occur if the patient is sitting in a chair with the leg elevated on a stool. Remember, the leg must be higher then the level of your heart.

A second emphasis is on the issue of activity. You should be walking. During walking, the muscles contract and act as a pump to send the fluid back to the heart.

The ankle pump exercise that was taught in the hospital is also helpful for contracting muscles and reducing swelling. While lying in bed, point and flex both feet slowly.

Lastly, swelling can be controlled by the use of compression stockings. These stockings should be knee length and worn during the day. Put them on in the morning and leave them until bed time. Do not leave them on at night as they can lead to pressure sores on the heels.

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Post Replacement Prevention for Invasive Procedures:

There are recommendations by the American Academy of Orthopaedic Surgeons for antibiotic therapy prior to any invasive procedures for people with total joint replacement. According to these guidelines:

Patients with Total Joint Replacements should have antibiotic therapy before invasive procedures for a lifetime following a joint replacement. Follow the advice of your surgeon.

Dental procedures for which prophylactic antibiotics are recommended include:

• Dental extractions

• Periodontal procedures

• Urological procedures

• Ophthalmic procedures

• Vascular procedures

• Gastrointestinal procedures

• Colorectal procedures

• Obstetric and Gynecological procedures

If you have any concerns, please call your surgeon before scheduling a procedure.

Patients with total joint replacements are encouraged to maintained good oral health by performing daily brushing to remove plaque and regular professional dental care.

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Chapter 7: FAQs

We are glad you have chosen Western Reserve Hospital to care for you during your hip or knee replacement surgery. Often times, patients have many questions about their upcoming surgery; we have provided a list of questions that patients frequently ask. If you have further questions, please do not hesitate to ask. We want you to be completely prepared and informed for your surgery.

What is arthritis?

Arthritis is an inflammation of one or more joints that result in pain, swelling, stiffness and limited movement.

There are more than 100 different types of arthritis; however, the most common type is osteoarthritis.

What is osteoarthritis?

Osteoarthritis, also called degenerative joint disease or “wear and tear” arthritis, most frequently occurs in weight-bearing joints–such as the knees, hips and ankles. The disease affects the cartilage, which normally covers the ends of each bone and creates a smooth surface within the joint. With osteoarthritis, this smooth surface becomes rough and pitted and may wear away completely. Without cartilage to act as a shock absorber, the bones grind against one another, causing inflammation, pain and restricted movement. Bone spurs may also form. With age, most adults are affected by osteoarthritis to some degree.

What are the symptoms?

The number one symptom is pain that is often described as deep and aching. Initially, pain may occur after activity and will be relieved with rest; however, as the disease progresses, pain may be felt with minimal movement. In severe cases, there is even pain at rest. Joint stiffness, lasting 20 to 30 minutes is also common, especially upon waking or following periods of inactivity. Other symptoms may include crackling, tenderness, joint enlargement and loss of flexibility.

What is knee replacement?

Knee replacement, also known as total knee replacement or knee arthoplasty, is a surgical procedure that is performed to remove worn, diseased or damaged bone and cartilage and replace it with an artificial joint, or prosthesis, that is made of metal and plastic. Undergoing knee replacement surgery can help relieve pain and allows patients to return to normal everyday activities. For those who have become bow-legged or knock-kneed over the years, it can also straighten the legs into a more natural position.

What is hip replacement?

Hip replacement is a surgical procedure that involves removing a worn, diseased or damaged hip joint and replacing it with an artificial joint, called a prosthesis. The artificial joint is composed of a ball and socket component made of metal and plastic or ceramic. Having a hip replaced can help relieve pain and get you back to enjoying normal everyday activities.

What are the major risks?

Most surgeries go well, without any complications. However, we do take precautions to reduce the risk of complications. Infections and blood clots are the two risks we focus most on. To avoid these complications, we may use medications and mobilize you early. We also take special precautions in the operating room to reduce the risk of infections. Those having a hip replacement: dislocation of the hip after surgery is a risk. Your surgeon and physical therapists will discuss ways to reduce that risk.

Will I need a blood transfusion?

Although not typical, you may need a blood transfusion after surgery. Bank blood is considered safe, but we understand if you want to use your own. For more information about donating your own blood, talk with your surgeon.

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How long does the surgery take?

We will reserve two hours for your surgery. Some of this time is spent preparing for surgery. Actual time spent in the operating room is about 90 minutes.

Do I need to be put to sleep for this surgery?

You may have a general anesthetic, which most people call “being put to sleep.” Some patients may be a candidate to have a spinal or epidural anesthetic, which numbs your legs only and does not require you to be asleep. Most would agree that you do not want to be awake for this kind of surgery. For this reason, no matter what approach of anesthesia is used, you will be sedated. The choice is between you and the anesthesiologist.

Will the surgery be painful?

Yes, you will have discomfort after surgery. Remember, the arthritis pain will be gone; however, you will have surgical pain. Many patients report this pain being more tolerable than the pain they had before surgery. And the best part; it will improve. Your surgeon, anesthesiologist, nurses, and therapists will make a specific pain management plan just for you to keep you most comfortable after your surgery. Please let us know if you feel there is something more that we can do. Our goal is to keep you at a comfortable pain level.

Will I need a walker after surgery?

Yes. We recommend that you use a walker or crutches for approximately 3-4 weeks after surgery. You will be instructed by your therapist and surgeon on when to stop using this equipment. While you are in the hospital, the therapists will teach you how to use a walker. Most of our patients go home with a walker because it is the most stable option for your balance after surgery.

Will I need any other equipment?

Those having a hip replacement may need a high toilet seat for a few months. You will be taught to use assistive devices to help with lower body dressing and bathing. You may benefit from a bath seat or grab bars in the bathroom. We encourage you to review Chapter 1 of this booklet to review the possible assistive equipment available. These are not covered by most insurances and it would be beneficial to purchase them prior to your surgery. Your occupational therapist will teach you how to use them while you are in the hospital.

How long will I be in the hospital?

Most patients are discharged on the second or third day after surgery. For example, if your surgery is Tuesday, you would be sent home on Thursday or Friday. Remember, there are several goals to achieve before leaving the hospital.

Where will I go after being discharged from the hospital?

Our goal is to get every patient directly back home, however you will need somebody to stay with you for the first two weeks. A social worker and case manager will help you with this decision and make the necessary arrangements, if needed.

Will I need help at home?

Yes. For the first several days or weeks, depending on your progress, you will need someone to assist you with meal preparation, laundry, cleaning, etc. Family or friends should be available to help.

What if I live alone?

Your progress will be watched closely. If you are unsafe to go home by yourself, our social worker and case manager will discuss different options with you. Most patients generally do better if they can return to their familiar home environment. One option available is to return home with family support. Sometimes a home health nurse, home physical or occupational therapist may be indicated. If a skilled nursing home is needed, our case management team will make those arrangements for you while you are in the hospital.

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Will I need physical therapy when I go home?

Knee patients: Yes. We encourage you to make an appointment with our outpatient physical therapy departments, “Easy Street”, Main Street or at Cuyahoga Falls Natatorium after leaving the hospital. Try to make your first appointment ahead of time: this should be made for the first business day after you go home. Your therapist will establish a schedule with a frequency of visits and duration of therapy. Physical Therapy in your home may also be an option through a home health care company as approved through your insurance. They will come to your home and establish a home PT program for you with follow-up visits as indicated. Our case management team can assist you with both of these options as ordered by your surgeon.

Hip patients: Yes, your recovery involves a progressive walking program. Typically, patients do need physical therapy once discharged from the hospital. If you do, our social worker and case manager will help arrange this for you.

Do I have any restrictions after surgery?

Yes. High-impact activities, such as running, tennis and basketball are not recommended. Injury prone sports such as downhill skiing are also dangerous for the new joint. Some hip patients will be restricted from crossing their legs, bending their hips more than 90 degrees, and twisting/pivoting for the first six weeks after surgery.

What are some safe activities I can do after I recover?

You are encouraged to participate in low-impact activities such as walking, dancing, golf, hiking, swimming, bowling, and gardening.

When can I can drive?

Do not drive without the permission of your surgeon. The ability to drive depends on whether surgery was on your right or left leg, and what type of car you have. If the surgery was on your left leg and you have an automatic transmission, you could be driving again in two weeks. If the surgery was on your right leg, your driving could be restricted at least six weeks. Of course no driving can be done while taking pain medications as they can interfere with your alertness, your judgment, and your reaction time.

When can I go back to work?

Do not return to work without the permission of your surgeon. Usually, we recommend you take at least 6-8 weeks off from work. Length of time before you can return to work can also depend on what your job is. A therapist can make recommendations for joint protection and energy conservation on the job.

How often do I need to see my surgeon?

You will be seen for your first postoperative office visit within two weeks of your surgery. The frequency of followup visits will depend on your progress. Many patients are seen at two weeks, twelve weeks, and then yearly. Your surgeon will let you know when to schedule your next visit.

Will I notice anything different about my new hip/knee?

Knee patients: Yes. You may have a small area of numbness on the outside of the scar; this is not serious.

Hip patients: In many cases, patients with hip replacement think that the new joint feels completely natural.

However, we recommend avoiding extreme positions or high impact physical activity. The leg with the new hip may be longer than it was before. This could be from a previous shortening caused by the hip disease, or because of a need to lengthen the hip (to help prevent dislocation). Most patients get used to this feeling in time, or can use a small lift in the other shoe. Some patients may have aching in the thigh for a few months after surgery.

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Chapter 8: Possible Complications

What are the possible complications?

Tell your orthopaedic surgeon about any medical conditions that might affect the surgery. Joint replacement surgery is successful in more than 9 out of 10 people. When complications occur, most are successfully treatable.

The surgeons and staff at WRH do everything possible to prevent any complications but at times they may occur.

Complications can include the following.

Infection

Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics.

Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood Clots

Blood clots result from several factors, including your decreased mobility causing sluggish movement of the blood through your leg veins. Blood clots may be suspected if pain and swelling develop in your calf or thigh. If this occurs, your orthopaedic surgeon may consider tests to evaluate the veins of your leg. Several measures may be used to reduce the possibility of blood clots, including:

• blood thinning medications (anticoagulants)

• elastic stockings

• exercises to increase blood flow in the leg muscles

• plastic boots that inflate with air to compress the muscles in your legs

Despite the use of these preventive measures, blood clots may still occur. If you develop swelling, redness or pain in your leg following discharge from the hospital, you should contact your orthopaedic surgeon.

Loosening

Loosening of the prosthesis within the bone may occur after a total joint replacement. This may cause pain. If the loosening is significant, a revision of the joint replacement may be needed. New methods of fixing the prosthesis to bone should minimize this problem.

Dislocation

Occasionally, after total hip replacement the ball can be dislodged from the socket. In most cases, the hip can be relocated without surgery. A brace may be worn for a period of time if a dislocation occurs. Most commonly, dislocations are more frequent after complex revision surgery.

Wear

Some wear can be found in all joint replacements. Excessive wear may contribute to loosening and may require revision surgery.

Prosthetic Breakage

Breakage of the metal or plastic joint replacement is rare, but can occur. A revision surgery is necessary if this occurs.

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Nerve Injury

Nerves in the vicinity of the total joint replacement may be damaged during the total replacement surgery, although this type of injury is infrequent. This is more likely to occur when the surgery involves correction of major joint deformity or lengthening of a shortened limb due to an arthritic deformity. Over time, these nerve injuries often improve and may completely recover.

Failure to heal:

Smokers, diabetics, rheumatoids, malnurished and people with other systemic diseases may be slow to heal or not heal at all. Failure to heal may result in continued pain or subsequent surgeries.

Blood vessel, tendon, ligament, skin or soft tissue damage:

All of these structures must be moved out of the way to perform orthopaedic surgery. In rare cases scarring and damage may occur.

Loss of a limb or Death:

Rarely occurs and we assure you that the staff at WRH does everything possible to ensure you have a safe and uneventful surgical experience.

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Chapter 9: Conservative treatments to Osteoarthritis

Modifications in lifestyle, weight loss, diet changes and controlled exercise can all benefit the arthritic patient.

Non-Steroidal anti-inflammatory (NSAIDS) medications:

Unfortunately side effects are also well known which may include gastrointestinal ulcers. This type of medication is also limited to those with normal liver and kidney function. New Cox II specific NSAIDS have provided a broader range of patients the opportunity to utilize NSIAD medications.

Cortisone Injections directly into the joint space in some cases can provide temporary relief of arthritic symptoms.

Chondroprotective Agents: Have been brought to the public’s attention by recent research. Newer research is focused on slowing the progression of osteoarthritis. Examples of such agents include: hyaluronic acid injections, glucosamine and chondroitin sulfate supplements.

Hyaluronic Acid serves as a lubricant and shock absorber in the synovial fluid, injections of this substance provide additional lubrication of the synovial membrane. It is injected into the joint and is well tolerated.

Glucosamine is a substance normally found in our bodies, In laboratory studies, glucosamine was demonstrated to be a stimulator of the process that builds new cartilage cells. It is felt that supplementation of one gram of glucosamine daily may offer protections of cartilage. It is usually well tolerated without toxic effects.

Chondroitin Sulfate is also a substance normally found in our bodies. It is found in cartilage, tendons, bones, disks, the cornea and heart valves. Among many things, it is known to inhibit enzymes that break down cartilage. A daily dose of 1200 mg has been shown in clinical studies to reduce pains associated with arthritis and was tolerated without side effects.

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1900 23rd Street, Cuyahoga Falls, OH 44223

(330) 971-7258 | westernreservehospital.org

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