Learn about what to expect through the process of managing your hip and knee problems.
Your initial consultation with your surgeon is very important as it forms the basis for your treatment. On your first visit, we will take a comprehensive medical history, with special emphasis on your hip or knee problem. A thorough and complete orthopaedic examination will be conducted by your surgeon to rule out other conditions that may be causing your symptoms. Most likely, ancillary studies such as X-rays will be requested to complete the evaluation if you have not had any previous and recent radiographs. We greatly encourage that you prepare for this visit by bringing with you the following:
- Referral letter from your GP
- Any previous X-Rays, MRI studies, bone scans or other studies of the region involved
- A written list of questions you may have.
- A list of your current medications (with dosages).
- A list of physicians you have seen in the past 2 years (with contact details, if possible). We routinely update the physician who referred you to us. We can also inform any other physician upon request.
- Any family members or friends you may want to have present to help in the discussion and decision making process.
- By the end of the initial consult, we would have discussed with you the pathology or orthopaedic condition that causes you symptoms, the treatment options, and the pros and cons of each alternative treatment. Depending on the complexity of your condition, we may also ask for further tests.
While we firmly believe in non-operative management of most hip and knee disorders, in some situations, either because of the basic nature or severity of the orthopaedic condition, we may recommend an operative approach. In these situations, the procedure is also discussed. You do not have to make a decision to proceed to surgery during this consult. While some patients are very much decided to have an operation even before the consult, many reserve the decision for a latter time after discussing it with friends and relatives.
Information sheets will be provided for patients to increase their knowledge regarding their condition and specifics of the operation and post-operative rehabilitation. You are encouraged to go over the materials prior to surgery and bring them with you as reading material on your hospital admission.
Reasons for a follow-up consult may vary. Mostly, it is to monitor for efficacy of non-operative treatment options. On some occasions, you may need to ask further questions that had not come up during the initial consultation. It may also be to indicate a decision to proceed to an operative treatment and to book the procedure. While the latter may be done on the phone, scheduling may involve working around a time when it is best for you, your relatives, and the surgeon; thus, a follow-up consult to discuss this timing may be appropriate.
Selecting a Date for Surgery
Selecting the exact date for surgery must be done after some thought. You must be both physically and mentally prepared for surgery by the designated schedule. Also, it must be a time where you may take some time off to recuperate after the procedure. Equally important is the availability of any support groups at home a week or so after the surgery to help in your rehabilitation. While the latter is not mandatory, it is preferred that somebody look after you during this time. Booking with a rehabilitation centre may also be an option if there is nobody else at home. Enough time must also be given to have the necessary blood work done and proper evaluation by a physician if necessary.
While many of these things may be accomplished sooner, most bookings are filled to about a month or so from the day you make a decision to proceed with surgery.
Setting an Appointment with the Anaesthetist
If you present with medical co-morbidities that may increase the risk for complications after surgery, your surgeon might opt to refer you to either an internist or arrange for a consultation with an anaesthetist prior to surgery. These specialists may order further ancillary tests and will assess your fitness for surgery. They may also make recommendations that would be crucial in making the operation as safe for you as possible.
For patients undergoing total joint replacement, admission on the afternoon before the surgery date is preferred. This allows for Dr Morgan or Dr Gamboa to have a final evaluation of you before the surgery and enables you to ask any final questions before the procedure. Also, you will be given you first dose of the anti-clotting agent the night before surgery.
Before going in to hospital, prepare the following items to bring in for your stay.
- Information sheets provided to you during previous consults regarding the surgery and post-operative rehabilitation
- While the hospital will provide you with comfortable gowns to wear while in hospital, you may bring your own if you wish
- Toiletries and make-up kits
- A list of important phone numbers, including those of relatives and friends whom you want us to call before and after your operation
- Comfortable footwear with non-skid soles
- Your favourite pillow, if you wish
- Medical insurance card
- Reading materials
- Walking aids such as crutches and walkers (if you already have them)
- We discourage the bringing of any valuables including large amounts of cash during your stay at the hospital. Credit cards are preferably handled by your relatives or friends.
The Heart and Lung Specialist and Anaesthetist will also have a final evaluation before surgery and will be more than willing to answer any queries that you may have. The anaesthetist will discuss with you the options for anaesthesia. While our surgeons and the team of anaesthetists that they work with prefer using a spinal anaesthesia with light general anaesthesia in most of the total joint patients, your specific needs and medical conditions may lead the Anaesthetist to recommend alternative options. The final decision in the type of anaesthesia to use will be made by you and the Anaesthetist. We recommend that you discuss these options thoroughly.
The Night Before Surgery
The nursing staff will provide you with an iodine scrub and will request you to shower twice on the night before surgery. Please be very thorough in scrubbing the operative site to decrease the chances of infection. You will receive your first dose of the anti-clotting agent at around 8pm the night before surgery. You will be served with a hefty dinner and it is recommended that you take a heavy meal as you will have to refrain from having anything to eat or drink for six hours before surgery. An intravenous line will be inserted to provide you with water, electrolytes, and some glucose.
We also recommend that you do not smoke or drink an alcoholic beverage within 48 hours of your surgery as these may increase anaesthetic risk.
The Morning Before the Operation
Patients are requested to do a final scrub on the operative site the morning before surgery. We recommend that you relax while awaiting transfer to the operating theatre. Watching television and reading a good book may help keep your mind off the operation. You will be given some pre-operative anti-anxiety medications if you need them.
You will be brought down to theatre around 30 minutes before your operation. This gives the anaesthetist time to induce you. For most first time replacements, total operative time will range from 60 to 90 minutes. Revisions may take considerably longer.
After the operation, you will be sent to the recovery room where you will be closely observed for an hour or so before clearing you for transfer back to your room. Your surgeon will call any of your relatives after the operation upon request.
The Immediate Post-operative Period
You will wake up in the recovery room. Most patients are comfortable and are pleasantly surprised about being "pain-free". Hip patients will find an abduction brace positioned between their legs to keep the extremities in a "safe" position while knee patients will find a machine underneath the operated extremity that will constantly bend and extend the knee to encourage early range of motion. Patients with a higher risk for clots (see Deep Vein Thrombosis) will have a pneumatic compression device on their extremities to lessen the chance for thrombosis. Once it has been determined that you are stable enough, you will be discharged from the recovery room into the ward. In some instances, the Anaesthetist may request you be further observed in the Intensive Care Unit (ICU); this may not mean a serious or life-threatening situation. Instead, this is done to closely monitor patients with advanced age and potentially serious pre-existing medical conditions and lessen the chance for post-operative problems.
We believe in the need for excellent pain control. While this is traditionally achieved by using large doses of narcotics, we utilize large doses of local anesthetic to produce the desired effect. While narcotics cause drowsiness, nausea, and constipation, the use of this novel pain control regimen allows a patient to get up and about and ready for ambulation at a much sooner time. In fact, most of our patients walk on the day of the surgery a few hours after being brought back to the ward! While this is easily achieved in many of our patients with the absence of narcotics, other factors such as anaemia and general condition of the patient may preclude this activity on the same day as the surgery. One major advantage of using local anaesthetic is that urinary retention is also prevented in most patients. This lessens the chance that a urinary catheter will be required. Not only is a urinary catheter uncomfortable and painful on application and removal, it also increases the chance of subsequent infection.
Large doses of local anaesthetic (within safe doses as computed based on your body weight) are infiltrated in various tissues during the operation. This is usually sufficient to keep pain at bay until the following where other forms of pain control have also kicked in. Most patients are extremely surprised with the amount of pain relief they have. A small percentage may request for supplementary pain relief and the anaesthetist routinely orders “rescue” drugs in case you feel a need for them.
We routinely use powerful antibiotics prior to and after surgery to lessen the chance for infection. We will also maintain you on an anti-clotting agent while you are at hospital and after discharge. We will routinely give you Paracetamol to control your temperature as most patients may run a fever after such operative procedures. Mostly, fevers are caused by the post-operative metabolic processes and minimal post-operative lung collapse, conditions that are not considered as a source of major concern.
Drugs are also ordered for nausea, constipation, and sleep. Most of these drugs are ordered as "per need" medications, which means that they are not routinely administered unless you need them. Feel free to talk to your nurse about what we can do to make you as comfortable as possible.
Suction Drainage Tubes
Suction drainage tubes are placed deep in the wound and into the joint to remove oozing blood that may collect after surgery. These tubes are removed the day after surgery.
Operative Wound Care
Wound care is very important in infection control. Wounds must be kept dry and ward nurses will change dressings as required. However, as long as the wounds remain dry, routine dressing change is just done after removal of the drains and catheters. Subsequent changes are minimized unless dressings are soaked or if your surgeon opens up the dressings to inspect the wound.
We believe in the importance of good post-operative rehabilitation. We work with Stephen Boyd and his associates, a group fully equipped to get you up and about at the soonest possible time. Many of our patients are able to take a short walk on the day of the surgery while the rest are able to do so the following day. The physio will instruct you on the amount of weight bearing and range of motion that you may perform. They will also give complete instructions on necessary precautions to protect the surgery. Lastly, the physio will help you get back to doing daily activities, such as getting in and out of the bed on your own, toilet and shower on your own, and go up and down the stairs on your own. Once you can accomplish all these activities and your observation parameters are good, the team may decide that you are fit to be discharged from hospital. This is usually accomplished at 4 to 8 days after surgery. For some patients who are elderly or may have poor or no support at home, transfer to a rehabilitation unit may also be arranged prior to going home.
We encourage you to continue your exercises at home and try to be up and about as much as you can. Again, common sense is key as your body will tell you if you are doing too much. Rest as much as you have to and do not overdo it.
Preparing Your Home
In general, no drastic modifications need be done to your home. However, as with any patient, it would be common sense to put rubber mattings on slippery areas such as the toilet and bathing area. Railings are preferred in strategic places in the house while loose rugs and carpets that may slip are discouraged. Especially for hip patients, the bed may be arranged such that you can get out on the side of the bed that is recommended to you by the physio. It is also preferred that toilet seats be raised to prevent extreme flexion for hip patients. Specific instructions will be given by the physio prior to your discharge. It is better if someone can be at home with you for at least portions of each day to assist you with shopping, meal preparation, etc. Constant nursing care is rarely needed at home.
Things to Watch Out For
It is not uncommon to develop some swelling of the knee, foot and ankle in the weeks after surgery. If this occurs, you should elevate your leg on pillows when you are not up and about. However, should sudden swelling of the calf associated with tenderness and pain on doing foot pumps be experienced, it would be best to give us a call to rule out clot formation. Chest pain, shortness of breath, or cough may be signs of an embolism, do not hesitate to call us if you suspect this. Fever, drainage or redness on the wound, and increasing pain on the joint may signify an infection. Early evaluation and treatment is the key to a good outcome. Again, do not hesitate to call us if you are worried.
First Post-operative Follow-up Visit (staple removal)
Wound sutures or staples are usually removed on the fourteenth day after surgery. While we encourage patients to drop by the rooms to have us remove the staples and inspect the wound, patients who find this an inconvenience may request a local GP to perform the staple removal. You are requested to inform us if this is your intention as we will send you a staple removal kit and some waterproof dressings to take home with you.
After staple removal, we will apply a fresh dressing which you will have to maintain for a day or two after which the wound may be left exposed.
Second Post-operative Follow-up Visit
The next follow-up is about 8 weeks (2 months) after surgery. You will have a new x-ray taken before this consult. We will evaluate the surgical wound, your gait, and extent of pain relief. They will also evaluate the x-rays for evidence of implant migration. During this consult, strengthening exercises may be recommended should your rehabilitation be lagging. Depending on your status, you may also be given clearance for most activities such as driving, regular work, lying on your side, and completely weaning from any walking aid.
Third Post-operative follow-up Visit
The next follow-up will be 6 months after the surgery. Again, an x-ray will be taken. You will be requested to complete a follow-up form identical to the questionnaire that you filled the day before surgery. Along with the physical examination and radiographic evaluation, these will enable us to have an objective and measurable means of monitoring your progress and compare you with your preoperative state.
We are extremely interested in having an idea how our patients are doing. We therefore encourage patients to see us yearly to assess your latest condition and pick up any possible problems with your surgery. This enables us to advise you promptly, prevent progression, and solve present problems immediately before they become severe. Although mainly to assess your orthopaedic condition, yearly follow-ups are also meant to update us of your other medical and social concerns. Many of our patients also write or email us about significant events of their lives, not necessarily related to their hip or knee condition. Our practice is dedicated in sustaining the healthiest possible doctor-patient relationship.
Long Term Care of your Joint Replacement
The most common long-term problems with joint replacement are wearing of the plastic components and implant loosening. Even with the latest technology, no implant design is known to last forever. Annual visits to our rooms will ensure early detection and prompt management of these problems either through activity modification or surgery.
Joint replacements must be treated with care. High impact activities such as jogging and running, jumping, and strenuous sports must be avoided if possible. Lifting heavy objects should not be done. You must also try to watch your weight. The heavier you are, the more stress you put on the joints. Although an occasional twinge now and then may be normal for patients who have undergone surgery, persistent and progressive pain may signify loosening of components or a delayed infection. You must call the rooms to book an appointment if you have any of these symptoms. You must also be aware that any infection in other parts of the body may seed into the artificial joints via the bloodstream. Thus, any form of infection must prompt a visit to your GP for immediate management. We also recommend prophylactic antibiotic coverage for any dental work after your surgery. Always inform your dentist of your replacement and insist on coverage. Any other surgery, especially of the gastrointestinal tract, must be preceded by antibiotic coverage. Lastly, do not allow physicians to inject steroids into your artificial joint as this may also predispose it to infection.