Preparing for Joint Replacement Surgery

Shoulder Joint Replacement

Getting ready to undergo total joint replacement surgery begins weeks before the actual surgery date. Your doctor may request you take the following steps:

• I. What to do Before you Check In
• II. The Day of Surgery
• III. When You Get Home

I. What to do Before you Check In

Preparing for total joint replacement begins weeks before the actual surgery. In general, you may be told to:

1. Donate blood –While some total joint procedures do not require blood transfusion, you may need blood before or after surgery. You may use donor blood or plan ahead to make an autologous donation of your own. You may also have a family member or friend with the same blood type as you designate a donation specifically for you.
2. Exercise under your doctor’s supervision – It’s important to be in the best possible overall health to promote the best possible surgical experience. Increasing upper body strength is important to help you maneuver a walker or crutches after surgery. Strengthening the lower body to increase leg strength before surgery can reduce recovery time.
3. Have a general physical examination – You should be evaluated by your primary care physician to assess overall health and identify any medical conditions that could interfere with surgery or recovery.
4. Have a dental examination – Although infections after joint replacement are not common, an infection can occur if bacteria enter the bloodstream. Therefore, dental procedures such as extractions and periodontal work should be completed before joint replacement surgery.
5. Review medications – Your orthopaedic surgeon can tell you which over-the-counter, prescription medications and herbal supplements should not be taken before surgery.
6. Stop smoking – Breaking the habit is particularly important before major surgery to reduce the risk of post-operative lung problems and improve healing.
7. Lose weight – For patients who are overweight, losing weight helps reduce stress on a new joint.
8. Arrange a pre-operative visit – It’s important to meet with healthcare professionals at the hospital before surgery to discuss your personal hospital care plan, including anesthesia, preventing complications, pain control and diet. Bring a written list of past surgeries and medications and dosages you normally take at home.
9. Get laboratory Tests – Your surgeon may prescribe blood tests, urine tests, an EKG or cardiogram, and chest X-ray to confirm you are fit for surgery. These tests should be performed within 14 days of the scheduled surgery in order to be acceptable.
10. Complete forms – You will need to fill out a consent form for your surgeon confirming that you agree to have the operation and that you know the risks involved, as well as hospital forms about your past history, medications, previous operations, insurance and billing information.
11. Prepare meals – You may want to prepare meals in advance and freeze them so they’re ready when you return.
12. Confer with physical therapist – The physical therapist will record a baseline of information, including measurements of current pain levels, functional abilities, the presence of swelling, and available movement and strength. You will also practice post-operative exercises using either a walker or crutches.
13. Plan for post-surgery rehabilitative care – Total joint replacement recipients may need help at home for the first few weeks, including assistance bathing, dressing, preparing meals and with transportation. If you can’t arrange for someone to help you at home, you may need to stay in a rehabilitation or skilled nursing facility. A medical social worker can assist with arrangements. Home therapy visits should end when you can safely leave the house and outpatient physical therapy should begin.
14. Fast the night before – No eating or drinking after midnight before surgery; however, you may brush your teeth or have a few sips of water if you need to take medicines. Discuss the need to take medications such as insulin, heart or blood pressure pills with your doctor or nurse to make sure you don’t miss them.
15. Bathe surgical area with antiseptic solution – Use antiseptic scrub brushes supplied by your health team the night before and morning of to reduce the risk of infection. Tell the nurse if you are allergic to iodine or soap. If possible, shampoo your hair. You must remove all nail polish and make-up. Do not shave your legs within 3-4 days of surgery.

Getting Your House Ready

Some common things in your home may now be dangerous. To prevent falls, you should remove or watch out for:

• Long phone or electrical cords that lie across the floor
• Loose rugs or carpet
• Furniture you might trip over in stairs and hallways
• Stacks of books, piles of magazines,mail, etc.
• Pets that run in your path
• Water spills on bare floors
• Bare bathroom tile or slippery floors
• Ice or mildew on outdoor steps

It would also help to:

• Arrange the most frequently used kitchen utensils and food on shelves and counters that can be reached easily.
• Have a chair or stool handy in the kitchen to sit in while preparing and cooking food.
• Leave most frequently used dishes in the dish rack, and most frequently used foods in the most accessible cabinets.
• Have a rolling cart to take food from the refrigerator to the counter, and from the counter to the table.
• Have a walker bag or apron with pockets to carry small items such as glasses, books, silverware, etc.
• Attach a cup holder to your walker to carry drinks in covered cups.
•  Arrange for someone to care for or feed your pets.

Packing Your Bags

Make sure to take these things with you to the hospital:

• Exercise shoes with closed-in heel and non-slip soles
• Knee length robe or cover-up for walking in the halls
• Grooming items such as shampoo, toothpaste, deodorant, etc.
• A list of medications you are currently taking at home, including the name, strength and how often you take each medication
• Papers from the blood bank if you have donated your own blood
• A list of allergies (to food, clothing,medicine, etc.) and how you react to each one
• Any education materials you received in pre-admission classes
• A copy of your Living Will and Health Care Power-of-Attorney, if you have either one. Hospital personnel are required by law to ask for these when you are admitted. They will make a copy for your medical record and return the original.
• A copy of your insurance card
• A walker if you already have one, and a list of other adaptive equipment you may have at home with your name on all equipment you take to the hospital
• Glasses, hearing aid, and any other items you use every day
• Short gowns, pajamas, underwear, socks/stockings and one set of street clothes to wear home
• Leave jewelry, credit cards, keys and checkbooks home. Bring only enough money for items such as a newspaper,magazine, etc.

Hip Safety Precautions

Once you have a new hip, you will need to follow some safety rules. This will help you heal faster and keep your new hip from dislocating. One of these rules is to always sit with your knees lower than your hips. So before surgery, check around your house to see if you need to adapt anything by sitting:

• On the side of your bed
• In your favorite chair
• On the sofa
• On the toilet
• In the seat of your car

If your knees are not lower than your hips in any of those situations, you will need to change the height by making accommodations such as propping up with pillows or buying a raised toilet seat.

II. The Day of Surgery

What to Expect Throughout

Your hospital stay will progress something like this:

Pre-Op

• Arrive at the hospital at the appointed time.
• Complete the admission process.
• Have final pre-surgery assessment of vital signs and general health.
•  Remove all personal belongings – dentures, hearing aids, hairpins, wigs, jewelry, glasses, contact lenses, nail polish, all underwear – and leave them with your family or friends during surgery. You will be dressed in a hospital gown and nothing else.
• There will be several checks to make sure the correct joint is being replaced: your surgeon will review your X-ray and mark the area to be operated on; nursing staff will check the consent form you signed to make sure it agrees with the procedure on the operating room list.
•  Final meeting with anesthesiologist and operating room nurse.
•  Start IV (intravenous) catheter for administration of fluids and antibiotics.
•  Transportation to the operating room.

In Surgery

Many people will be with you in the operating room during your one to three-hour surgery, including:

• Orthopaedic surgeon(s) – your doctor(s) who will perform surgery.
• Anesthesiologist or nurse anesthetist – the doctor or nurse who gives you anesthesia.
• Scrub nurse – the nurse who hands the doctors the tools they need during surgery.
• Circulating nurse – a nurse who brings things to the surgical team.

Your surgeon and the anesthesiologist or nurse anesthetist will help you choose the best anesthesia for your situation. No matter what type of anesthesia you have, be assured you will not feel the surgery. Options include:

• General Anesthesia – You are put to sleep. Minor complications such as nausea and vomiting are common, but can usually be controlled and settled within 1-2 days.
• Epidural – You are numbed from the waist down with medicine injected into your back. (This is also used for women giving birth.)
• Spinal – Much like the epidural, you are numbed from the waist down with medicine injected into your back.

You may have any of the following inserted:

• An Intravenous Tube (IV) – This is placed in your arm and used to replace fluids lost during surgery, administer pain medicine, or deliver antibiotics and other medications.
•  A Catheter Tube – This may be placed in your bladder to help your healthcare delivery team keep up with your fluid intake and output. It is most often removed the day after surgery.
• A Drain Tube – This may be inserted in your bandage site to help reduce blood and fluid buildup at the incision.

Elastic stockings will be put on your legs to help the blood flow. You may also have compression foot pumps wrapped around your feet and connected to a machine that blows them up with air to promote blood flow and decrease the possibility of blood clots.

Immediately After

After surgery you will spend at least an hour in the recovery room. While there, your blood pressure and heart rate will be monitored closely until you are stabilized. You will have a mask over your face for oxygen.

You will find a large dressing has been applied to the surgical area to maintain cleanliness and absorb any fluid. If you had a hip replacement, you may also notice a V-shaped wedge pillow (abduction pillow) between your legs. This keeps your new hip in the best position while you are in bed.

Knee replacement recipients may use a continuous passive motion (CPM) machine to continuously bend and straighten the knee quadriceps (thigh muscles). This machine, propped under your leg in bed, helps keep your knee from becoming stiff after surgery.

Back in Your Room

Once your condition is stabilized post-surgery, you will be transported to your own hospital room where you will continue to have your vital signs and surgical dressing monitored. Once you’ve settled in, several members of your care team may drop in to orient you to your hospital routine.

Pain Management

Some patients experience back discomfort after surgery. This is caused by general soreness of the surgical area and the prolonged lack of movement before, during and after surgery. Periodic change of position helps relieve discomfort and prevents skin breakdown.

You will be able to have medicine for pain so you can move around without much discomfort.Make sure to talk with your doctor before surgery about your pain management options. You may receive pain medicine through your IV, through the epidural or in shots or pills.

Breathing

Right after surgery, the health team will remind you often to take deep breaths and coughs. It is very important to do this at least every 2 hours. Deep breathing can help prevent pneumonia or other problems that can slow down your recovery and lengthen your hospital stay.

Your doctor may want you to use a device called an incentive spirometer, which helps you breathe in and out correctly. Using it regularly can help keep your lungs clear.

Your Diet

Immediately after surgery, you can have a diet of clear liquids or soft foods as tolerated. If constipation becomes a problem later on, try:

• Eating 5-7 servings of fresh fruit and vegetables daily
• Eating a hot breakfast with a hot beverage daily
•  Increasing fiber in your diet with whole grain cereals and breads
•  Drinking at least 6-8 8oz. glasses of water daily
•  Increasing physical activity as much as you can tolerate

Positioning

If you are a hip patient, the head of your hospital bed should not be elevated more than 70 degrees during the first few days after surgery. Sitting up too high might allow the artificial ball to dislocate from the hip socket.

If you are a knee patient, your physician may order a leg splint called an immobilizer to keep you from bending your knee. It should be worn when you are out of bed or at night when you are sleeping.

A staff member will help you turn and change your position in bed. Make sure you avoid twisting your leg when turning in bed.When turning in bed you should have a pillow between your legs. Avoid resting with a pillow under your knee.

Exercising

You will be evaluated by a physical therapist, who will go over exercises and precautions for avoiding dangerous movements. You may be surprised at how soon after surgery joint replacement patients are encouraged to get up and start moving—often as early as the day of surgery. The more quickly you start moving again, the sooner you will be able to regain independence. Mild exercises of ankle pumping and gluteal sets are usually recommended by your physical therapist as soon as you are awake from surgery and able to perform them.

As You Recover

In the days following surgery, your orthopaedic surgeon, nurses and physical therapists will closely monitor your condition and progress.

You’ll spend a great deal of time exercising your new joint and continuing deep breathing exercises to prevent lung congestion. Gradually, your pain medication will be reduced, the IV will be removed, your diet will progress to solids and you will become increasingly mobile.

Physical therapy for knee patients will address range of motion. Gentle movement, such as the CPM machine, will be used to help you bend and straighten the knee. Your leg may be elevated to help drain extra fluid.

Your physical therapist will also go over exercises to help improve knee mobility and to start exercising the thigh and hip muscles. Ankle movements help pump swelling out of the leg and prevent the possibility of a blood clot. When you are stabilized, your physical therapist will help you up for a short outing using your crutches or walker.

Hip patients begin physical therapy soon after waking up from surgery, with your physical therapist helping you move from your hospital bed to a chair. By the second day, you’ll begin walking longer distances using your crutches or walker.Most patients are safe to put comfortable weight down when standing or walking. However, if your surgeon used a non-cemented prosthesis, you may be instructed to limit the weight you bear on your foot when you are up and walking.

Hip patients will also do exercises to tone and strengthen the thigh and hip muscles, as well as ankle and knee movements to pump swelling out of the leg.

Whether you are sent directly home or to a facility for rehabilitation will depend on your physician’s assessment of your abilities. In general, if you live with someone who will be assisting you, discharge home is the usual procedure. The case manager will make your arrangements for further home or outpatient physical therapy. Most patients can go directly home if it is deemed safe by their surgeon and physical therapists.

If you live alone or are in an environment at home where your safety is a question because you have not achieved your discharge goals, you may be recommended for placement in a rehabilitation center. These facilities are usually available to a patient for a 3-5 day stay, with emphasis on returning the patient home in a short period after aggressively addressing any problems with patient independence. If you live alone or are not progressing rapidly enough in therapy sessions and it is unlikely you will be able to do so in a rehab setting, a sub-acute facility may be recommended for a longer period of recuperation. Insurance coverage for these post hospital stays vary according to condition and plan and will need to be discussed by the patient, the case manager and the insurance company as warranted.

Before you are discharged home, you should be able to safely get in and out of bed, walk up to 100 feet with crutches or walker, go up and down stairs safely, access the bathroom and consistently remember to use hip precautions to prevent dislocation before going home. These tasks should be able to be completed independently or with minimal assistance.

Before you Leave the Hospital

Before you leave the hospital, you will learn how to:

• Get in and out of bed by yourself
• Walk down the hall with your walker or crutches
•  Get in and out of the shower by yourself
•  Get in and out of a chair
•  Manage steps at home
•  Get in and out of your car

III. When You Get Home

What to Expect, What to Watch For, & How to Recover Safely

When you leave the hospital, your family will need to bring extra pillows for you to sit on in the car. It will be most comfortable to sit in the front seat. Your physical therapist will show you how best to get in and out.

All of the tubes will be out. All that should remain is a bandage on your wound site. If you have been instructed to use an abduction wedge you will still need to use this at night when you are sleeping.

You’ll need to continue taking medications as prescribed by your doctor. You may be sent home with prescriptions for preventing blood clots, some of which require monitoring through blood draws two times per week. Make sure to take pain medication 30 minutes before exercises—it’s easier to prevent pain than to chase it later.

Your surgeon may recommend taking a multi-vitamin with iron daily for a month. You may also be advised to take 1-2 enteric-coated aspirin daily for 6 weeks and non-steroid anti-inflammatory medication for pain and swelling unless you are on blood thinners such as Coumadin or Lovenox. Check with your doctor about special precautions while on these bloodthinning medications.

Hip Precautions

After hip replacement, you will need to observe some important safety rules to help prevent dislocation. Here are some of the most frequently advised precautions. Review them with your surgeon and discuss how many months you will need to follow these, or any other safety rules prescribed after surgery:

• Don’t bend your hip past 90º
• Don’t cross your legs; keep knees 12-18 inches apart
• Don’t lean forward while sitting in a chair
• Don’t sit on a chair that does not have arms
• Don’t lean forward while sitting in bed
• Don’t sit more than 60 minutes at a time; get up and walk frequently
• Don’t sit on a toilet or commode that does not have handles or side arms
• Don’t let your knee move inward past your navel
• Don’t turn your feet in or out
• Do use pillows between your legs at night to keep your hips properly aligned

Special Equipment

Ask your occupational therapist about special equipment to help you do routine things for yourself without placing your hip in danger of dislocation. These tools include:

• Dressing sticks – to help you put on and take off your pants or underwear
• Long shoe horns – to help you put on your shoes
•  Elastic shoe laces – to make your laced shoes into slip-ons
•  Grabber – to help you pick up things without bending over, reach items from high and low shelves, get clothes in an out of front loading washers and dryers, etc.
•  Long-handled sponge – to help reach without stretching inappropriately
•  Soap on a rope – to prevent bending to retrieve items in the shower
•  Extender for woman’s razor – for shaving legs safely
•  Raised commode seat – to put your knees in proper position below hips
•  Bathtub benches and handrails – to improve bathroom safety
•  Handheld shower – for washing while seated
•  Long-handled feather duster – for dusting low and high items
•  Long handled Johnny Mop – for cleaning out the tub or shower

Knee Precautions

• Never rest with a pillow under your knee – you may lose the ability to straighten your knee.
• Carefully follow instructions from your doctor about how much weight you can put on your operated leg:
•  No weight bearing – no foot contact with ground
•  Touch down weight bearing – touch foot to ground for balance only
•  Partial weight bearing – usually one-fourth to one-half body weight
•  Weight bearing as tolerated – as much as comfortable
• Don’t cross your operated leg over your non-operated leg
•  Continue to use your walker or crutches after surgery as advised by your doctor or physical therapist

Incision Care

Keep your incision clean and dry and check it daily. Call your doctor if you notice any of these symptoms:

• Fever over 100º
• Drainage from incision
•  Redness around incision
• Increased swelling around incision
•  Incision hot to touch
•  Chest pain
•  Chest congestion
•  Problems with breathing
•  Calf pain or swelling in your legs

Don’t shower or sit in a bathtub until your surgeon okays this activity.

Your staples or stitches will be removed about 10 to 14 days after surgery. Your incision will heal, and the swelling and bruising will get better over the next few weeks.

Exercise

When you get home, keep up the exercise program you learned in the hospital.

You may see your physical therapist for several in-home treatments. This is to ensure you are safe in and about the home and getting in and out of a car. Your physical therapist will make recommendations about your safety, review your exercise program and continue working with you on range of motion for knees and hip precautions for avoiding dislocation.

Expect to regain strength and endurance as you begin to take on more of your normal daily routine. Home therapy visits should end when you can safely leave the house and outpatient physical therapy should begin.

The following pages provide some examples of common exercises that are usually recommended in a home exercise program. However, your orthopaedic surgeon and physical therapist will outline a specific plan that you should follow. You can refer to the following pages to assist you in performing your recommended exercises.