Download William Beaumont Hospital - Oakland Orthopaedic Surgeons

Table of Contents
Surgeon Profiles ....................................................................................... Section A
Letter to Patients ...................................................................................... Section B
Pre-Operative Checklist ........................................................................... Section C
Medication Guide ..................................................................................... Section D
Mupirocin (Bactroban) Nasal Ointment .................................................... Section E
Chlorhexidine Gluconate 4% Skin Cleanser ............................................ Section F
Your Surgical Experience ......................................................................... Section G
Instructions for 4–6 Weeks After Surgery ................................................ Section H
Commonly Asked Questions ..................................................................... Section I
Additional Resources ................................................................................ Section J
Surgeon Profiles
Dr. Brown, Dr. Greene, Dr. Mayo and Dr. Kaplan are Orthopaedic surgeons on
staff at William Beaumont Hospital. All are faculty members of the Oakland
University William Beaumont School of Medicine. They specialize in total joint
replacement surgery exclusively at the Royal Oak campus.
William Beaumont Hospital
William Beaumont Hospital is considered one of the nation’s finest medical
centers. Beaumont–Royal Oak is a 1,061-bed major teaching facility and medical
referral center. The newly renovated Madeline and Sidney Forbes Orthopaedic
Center of excellence in the South Tower is a 113 bed orthopaedic unit with over
40 private rooms and new state-of-the-art orthopaedic operating rooms. More
than 800 physicians in 39 medical specialties and approximately 380 residents
and fellows in nearly 37 medical specialties provide a wide range of healthcare
services to metropolitan Detroit residents. The hospital provides services to more
than 58,000 inpatients each year and operates one of the busiest outpatient
surgical centers in the nation. William Beaumont Hospital was voted one of the
top hospitals in orthopaedics by the US News and World Report.
Lane R. Brown, M.D.
Dr. Brown has been on the staff at William Beaumont Hospital since 1981. He
graduated from Birmingham Groves High School and attended the University of
Michigan for both his undergraduate and medical school education. After five
years of training as an orthopaedic surgery resident at Beaumont Hospital, he
joined the chief of the department, Dr. Stanko, who was a pioneer in the field of
hip and knee replacement surgery in southeastern Michigan.
Dr. Brown currently is involved in the training of residents at Beaumont Hospital
and is on the Education Committee of the orthopaedic department. He is Board
Certified by the American Board of Orthopaedic Surgery and is a charter member
of the American Association of Hip and Knee Surgeons.
Section A, Page 1
He also belongs to the American Medical Association, the American Academy of
Orthopaedic Surgeons, the Michigan State Medical Society, the Michigan
Orthopaedic Society, and the Oakland County Medical Society.
Perry W. Greene, III, M.D, FACS
Dr. Greene is a graduate of the Wayne State University School of Medicine. Dr.
Greene completed his postgraduate training in Orthopaedic Surgery at William
Beaumont Hospital in Royal Oak. He then completed a fellowship in total joint
replacement at William Beaumont Hospital. As part of his fellowship, Dr. Greene
studied at the Mayo Clinic in Rochester, Minnesota, Massachusetts General
Hospital in Boston, the Rothman Institute in Philadelphia, the Phoenix Institute for
Bone and Joint Disorders, and Wayne State University in Detroit.
Dr. Greene is Board Certified by the American Board of Orthopaedic Surgery, a
Fellow of the American College of Surgeons and a member of the American
Association of Hip and Knee Surgeons. He is a member of the American Medical
Association, the Michigan State Medical Society, Oakland County Medical
Society, Michigan Orthopaedic Society, and the Detroit Orthopaedic Academy. In
addition, Dr. Greene is the director of Adult Reconstructive Services at William
Beaumont Hospital and clinical director of the implant retrieval laboratory for the
Gehring research laboratory. Dr. Greene participates in training of orthopaedic
residents, therapists, and allied health professionals at William Beaumont
Hospital in Royal Oak.
David B. Mayo, M.D.
Dr. Mayo is an orthopaedic surgeon who specializes in reconstructive surgery of
the hip and knee including: primary and revision total joint replacement surgery,
arthroscopy of the knee, cartilage restoration and treatment for avascular
necrosis (osteonecrosis) of the hip and knee. He cares for patients ranging from
teenagers to the elderly who have arthritic or traumatic injuries of the hip and
knee joints.
As a graduate of the University of Michigan Medical School in Ann Arbor, Dr.
Mayo completed an orthopaedic residency at Henry Ford Hospital in Detroit. He
then completed a fellowship in joint reconstruction at the University of Colorado
Section A, Page 2
Health Sciences Center in Denver. Since completion of his formal training, he
has pursued additional study at Duke University, the Steadman-Hawkins Clinic,
the Cleveland Clinic, the University of Montreal and attended numerous scientific
and clinical conferences.
Dr. Mayo is Board Certified by the American Board of Orthopaedic Surgery. He is
a member of the American Academy of Orthopaedic Surgeons, American
Association of Hip and Knee Surgeons, Michigan Orthopaedic Society, and the
Detroit Orthopaedic Academy. Currently, he is on staff at William Beaumont
Hospital in Royal Oak, MI where he has been involved in clinical research. Dr.
Mayo is active in the education and training of residents and fellows in
orthopaedics, medical students, as well as other health care professionals.
Lige M. Kaplan M.D
Dr. Kaplan is a native of Cleveland, Ohio. His undergraduate degree was
obtained from Miami University. After earning his medical degree from the
University of Cincinnati College of Medicine, Dr. Kaplan completed his residency
in orthopaedic surgery at Henry Ford Hospital in Detroit. He then completed a
fellowship in Adult Reconstruction Surgery at William Beaumont Hospital. Dr.
Kaplan has a special interest and advanced training in joint replacement surgery
of the hip and knee, minimally invasive techniques and revision surgery. His
practice centers on surgical treatment of arthritic conditions of the hip and knee.
Dr. Kaplan plays an important and active role in the ongoing research at the
Beaumont Research Institute. His research has been presented at local, regional
and national meetings, and published in peer-reviewed journals. Projects are
typically focused on the advancement of hip and knee arthroplasty using the
implant retrieval laboratory and the joint replacement registry data. Dr. Kaplan is
also the Director of Clinical Outcomes for the Department of Orthopaedic Surgery
at William Beaumont Hospital and is an Associate Professor of Orthopaedic
Surgery at William Beaumont College of Medicine.
Dr. Kaplan is board certified by the American Board of Orthopaedic Surgery and
is a fellow member of the American Academy of Orthopaedic Surgeons and
American Association of Hip and Knee Surgeons.
Section A, Page 3
Letter to Patients
Dear Patient:
Now that you have decided to have joint replacement surgery, we are anxious to
work closely with you to help you with your arthritis pain.
Please familiarize yourself with the contents of this booklet. It contains a great
deal of information you need to be aware of. The more educated a patient is prior
to surgery, the less the anxiety about the surgery, the more they will be able to
participate in their recovery, and therefore the better the experience and the
result will be.
Total joint replacement produces the most dramatic relief of arthritis pain that has
ever been afforded to patients. In this operation, major surgery is performed to
replace the ball and socket of the hip or, in the case of the knee, the femur (thigh
bone), tibia (shin bone), and the kneecap may be resurfaced. Cemented and
noncemented techniques have been developed to anchor the components to the
bone surfaces. Generally, the artificial joint is made of a combination of super
durable plastic, high-strength metal alloys such as titanium and cobalt, or
ceramic materials.
Advantages
The advantages of total joint replacement are striking. There is significant, if not
total, relief of arthritis pain. Usually there is improved motion of the involved joint
and significantly reduced time of rehabilitation from past types of surgery for
arthritis. In many cases, leg length differences can be corrected. However, some
deformities may prevent attainment of equal leg lengths. Stability of the involved
joint is the primary goal. Most patients will be able to resume normal daily
activities without the use of a walker or cane a short time after surgery.
All of these advantages of joint replacement surgery take second place to the
most important feature of this surgery, which is relief of your pain. Ninety percent
of patients who are having their first operation for common arthritis problems can
walk without a limp or only a slight limp. By far, total joint replacement is the most
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effective of the modern day “organ replacement” surgeries. Clearly, however, the
results of second operations or reoperations may not be as good.
From the material presented so far, it is clear that the decision for surgery of this
type is a serious one. Surgery, because of its risks, should only be performed for
significant pain symptoms. Generally, the patient is the only one who should
make the decision to have a joint replacement surgery. Only when the patient is
unable to tolerate the pain symptoms or its imposition on lifestyle should the
decision for total joint surgery be made.
Limitations and Disadvantages
To achieve the advantages that total joint replacement may offer, each patient
must accept certain limitations, be exposed to a number of significant potential
complications, and assume some risks. You will see from the material that you
are about to read that many special precautions are now taken to minimize the
chance of a complication occurring.
The artificial joint replacement is not a normal joint. It is good but it is man-made.
It is not able to withstand repeated heavy impact without risk of loosening or
breaking. Activities such as jogging and jumping are discouraged. Swimming,
walking, golf and bike riding are generally safe to resume after surgery.
The durability of your joint replacement depends on many factors. Even if high
impact activities are avoided, each of the components, such as the cement, bone
ingrowth, and implant materials are subject to wear and failure. The cement may
loosen or crack leading to failure over a number of years. The joint replacement
may loosen or the bone around it may fracture. The weight of the patient is
crucial. Joint replacements are more successful and have fewer complications in
patients who are not overweight. IT IS IMPERATIVE THAT OVERWEIGHT
PATIENTS LOSE WEIGHT AND BECOME MEDICALLY FIT FOR THEIR OWN
HEALTH AND THE LONGEVITY OF THEIR ARTIFICIAL JOINT.
Likewise, younger patients, because of their more active lifestyles, will place
higher demands on their artificial joints and face greater chances of failure of the
surgery, thus leading to reoperations of the joint replacement. A revision, or reSection B, Page 2
operation, of a failed total joint replacement may be needed due to many factors
including loosening of the prosthesis, wearing of materials, bone fracture, or
infection. Revision surgery may require extra considerations including the
possibility of special implants or bone grafts called allografts to replace bone time
loss. The risks, complications, and outcomes may not be the same as in a firsttotal joint replacement. Yet, with advances in technology of the implants and
techniques, the success of revision surgery has improved dramatically.
Risks of Total Joint Replacement
There are a number of potential complications related to joint replacement
surgery that are typical of any major surgery. The percentage of patients that
have a serious complication is very small. The general risks of joint replacement
are heart attack, stroke, pneumonia, bleeding, kidney failure, blood clot, heart
failure, urinary dysfunction, bladder infection, neurovascular injury, loss of limb,
wound complications, medication reactions, and possible need for reoperation.
The risk of a serious complication is less than 5% and the risk of death after total
joint replacement is very low (0.1%–0.5%). This list is not comprehensive.
BLOOD CLOTS
Joint replacement surgery coupled with advanced age and/or previous blood
clotting abnormalities exposes the patient to the risk of blood clots forming in
their legs and occasionally breaking loose and traveling to the lungs. A blood clot
that lodges in the veins of the leg is called deep vein thrombosis (DVT). A blood
clot that travels to the lungs is known as a pulmonary embolus (PE) and can
potentially be fatal. In patients treated with anticoagulants, the incidence of DVT
after surgery is 2 to 4% and the incidence of PE is less than 0.5%, however
many of those patients do not ever develop symptoms associated with clots.
Precautionary measures that are implemented to reduce the risk may include
early ambulation after surgery, automatic leg pumps, and blood thinners (Aspirin,
Lovenox, Coumadin, Xarelto). The occurrence of a clot may require longer
hospitalization and/or longer treatment with a blood thinner.
HEART ATTACK and STROKE
Heart attacks and stroke are rare after total knee replacement. You will be seen
by your primary care physician prior to surgery to help identify risk factors and
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minimize the occurrence of either of these complications. In addition, a hospitalist
physician will be available after your surgery to help handle these problems
should they occur.
BLEEDING
All patients lose blood during the operation. Blood loss is controlled by the
surgeon during the operation and most bleeding stops within 1–2 days after
surgery. Depending on the length and complexity of surgery a transfusion may
be necessary. The risk of needing a transfusion after joint replacement surgery is
low. If you have a history of anemia (low blood count), see your primary care
physician to optimize your blood counts prior to surgery. This can greatly reduce
your need for a transfusion.
NERVE INJURY
The possibility of major nerve injury following total joint replacement is less than
1%. Nerve recovery is partial in most cases and the outcome is ‘good’ for about
50% of these patients. All patients routinely notice numbness in the skin
surrounding the incision as the result of nerve endings in the skin. The area of
numbness usually decreases in size but will take time, even as long as a year
after surgery. The risk of nerve injury is increased in revision cases.
VASCULAR INJURY
Injury to the blood vessels is extremely rare and only occurs in about 0.05% of all
total knee replacement surgeries. This is a serious injury that can be lifethreatening. The injured blood vessel is typically repaired surgically to avoid any
reduce the threat to life or the extremity.
FRACTURE
The incidence of fracture in one or more of the bones during joint replacement
surgery is less than 1%. These fractures may be repaired during the surgery by
using surgical wire, screws, and/or plating systems for stabilization. Fractures
around prosthetic joints after surgery may require surgical stabilization or implant
revision.
Section B, Page 4
BLADDER PROBLEMS
Occasionally, patients with total joint replacements may have trouble emptying
their bladder. A catheter (tube) can be placed in the bladder and will be removed
one or two days after the operation to decrease the risk of a bladder infection,
which could spread to your joint replacement.
REACTION TO ANESTHESIA
Some patients may have a problem with the medicines used for anesthesia. The
anesthesiologist will monitor you carefully to avoid such a problem.
INFECTION
The risk of post-operative infection after total joint surgery is approximately 1%.
This can occur as early in the post-operative phase as 5 to 7 days or as late as
many years after surgery. Patients with systemic illnesses (diabetes, rheumatoid
arthritis, kidney failure) have a slightly higher risk of infection. Antibiotics will be
given to you immediately prior to surgery and will continue for 24 hours after
surgery to reduce this risk. Many precautions are taken during surgery to reduce
the risk of infection. These include special air flow in the operating room,
specialized sterile suits worn by the operating team, and sterile preparation of the
surgical site before incision. Additionally, you may need antibiotics any time you
undergo invasive procedures such as dental work, urologic procedures, or for
any local infections (skin, ear, throat, sinus) for the life of the implant. The
occurrence of an infection in your joint replacement can result in the temporary or
permanent removal of the artificial components, prolonged IV antibiotics and/or
the use of crutches, walker or wheelchair for an indefinite period of time.
Risks Specific to Hip Replacement
DISLOCATION
This occurs when the ball comes out of the socket. The risk of dislocation of a
total hip is 1-5%. A dislocation can usually be put back into place but may require
the use of a brace and/or revision surgery to be resolved. Strict adherence to the
total hip precautions can greatly decrease the risk of dislocation. These
precautions include avoidance of leg crossing, not bending over at the waist, and
staying away from low chairs, toilets and car seats. Newer total hip designs and
fixation techniques have led to a significant reduction in dislocation rates. Please
Section B, Page 5
refer to the section on hip dislocation precautions in this manual to avoid this
complication.
LEG LENGTH INEQUALITY
Every attempt is made surgically to restore normal length and alignment of a hip.
Usually this is successful. Occasionally, surgical considerations dictate that leg
lengths are not exactly equal following total hip surgery. If this does occur, it is
usually minor and not noticeable to the patient during walking or normal function.
Noticeable leg length changes can rarely occur and may or may not require
additional surgery, depending on a variety of factors.
STIFFNESS
Some patients have difficulty achieving full extension (straightening) or full flexion
(bending) of the knee following knee replacement surgery. Due to the design of
the prosthesis, full motion is not always expected. Significant deficits of motion
may require additional physical therapy, manipulation of the joint under
anesthesia, or additional surgery. The biggest predictor of postoperative knee
motion is preoperative knee motion.
INSTABILITY
The occurrence is rare, but a knee replacement surgery may result in a ‘loose’
sensation in the knee. This can usually be treated successfully with bracing and
strengthening exercises over time but occasionally surgical intervention is
necessary.
New Technology
Orthopaedic Joint Replacement surgery is a field of medicine with constant and
ongoing research and development. There are many new advancements in
implant technology, rehabilitation and recovery and surgical techniques that are
being presented to both surgeons and patients on a frequent basis.
Minimally invasive surgery (MIS), Fast-track rehab protocols, advanced bearing
surfaces and alternative surgical exposures are some of the more recent
advancements.
Section B, Page 6
For hip replacement, the surgical approach may be from the back of the hip
(posterior), the side (lateral), or the front of the hip (anterior). There are
advantages and disadvantages to each exposure and certain patient and disease
characteristics may play a role in which is best for you. Your surgeon will discuss
with you the merits and/or limitations of these techniques.
It is also important that you and your surgeon discuss any new technology or
technique prior to implementation, as there are inherent risks when adapting new
aspects of treatment into practice.
Section B, Page 7
Pre-Operative Checklist
After your surgical date has been scheduled, the following items must be
completed prior to your operation.
❏ Medical/Cardiac Clearance: It is necessary to see your internist and/or your
cardiologist prior to your surgery in order to obtain medical clearance. Please
have your internist or cardiologist send a report of the pre-operative
consultation to our office regarding your medical status for the proposed
surgery. Clearance must be received by our office no less than 3 weeks prior
to your surgery or your operation may be rescheduled to the next available
surgical date.
❏ EKG: The hospital requires that all patients who meet any of the following
criteria have an EKG within the 6 months prior to their surgery date:
1. All males over the age of fifty.
2. All females over the age of sixty.
3. All patients who have high blood pressure or a cardiac history.
4. All patients with diabetes who have been on insulin for three or more
years.
Ask your internist or cardiologist to do an EKG at their office visit.
❏ Dental Appointments: If you haven’t seen your dentist within the past 6
months, please make an appointment as soon as possible for a dental exam.
You should not have any major dental work or cleaning in the month prior to
your surgery or for 3 months after surgery.
❏ Preoperative Testing (Lab Work): In the third week prior to your surgery, go
to an outpatient laboratory for testing. You will be provided a prescription that
Section C, Page 1
must be brought to the Outpatient Laboratory, but you do not need to
schedule an appointment for this lab work. You do not need to fast for this
blood work.
❏ Joint Adventure Class: The Joint Adventure class at William Beaumont
Hospital–Royal Oak is a program that should be attended by you and your
family, if possible. If you are not able to attend the class you can view it on
line. Please see attached handout for instructions to register for either class.
❏ Flu Shot: If you choose to get a flu shot, you should get it at least 4 weeks
prior to your surgery date. If you have not already received a flu shot and
would like one, you will receive one after your surgery while you are in the
hospital.
❏ Religious Beliefs: If you have religious beliefs that would affect your medical
care, please notify us immediately.
Section C, Page 2
Medication Guide
• You are to have no food or milk products after midnight the night before your
surgery. You may have clear tea, black coffee, apple juice, cranberry juice,
sports drinks, carbonated beverages (Sprite, Pepsi, Coca Cola, ginger ale) or
water up to 2 hours prior to the time you are to report to the hospital.
• If you drink more than two alcoholic beverages a day, you may experience
withdrawal symptoms after surgery. Symptoms include mild shakiness,
sweating, hallucinations, and other more serious side effects. Interventions can
be taken before surgery to minimize withdrawal symptoms. Please let your
surgeon and anesthesiologist know about alcohol use. The best goal is for you
to stop drinking at least two weeks prior to surgery.
• Stop smoking immediately when your surgery has been scheduled. The longer
you stop smoking before surgery the lower the risk of smoking related
complications.
• Certain medications thin your blood and must be stopped before surgery.
Please see the list below.
• Anti-inflammatories (Ibuprofen, Advil, Motrin, Aleve, Naprosyn,
Meloxicam [Mobic], Relafen, Daypro, Aspirin): Stop 7 days prior to
surgery.
• Celebrex: Does not need to be stopped prior to surgery but DO NOT
take it on the morning of surgery.
• Coumadin (Warfarin), Plavix, Pradaxa, Xarelto, or other blood
thinners: Ask your internist or cardiologist when you should stop taking
these medications prior to surgery. Make sure your surgeon knows you
take one of these.
• Vitamins: Stop taking all vitamins 7 days prior to surgery.
• Herbal supplements and diet medications: Stop 14 days prior to
surgery.
Section D, Page 1
• Pain pills such as Hydrocodone, Lortab, Vicodin, Norco, and Percocet
should not be taken the morning of surgery.
• The pain pill, Ultram (Tramadol), can be taken the morning of surgery.
• All other prescription medications can be continued up until the day of
surgery unless otherwise directed by your internist or surgeon.
Beaumont’s Pre-Anesthesia Department will call you a few days prior to
surgery to review which medications you should take the morning of
surgery. If you are diabetic, they will advise you on how much medication
or insulin to take the morning of surgery.
Section D, Page 2
Mupirocin (Bactroban) Nasal Ointment
When you have your pre-operative lab work the technician will swab your nose to
find out if you carry a germ called Staphylococcus aureus. Thirty-five percent of
the population carry Staphylococcus aureus in their nose. The germ can then be
transferred to the skin. Studies have shown that eliminating this germ from your
nose prior to surgery may reduce your risk of developing a surgical site infection.
If you test positive for Staphylococcus aureus we will call you to let you know. We
will call a prescription in to your pharmacy for Mupirocin (Bactroban) ointment to
be applied to your nostrils.
Are there any side effects when using Mupirocin?
Side effects are uncommon. Discontinue use and notify your surgeon if burning
or itching develops.
If instructed, apply Mupirocin on the following dates:
Three days prior to surgery: ____________________
Date
Two days prior to surgery:
____________________
Date
One day prior to surgery:
____________________
Date
Morning of surgery:
____________________
Surgery Date
Section E, Page 1
Chlorhexidine Gluconate 4%
Skin Cleanser
Why will I be following a special showering procedure?
The use of chlorhexidine gluconate 4% skin cleanser has been shown to
decrease bacteria (germ) levels on the skin and may reduce your risk of a
surgical site infection.
Shower with this product on the following dates:
One shower two days prior to surgery:
____________________
Date
One shower the day before your surgery: ____________________
Date
One shower the morning of surgery:
____________________
Surgery Date
Chlorhexidine gluconate 4% skin cleanser can be purchased at your local
pharmacy. A 4 ounce bottle should be sufficient to complete all three of your
showers. Some pharmacies stock a 4 ounce and an 8 ounce bottle. Other
pharmacies will need one to two days notice to order the cleanser. Please plan
ahead so that you can begin your showers two days prior to your surgery day.
How Do I Perform the Chlorhexidine Shower?
YOU WILL NEED:
❏ Clean bath towel each day
❏ Clean terry cloth washcloth each day
❏ 4 ounce bottle of chlorhexidine gluconate 4% (CHG) skin cleanser
1. Wash and rinse your hair, face and genitals (private parts) as you
normally would.
Section F, Page 1
2. Moisten your entire body with water and step away from the shower
stream.
3. Wet a clean terry cloth wash cloth and apply two tablespoons of
chlorhexidine gluconate skin cleanser to your washcloth. It is important
to use a clean washcloth every day. Do not use back brushes, sponges,
foaming puffs, etc. that you may have in your shower.
4. Cleanse your entire body from the neck down. Do not use this
product on your face, ears, eyes, mouth, genitals, or open wounds.
5. Step back into the shower stream and rinse thoroughly.
6. Dry gently with a clean towel.
7. Do not apply creams, lotions or powders after your shower.
8. Put on clean clothing, including underclothing and socks each day.
9. Change bed sheets two days prior to your surgery so that you will be
sleeping on clean sheets once you start your chlorhexidine showering.
One change of sheets is sufficient.
IMPORTANT LAUNDERING ADVICE: Chlorhexidine gluconate (CHG) binds to
many fabrics. Special laundering procedures should be considered for fabrics coming in
contact with skin bathed in CHG, for instance sheets, towels and clothing. Wash these
fabrics without the use of chlorine bleach as bleach may cause staining of the fabric. Use
of a peroxide type bleach such as perborate, sodium percarbonate or hydrogen peroxide is
recommended if a bleach product is necessary.
Section F, Page 2
Your Surgical Experience
Reporting to the Hospital
You will receive a phone call the day before your surgery from a William
Beaumont Hospital representative to inform you of the time you should report to
the hospital. Someone should drive you to the hospital and be present during the
entire time you are in surgery.
Length of Surgery
Before your surgery, you will spend some time in the pre-operative area meeting
the anesthesiologist and getting prepared for surgery. The length of the surgery
will vary based on the type of surgery. After your operation, you will be taken to
the recovery room. Once you are awake, you will be moved to your hospital
room.
Pain Management
The management of your pain is a very important component of your recovery.
The advances in understanding and managing your pain for hip and knee
surgery are dramatic. Besides the anesthetic itself most patients receive “multi
modal” analgesia which is a planned approach to controlling pain that starts
before the surgery begins. Many patients, depending on the health and
sensitivities to medications, will receive a “cocktail” of medications before the
surgery begins. This may consist of anti-nausea medication, Tylenol, timed
release 12 hour medication, and an anti-inflammatory. At the end of the
operation, the wound may be injected with a “pain block” that consist of a long
acting local anesthetic (numbing medication), a pain medication and a strong
anti-inflammatory. After the surgery you will be encouraged to use regular dosing
of pain medications to “stay ahead” of the pain. It is especially important to take
pain medication before your therapy to get the most out of your recovery. Every
patient responds differently. Each patient may require different combinations to
optimize their pain control. By using the strategy of pain management before,
during and after surgery patients have enjoyed dramatic improvements in pain
control. We encourage the patients to discuss pain control for themselves with
their nurses, therapists and surgeons.
Section G, Page 1
Anesthesia
The Anesthesia Department at William Beaumont will call you 2–3 days before
surgery to discuss anesthesia. A spinal anesthetic is commonly used for total
joint replacement surgery. You will be numb from your waist down and will
receive medication to make you sleep during the surgery. The day of your
surgery the anesthesiologist will speak with you in the pre-op area about any
individual concerns or the possibility of using other types of anesthetics for your
surgery such as general anesthesia, epidurals, pain blocks, as well as their
inherent risks and benefits.
Length of Hospitalization
Most patients will be in the hospital for approximately one or two days following
surgery. Members of the Continuing Care Department will work with you to
facilitate your discharge from the hospital.
Discharge
Patients are encouraged to go home or to the home of a friend or family member
at the time of their discharge. You will need someone at home to assist you for at
least the first two days you are home. Referrals for home care services will be
initiated through our office.
Patients who do not have assistance at home can arrange a transfer to a
rehabilitation facility, convalescent center or sub-acute facility. The Care
Management department at the hospital will assist you with the transfer.
Equipment for Home
Most patients will need a walker, elevated toilet seat, tub/shower bench, etc. for their
recovery. Equipment may be obtained before surgery or a member of the Care
Management department at the hospital will make arrangements for all necessary
equipment to be delivered to your home. Equipment may not be covered by insurance.
Continuing Care
The continuing care department will assist you with home care referrals for
visiting nurse services and home physical therapy if appropriate. If you are
Section G, Page 2
unable to recuperate at home, arrangements will be made for you to go to an
extended care facility.
Private Room
If you wish to have a private room while you are in the hospital, request one at
the time of your admission to the hospital. Be aware that this request may not
always be available and depends on hospital bed status.
Section G, Page 3
Instructions for 4–6 Weeks After Surgery
Medications
You will be discharged from the hospital with a prescription for oral pain
medication. Pain medication can only be renewed during regular business hours.
If you need a refill, please call us at the office between 8:30 AM and 4:30
PM. Because some medications require a printed prescription from your
physician it is important to call 48 hours in advance of running out.
If you find you do not require prescription strength pain medication, you may use
Extra-Strength Tylenol (500 mg. per pill) as needed for milder pain. You may also
combine the two if you wish to cut back on your narcotic medication. If combining
prescription strength medication and Tylenol, please make sure that you do not
exceed 3,000 mg of Tylenol in a 24-hour period. Most narcotic pain pills (Norco,
Vicodin, Lortab, and Percocet) have 325 mg of Tylenol per pill.
Managing Constipation
After surgery, you may experience a change in your bowel habits related to the
effects of anesthesia or from your narcotic pain medications. Be proactive in
heading off problems. Make sure you increase your fluid intake and eat foods
high in fiber, such as fruit, vegetables and high fiber cereals. Warm liquids,
including tea and coffee, can also help.
It is helpful to take an over-the-counter stool softener while taking narcotic pain
medicines. The following is a step-wise approach to maintaining a regular bowel
pattern.
• Colace or Senokot: You can start either one of these medications two days
prior to surgery. Take 1 or 2 pills in the morning. Continue taking after surgery.
If you are having difficulty having a bowel movement, you can increase your
dose to 2 pills in the morning and 2 in the evening.
• Miralax: Miralax can also be used. Dissolve a packet in 4–8 ounces of liquid
and take daily.
Section H, Page 1
• Milk of Magnesia: If it has been several days since you have had a bowel
movement and you’ve tried Colace or Senokot or Miralax, you can try Milk of
Magnesia. We suggest you take the recommended dose on the bottle mixed
with prune juice. Warm the mixture in the microwave. If you have no results,
you can take the mixture again in 8 hours.
• Other medications you can try if the above suggestions don’t work are
Dulcolax tablets, a suppository, or a Fleets enema. Do not try multiple
products. Use one laxative at a time. If you develop diarrhea, stop taking the
laxatives for a day. Persistent diarrhea should be reported to our office or to
your family doctor.
If at any time after surgery you have nausea, vomiting, abdominal pain,
bloating, or cramping along with no bowel movement for several days,
please call our office for further direction.
Blood Thinners
You will be placed on a blood thinner after surgery. Your doctor will prescribe
one of the following:
• Coumadin: You will take Coumadin for one month after surgery. The dose
should be taken daily in the evening. A visiting nurse will draw blood to monitor
the effects of Coumadin. A nurse in the office will monitor your blood work and
call you only if your Coumadin dose needs to be changed.
OR
• Lovenox: Lovenox is injected into your superficial skin once a day. You will be
taught how to give yourself the injections when you are in the hospital. You will
use Lovenox for 10 days after your surgery. Lovenox does not require any lab
work or monitoring of your blood levels.
OR
Section H, Page 2
• Xarelto: You will take one pill daily for the number of days directed by your
physician. The medication will be started in the hospital. No lab work is needed
to monitor your blood while on Xarelto.
OR
• Aspirin: If you are instructed to take Aspirin refer to your discharge instruction
sheet for how much to take daily. Your surgeon will tell you when to stop the
Aspirin when you come in for your one month office visit.
Incision Care
If staples are used to close your incision, they will be removed by the visiting
nurse or at the extended care facility between 10 to 14 days after surgery. Do not
put any lotions or powders on your incision for 4 weeks. After 4 weeks, you may
apply a gentle, non-perfumed lotion such as Aquaphor or Eucerin to your incision
3–4 times a day. Do NOT use any products containing Vitamin E on your
incision.
Swelling and Bruising
Some swelling over your incision and your legs and feet is normal. Usually you
will notice it toward the end of the day. The following will help to minimize
swelling:
1. Elevate your operative leg on pillows so that your toes are above your
heart several times a day for 30 minutes each time. If your hip has been
replaced lean back on the couch or bed so that you don’t over-flex your
hip.
2. Use ice packs anywhere, anytime you like as a mild pain reliever. Do
not use a heating pad. It may cause more swelling.
3. Get in the habit of doing ankle pumps and circles whenever you are
sitting still. Muscle action helps to move collected fluid out of the tissues
and improve circulation.
Section H, Page 3
4. Report any persistent swelling, calf tenderness, or pain in the calf to our
office.
5. Bruising around your incision is normal and might move down your leg,
even to your foot.
Nutrition and Energy Level
It is not unusual for your appetite to be decreased after surgery. Try to eat foods
that are appealing to you while maintaining a balanced diet. It will take a few
weeks for your energy level to return to normal. Take frequent rest periods and
try to get a good night’s sleep.
Physical Therapy
Total knee replacement patients usually have in-home physical therapy 3–5
times per week for several weeks and then will start outpatient therapy. It is
important NOT to have gaps (more than 3 days) between physical therapy
sessions. If this is a problem talk to your therapist or call our office.
Total Hip replacement patients are instructed to continue with the exercise
program learned in the hospital until their first post-operative office visit. In-home
physical therapy is typically not done. Outpatient physical therapy is typically
initiated two weeks after your surgery. Call the facility you plan to attend one
week before you plan to start to schedule an appointment. When you start
outpatient physical therapy, you will receive a prescription for 3 therapy sessions
a week for one month. If you require additional treatment, the physical therapist
will contact our office.
We can provide a list of physical therapy sites at your office visit. Land therapy is
the preferred form of exercise. Pool therapy is generally not recommended.
Walking
You will start walking with a walker but can transition to a cane when you feel
ready unless instructed otherwise by your surgeon. If you are stable in your
home you can walk without the cane. A cane is recommended in the community
Section H, Page 4
to alert others of your mobility issues. A cane is used in the hand opposite your
surgical side. We recommend a standard, adjustable cane. Walk at least 4-5
times per day. It is the best exercise you can do.
Stair Climbing
In the hospital, the physical therapist will teach you how to climb stairs safely.
You may climb stairs only as needed. Generally climb stairs once or twice a day
for the first two weeks. Do not use stair climbing as an exercise. As you feel
stronger, you will be able to climb stairs more frequently.
Exercise
Continue the exercises you have been doing in the hospital 10 times a day. As
you feel stronger, increase the number or repetitions you do each session rather
than introducing new types of exercises.
The following activities are restricted until 6 weeks after your surgery:
1. Swimming
2. Whirlpool/Jacuzzi
For the first 2 weeks after total hip surgery:
• Do use a pillow between your legs while sleeping on your non-surgical side.
• Do follow your hip precautions. (No twisting, bending, crossing your legs or
putting on your own socks or shoes without an aid.)
• Do use your elevated toilet seat.
For the first 4 weeks after total hip surgery:
DO NOT’S
• Do not sleep on your surgical incision.
Section H, Page 5
• Do not sit on low couches, sofas or chairs.
For the first 6 weeks after total knee surgery:
• Exercise your knee 15 minutes, 10 times daily.
• Do bending (flexion) and straightening (extension) exercises that you were
taught.
• Your goal (unless otherwise told) is at least 0° (straight) to at least 90°
(bending) within one week of surgery.
• Avoid sleeping with a pillow under your knee.
Bathing
You may take a shower usually within 2 days of your surgery. Do not take a tub
bath for at least 6 weeks after surgery.
Sexual Activity
You may resume sexual activity 4 weeks after your surgery if you had a hip replacement.
If you had your knee replaced, sexual activity can be resumed at your discretion. Do not
kneel for six weeks after your surgery. Refer to www.recoversex.com for positioning
suggestions following hip and knee replacement.
When to Call the Office
• Temperature consistently greater than 100.5 degrees.
• Redness, warmth or drainage from the surgical incision.
• A sudden increase or persistent increase in swelling of your surgical
leg.
• Unusual pain in your calf, knee, thigh, or hip.
Section H, Page 6
• Cough, shortness of breath, dizziness or chest pain. If you have
shortness of breath or chest pain, call 911 immediately.
Office Hours
Our office hours are 8:30 am to 4:30 pm Monday through Friday. After hours or
on weekends, there is an answering service on duty that can be reached by
calling (248) 524-6323
*** Please note that the answering service is for EMERGENCY use. ***
Routine questions, medication refills and appointment scheduling should be held
until business hours the following day.
Office phone number: (248) 280-8550
Section H, Page 7
Commonly Asked Questions
What type of exercise/activities should I NOT do after my total
joint replacement?
It is best to avoid any exercise that will cause impact to your joint replacement.
This includes running and jumping sports such as singles tennis, basketball and
jogging.
What types of exercises/activities can I do after my total joint
replacement?
General aerobic exercise is encouraged such as walking, swimming, stationary
bike, and moderate weight lifting. Many patients enjoy golfing, bowling, and
hiking. Your specific hobbies will be discussed with you.
When can I swim after a total joint replacement?
You can generally swim 6 weeks after surgery as long as your incision is
completely healed. For hip replacements, the pool must have walk in steps. You
cannot use the vertical ladder to get in or out of the pool.
When can I drive?
Generally, you can drive when you have no weight bearing restricitons and you
can walk using only a cane. You may not drive if you are taking narcotic pain
medications, Norco, Vicodin, Lortab, Percocet, or Oxycodone for instance.
How long do I have to maintain hip precautions?
Hip precautions should be maintained for 2 weeks after surgery. Then you can
return to moving normally. Be careful not to bend your knee inward in a forceful
manner. Use common sense with your activities. If your hip feels uncomfortable
with certain positions or activities stop doing them.
Section I, Page 1
I have noticed that my knee or hip incision feels warm. Should I
be concerned?
As long as the incision is not reddened or draining and you are not running a
fever, warmth at the incision site can be present for about 6–12 months. This is
due to the increased blood flow to the surgical site that aids in the healing
process.
Can I kneel on my new knee?
Yes. You may kneel on your total knee 6 weeks after surgery, based on your
comfort level.
What happens if I feel/hear clicking in my knee after a knee
replacement?
Clicking can commonly occur after a knee replacement especially as your activity
increases. As long as the clicking is not associated with pain, it should be nothing
to worry about.
When can I see the dentist after the total joint replacement?
Certainly if there is a dental emergency, you should see them immediately.
REMEMBER, YOU MUST ALWAYS PRE-MEDICATE WITH ORAL
ANTIBIOTICS PRIOR TO ANY DENTAL WORK FROM THIS POINT
FORWARD. THIS IS A NOT A TEMPORARY PRACTICE. If your dental work is
routine, it is best to wait for 12 weeks after surgery.
Who will prescribe the antibiotics for dental visits?
On your first post-operative visit, your surgeon will give you a prescription for
dental visits. After this, your dentist will prescribe the antibiotics when you call to
make your appointment. The surgeons want to make sure you have something
on hand in the event of a dental emergency arising prior to you seeing your
dentist.
Section I, Page 2
What infections do I have to worry about after my total joint
replacement?
The common cold (a virus) is not usually a problem. However, if that cold turns
into bronchitis or a sinus infection, then you should see your internist for
antibiotics. The antibiotics given to you for the dentist may not be the
correct one for other types of infections. So call your internist!
Other infections to worry about:
• Tooth abscess
• Urinary tract infections
• Wound infections
If you are uncertain, do not hesitate to call us and ask.
What procedures do I not have to pre-medicate with antibiotics
for?
Routine pap smears; lab draws; donating blood; eye surgery (as long as the
surgery is not for an eye infection); and mole removal.
Will I have problems with security at the airport?
At the airport your replaced joint will show up on the x-ray machine. We do not
give out airport cards because they do not recognize these as valid proof of a
joint replacement. Because total joints are so common now, the airport usually
handles this process pretty swiftly.
Am I able to have a MRI (Magnetic Resonance Imaging)?
Yes. The metal alloys used today for the total joint replacement are compatible
with MRI machines.
What is the success rate of joint replacement surgery?
95% to 98% of patients will say they are pleased with the results of their surgery
and they are able to return to the activities they enjoy. Total hip replacements
Section I, Page 3
may last 20 years or more. Total knees may last 15 years or more. With
advances in technology, these averages are likely to get better over time.
How long does it take to recover following surgery?
Recovery depends on your age and overall health. Generally after 2 months, you
will be able to return to your normal activities.
When can I return to work?
If your job involves mostly sitting activities, you may be able to return to work in 2
to 4 weeks. This will be discussed at your first post-operative visit. If you have a
more strenuous work situation involving standing, walking, bending, etc., you will
likely be able to return to work 6 to 8 weeks after surgery. Again, this will be
discussed with your surgeon before a determination is made.
Section I, Page 4
Additional Resources
Looking for more information about total joint replacement?
The following Web sites are excellent resources:
• Oakland Orthopaedic Surgeons: www.oaklandortho.com
• American Academy of Orthopaedic Surgeons (AAOS): www.aaos.org
• American Association of Hip and Knee Surgeons (AAHKS):
www.aahks.org
• See link to www.OR-Live.com for a short video of joint replacement
surgery
• The Hip Society: www.hipsoc.org
• Arthritis Foundation: www.arthritis.org
• www.recoversex.org
• www.orthonurse.org
William Beaumont Hospital Information
www.beaumonthospitals.com
Joint Replacement Manufacturers
• Stryker: www.stryker.com
• Zimmer: www.zimmer.com
• Depuy: www.depuy.com
Section J, Page 1
Books
Arthritis of the Hip and Knee: The Active Person’s Guide to Taking Charge
by Ronald J. Allen, Victoria Anne Brander, & S. David Stulberg.
All About Hip Replacement: A Patient’s Guide by Richard Trahair.
A Patient’s Guide to Knee and Hip Replacement: Everything You Need to Know
by Irwin Silber.
Getting Hip: Recovery from a Total Hip Replacement by Sigrid MacDonald.
Total Knee Replacement and Rehabilitation: The Owner’s Manual
by Daniel J. Brugioni and Jeff Falkel.
Books can be ordered on amazon.com
Section J, Page 2