So…you’ve had your first meeting with your orthopaedic surgeon. You’ve signed a consent form indicating you understand the implications and risks of undergoing a total hip or total knee replacement. And now you’re dwelling on the reality of surgery, wondering “What’ve I got myself into?”
Sure, the pain is intense and persistent, but at least it’s the devil you know. Much as you’d love to part ways with this constant companion, now you’re headed down a stange new path. And it’s a bit scary. Is the destination really worth the trip?
During your first appointment, your surgeon probably outlined some of the things to expect in the near future: lab tests, exercises, physiotherapy, preparation for surgery…blah, blah, blah, blah…recovery, small changes in lifestyle…blah, blah, blah…exercises…blah, blah. If you’re like most people under emotional stress, most of the details went in one ear and leaked out the other.
Not to worry. You’ll have a second chance to learn all the ins and outs at the pre-operative clinic. Just make sure you or the surgeon’s administrative assistant books an appointment for this all-important, day-long educational session – ideally four to six weeks before the actual surgery. Once you’re booked, you’ve taken the first step along the “care path” to recovering function and mobility. Congratulations! You can now breathe a little easier.
And since you probably have some time on your hands before the clinic, we thought a map of the road ahead would help you prepare for the journey and smooth out any unexpected curves. Aside from knowing in theory what the surgery is all about, there are a number of practical considerations you need to take into account, especially if you work or live alone.
Most Canadian hospitals have adopted “care paths” for orthopaedic surgery, a treatment approach that directs patients into appropriate “lanes” according to their individual needs so that they can receive the best possible care. Most will travel in the express lane that leads directly to surgery a month or so down the road. Some fellow travellers, however, will need to make brief detours because of other medical conditions (high blood pressure, for example, or diabetes or fibromyalgia).
Before: the pre-operative clinic
The starting point for everyone is the aforementioned pre-operative clinic. There you’ll undergo a thorough physical examination and fill out a detailed questionnaire about your medical history. This is your opportunity to go on record with any other health problems you might have and any medications or herbal remedies you might be taking regularly. If your condition warrants consultation with a specialist, an appointment will be booked to review your case and undergo specific tests that will better tell medical staff how to tailor the surgery to your needs.
You’ll also undergo blood tests to determine your blood type and to detect any possible infections that need to be cleared up before surgery. Your urine may also be tested, again to check for infections. If there are any problems, there’ll be enough time to clear them up before surgery. X-rays are taken so your surgeon has an up-to-date picture of what to expect during the operation. If for some reason you haven’t already signed a consent form, you’ll get another chance during the clinic.
One of the reasons the clinic is held so far in advance of the surgery is to allow you to bank your own blood for the big day, should you wish. If necessary, you can donate blood on a weekly basis during the four to six week interval between the pre-operative clinic and the surgery. The quantities needed vary according to the type of surgical procedure (hip versus knee, for example) and the length of the operation. Revision surgery usually takes more time and hence often requires more blood for transfusion.
Appointments and tests aren’t the pre-operative clinic’s only purpose. There’s a learning component, too. Usually instruction is overseen by a physiotherapist, but you’ll also likely have sessions with an anaesthiologist, nurse, occupational therapist and social worker. Together, they’ll try to sketch out as complete a picture of what lies ahead on the day of surgery and afterward, as well as answer your questions.
No matter what type of surgery you’re going in for, physical therapists (PTs) or their assistants will loom large in your life since they specialize in post-operative rehabilitation. Actually “rehab” begins even before the surgery. You will be encouraged to start right away doing a series of exercises, three to four times a day, specifically designed to strengthen the affected joint and preserve its range-of-motion. The recommendation isn’t simply because PTs are physical-fitness fanatics; rather it’s because a daily exercise routine prior to surgery has a very real impact on how quickly you regain your strength and muscle tone after the operation.
Another good reason for exercising regularly is improved blood circulation and, as a result, a lower risk of developing a blood clot in your leg (a complication called DVT or deep vein thrombosis, in clinical jargon). After the trauma of surgery, the veins of the lower limbs and pelvis are more susceptible to developing clots, largely as a result of local pressure on a vein from the immobility of prolonged bed rest. It’s a serious complication since the clot can easily loosen and become lodged in the lungs or the pulmonary artery, the main source of blood to the lungs. If the clot is small, it may cause chest pain and difficulty breathing if the clot is large enough to block the artery completely, it can be fatal. Hospital and rehab staff are trained to recognize the symptoms of DVT (local pain and swelling of the calf or the entire leg) and to initiate treatment immediately (anti-clotting drugs and, sometimes, surgery to remove the clot). In some hospitals, drugs such as heparin and warfarin are prescribed as a preventative measure, especially if a patient has a prior history of clotting problems.
As soon as you regain sensation in your lower limbs after the anaesthetics have worn off, you’ll be encouraged to do foot-and-ankle pumping to decrease inflammation and increase circulation. It’s a simple exercise you do while lying down that involves pointing your toes out straight and then pointing them toward your nose – like pumping the brake pedal on your car. Do this movement often throughout your rehabiltation period and especially during the first days after surgery. Combined with your prescribed exercise regimen, you’ll experience much less post-operative pain and swelling, and regain mobility much more quickly. The faster you’re back on your feet, the more the danger of DVT decreases.
Next on the pre-clinical agenda will probably be an anaesthetist who will explain what to expect from general or local anaesthesia. In both cases, you’ll feel no pain during surgery, which is the whole point. Recovery time from the effects of general anaesthetics is variable (a day or more), and the feelings of disorientation and listlessness can occasionally be accompanied by headache, nausea or constipation. If your general health is good you can choose a local anaesthetic, which causes less of a post-operative “hangover” but means you will be awake during the surgery, although your view will be obstructed by a curtain. Not surprisingly, most people opt for general anaesthesia.
A nurse will discuss the sequence of events on the day of surgery and the care path’s “rules of the road.” A stay in the hospital is no trip to the spa; nevertheless, you’ll need to take some personal items with you. You will be in hospital for anywhere from three to five days, so take such things as slippers, a bathrobe, a change of night clothes and personal care items (toothbrush, toothpaste, mouthwash, your own soap, lotion, razor, comb, deodorant, feminine hygiene products, etc.).
You should also pack up all of your regular medications. Keep them in their original containers so nursing staff can see exactly what they are. Do not take any medications or herbal remedies if you are told not to; they could interfere with the anaesthetics and painkillers you are given in hospital. If in doubt, ask. You’ll also be asked to not eat or drink anything starting at midnight before the day of surgery. Anything in the upper digestive tract might interfere with the anaesthetics or lead to vomiting and possible choking during the operation.
Hospitals are busy places, with lots of people ranging from cleaning and nursing staff and numerous visitors walking around. It’s advisable not to take anything of value with you for your stay in case it gets lost or stolen. Leave cash, jewelry, CD players and other valuables at home.
You’ll be given some disinfectant soap, usually in a tube. This is to use over the affected joint when you shower either the night or morning before surgery. The nurse may also explain the workings of an intravenous analgaesic pump for post-operative pain control.
An occupational therapist (OT) will discuss some of the upcoming lifestyle changes you should expect. For instance, during the first few weeks after the operation, you’ll need to be careful how you walk and do everyday tasks while your body heals and adapts to the new implant. For example, if you had hip-replacement surgery, to avoid possible dislocation during the recovery period, you must avoid crossing your legs and keep your knees below the level of your hips when seated. The OT will make available a handy wedge cushion that, when placed on the seat of a chair, will automatically push your hips higher than your knees.
Before leaving for hospital, it’s important to organize your home for your return. Do a clean-up before you leave, or get some help with this. Prepare meals ahead of time and put them in the freezer, or stock up on frozen dinners. Bending down to reach into the oven may be too difficult during the early days after surgery. Can these foods be microwaved instead?
Everybody’s home situation is unique. The OT can help you list the things you do day-to-day, and think of ways to make them easier over the next few weeks. For example, who’ll walk the dog? Are household items too high or too low and hard to reach? Storing things at a level between your waist and shoulders is best. Lifting things such as laundry loads and garbage will be activities you’ll need to avoid for several weeks. Make sure to remove scatter rugs and cables that could interfere with either crutches or a walker. Is there a handrail on your staircase that can take your weight? You get the idea.
Finally, the social worker at the pre-operative clinic can help you with other practical considerations for your recovery period. You may need someone at home to help perform routine activities such as bathing, preparing meals or doing laundry. If you live alone or your close family is unable to provide support, the social worker can arrange for a professional home-care attendant to help out while you heal. If you’re working, you need to book sufficient time off, and, depending on your work setting, maybe ask about getting reassigned to less physical tasks. The social worker will know the various labour-relations regulations that apply to your situation, so you’ll know how to frame your request. If your work is unionized, check with your union rep.