University of Maryland Charles Regional Medical Center for Orthopedics Joint Replacement Program University of Maryland Charles Regional Medical Center for Orthopedics Joint Replacement Program University of Maryland Charles Regional Medical Center Patient Education For Knee Replacement 5 Garrett Avenue P.O. Box 1070 La Plata, MD 20646 www.charlesregional.org
WELCOME TO UNIVERSITY OF MARYLAND CHARLES REGIONAL MEDICAL CENTER JOINT REPLACEMENT PROGRAM _ WHAT IS A TOTAL KNEE REPLACEMENT? YOUR PATH TO A MORE ACTIVE LIFESTYLE APPENDIX A A. Frequently Asked Questions APPENDIX B F B. Anesthesia C. Pain Management D. Potential Complications E. Patient Rights/Advance Directives F. What to Bring to the Hospital APPENDIX G J G. Total Knee Precautions H. Physical and Occupational Therapy I. Home Safety/Self Care J. Helpful Telephone Numbers
Welcome to University of Maryland Charles Regional Medical Center Joint Replacement Program Our goal is to provide the highest quality and innovative care to you in a safe, comfortable and healing environment. The Joint Replacement Program at UM CRMC is a unique program combining state of the art care with clinical expertise and efficiency, all in your community and with a focus on service excellence. Choosing UM CRMC means access to multidisciplinary care delivered on an individual basis. This guide should answer many questions you may have about the care you will receive while at UM CRMC. Having the appropriate information you need, can ease concerns you may have about your joint care and rehabilitation. The UM CRMC Joint Replacement Program was conceived to bring patients with joint problems new hope for greater mobility and painfree living. Our center represents the best of a community hospital environment combined with the talent, skill and compassion of a dedicated group of health professionals. We are proud of the personalized care we provide and the hospitality for which we are known. Best wishes for your improved health.
The Civista Center for Orthopedics: Joint Replacement Program The Center for Orthopedics brings together a variety of disciplines to provide patients access to a full range of services related to joint care and joint replacement. Your team includes a network of physicians, nurses, physical therapists, case managers and occupational therapists specializing in total joint care. Our goal is to transition you from chronic joint pain and/or degenerative joint disease to living pain-free with greater mobility and independence. To achieve this, you, the patient will be involved in all aspects of your care. It is your responsibility, as well as ours, to work toward your independence. About this Guide The Total Knee Replacement Guide will help prepare you for your surgery and recovery. This Guide is also designed to give you helpful information on what to expect with a total knee replacement. If you have any questions on subjects that are not covered, please ask your physician, nurse, therapist, or case manager for further information. Remember: This is just a guide. Your physician, nurse, or therapist may add to or change the recommendations. Always use their recommendations first and be sure to ask questions if any information or instructions are unclear.
What is a Total Knee Replacement? In order to understand what a total knee replacement is, it is necessary to understand how a healthy knee works. The knee joint is a hinge joint. The joint is where the thighbone (femur), the shinbone (tibia) and the kneecap (patella) meet. It is supported by muscles and ligaments. Cartilage lines and cushions the joint. Over time, the cartilage can wear away and the bone surfaces can become rough, causing pain and stiffness. Conditions that may lead to an unhealthy or painful knee are: Osteoarthritis, Rheumatoid arthritis, previous knee injury, metabolic bone disease and abnormality of growth. Total knee surgery is done to replace a knee joint that has been damaged by injury or arthritis. Generally speaking, the total knee procedure will replace the bottom part of the femur and the top of the tibia. In most cases, your surgeon will also decide that your patella needs to be replaced. When your surgeon recommends a total knee replacement, he or she will choose the best artificial knee components (prosthesis) for you. Your surgeon will provide you with specific information based on his or her recommendations. Ask your surgeon if you have specific questions about your surgery or the types of implants available to replace your knee.
Your Path to a More Active Lifestyle Modern medicine has made it possible for a stiff and painful knee to be replaced with one that will function nearly the same as a normal healthy knee. It is important for you to realize that you will be responsible for a major portion of your postoperative rehabilitation, but rest assured that there will be many health care professionals to guide you through your rehabilitation step by step. As long as you follow the instructions of your physicians, therapists and nurses, and are willing to follow through with recommended exercises and rehabilitation, you will soon be on your way to a more active lifestyle. If, at any time, you do not understand any of the tests or devices we use, please ask us to further explain.
Before Surgery Pre-Operative Visits Pre-operative visits with: Your Orthopedic Surgeon and at Civista for testing and education. Tests Labwork, x-ray and/or EKG studies as ordered by your physician. Medications Bring all of your medications to your pre-operative appointments. Be sure to include all prescriptions, over-thecounter medications and vitamins or herbal supplements all in their original containers. You may be instructed by your doctor or nurse to stop some of your usual medications prior to surgery. Diet You will receive instructions to not eat or drink beginning at midnight the night before your surgery. Hospital Visit During your pre-operative visit, you will meet with, 1) A Nurse to gather your health history and to receive specific pre-surgery instructions; 2) A Physical Therapist to receive instruction on what to expect in therapy during your hospital stay; and 3) A Case Manager to begin planning for your discharge. Planning Your Your Case Manager will help arrange for equipment and post Discharge discharge services that you may need following surgery. *See Appendix Home Safety/ADL s for tips on preparing your home for your return from the hospital. Pack Your Bag The following items must be brought to the hospital with you: ü Total Knee Replacement Guide ü Medications in their original containers or a list with the name of the drugs, how much you take and when you take them. ü Insurance Cards ü Copy of your Advance Directive. Notes Case Manager: 301-609-4189
Tests Medicatio ns Diet Support Equipmen t Activity Exercise Self Care Planning Your Discharge Day of Surgery Labwork, x-ray and/or EKG studies as ordered by your physician. Your physician will review your home medications and continue the appropriate medications while in the hospital. You will not be allowed to keep your personal medications at the bedside. Your physician will also order new medications for pain management, prevention of infection and prevention of blood clots. Nothing by mouth the morning of surgery. (You may be instructed to take a pill with a sip of water before coming to the hospital.) Following surgery, a diet will be started once you are awake. For surgery and recovery you may have one or all of the following: IV, pain management pump, urinary catheter, elastic stockings, sequential compression device for nonoperated leg, wound drain, oxygen device, trapeze on your bed. Turn, cough and deep breathe exercises as instructed by your nurse. Use overhead trapeze on bed to help with movement If you have a morning surgery, PT may begin this afternoon. Begin ankle pumps when awake. Staff will assist you with repositioning and personal hygiene. Case Manager will follow-up with plans made during pre-op visit. Notes
Tests Medications Diet Support Equipment Activity Exercise Self Care Planning Your Day 1 After Surgery Labwork and any other x-ray or EKG studies as ordered by your physician. Pain management continues, preventive antibiotics, anticoagulant therapy based upon daily labwork, and stool softeners. Sleeping pill may be added to your medications. Advance diet as tolerated. Try to drink plenty of fluids to prevent constipation. Wound drain and urinary catheter may come out today. Continue with IV, sequential compression device, elastic stockings, and oxygen as needed. Physical Therapy (PT) twice a day: Out of bed to a chair; Walk with a walker. Avoid pillows under the operated knee-positioning with the knee bent will make it more difficult to complete exercises and to walk normally. Leg exercises with PT. Breathing exercises with incentive spirometer, every 2 hours to help prevent pneumonia and to maintain good lung function. Begin own self care with instruction and assistance from Occupational Therapy (OT) and Nursing. Feed yourself and bathe face and upper body. Begin use of bedside commode. Case Manager will follow-up with plans made during pre-op visit. Notes
Discharge Tests Medications Diet Support Equipment Activity Exercise Self Care Planning Day 2 After Surgery Labwork Pain management switches to oral form, anticoagulants continue based on daily lab results. Continue your regular diet. To help prevent constipation, eat plenty of fresh fruits and vegetables and drink several glasses of fluids daily. Continue, as needed, with IV, oxygen and elastic stockings. PT twice a day: Out of bed to a chair; Walk in hallway with a walker or crutches; Practice stairs, if needed for home; Discuss getting in and out of a car. Avoid pillows under the operated knee positioning with the knee bent will make it more difficult to complete exercises and to walk normally. Leg exercises with PT. Breathing exercises with incentive spirometer, every 2 hours to help prevent pneumonia and to maintain good lung function. Advance with own self care with instruction and assistance from OT and Nursing. Begin use of bathroom. Case Manager will confirm plans for discharge Notes
Your Discharge Tests Medications Diet Support Equipment Activity Exercise Self Care Planning Your including any equipment and ongoing therapy needs. Day 3 After Surgery Labwork Continue oral pain medications as needed, anticoagulants based on daily lab results. Continue your regular diet. To help prevent constipation, eat plenty of fresh fruits and vegetables and drink several glasses of fluids daily. Stockings as ordered, orthopedic devices. PT twice a day: Out of bed to a chair; Walk around hallways with a walker or crutches; Practice stairs, if needed. Avoid pillows under the operated knee positioning with the knee bent will make it more difficult to complete exercises and to walk normally. Leg exercises with PT. Breathing exercises with incentive spirometer, every 2 hours to help prevent pneumonia and to maintain good lung function. Advance with own self care with supervision from OT and Nursing. Use bathroom. You and your family will receive verbal and written discharge instructions: medications, care of your Notes
Discharge incision, signs of infection, signs of blood clots, nutrition. PT and OT will continue at home or as an outpatient. Tests Medications Diet Activity Exercise Self Care After Discharge From Hospital Labwork to monitor therapeutic range of anticoagulant medication. Anticoagulant, pain medications and previous home medications as ordered by physician. Continue your regular diet. To help prevent constipation, eat plenty of fresh fruits and vegetables and drink several glasses of fluids daily. Continue to use walker or crutches until advanced by your PT or Orthopedist. Your Orthopedist will let you know when you can return to driving and to work. Continue with leg exercises as instructed by your PT. Your Exercise program will be advanced as you continue in PT. Continue with your own self care using adaptive equipment as instructed by your OT. Begin to resume your normal responsibilities in the household. Notes
Follow-Up Follow-up with your Orthopedist. PT and OT will continue at home, in Rehab Center or as an Outpatient.
Appendix A. Frequently Asked Questions 1. What are the major risks of surgery? Infection a blood clots are two serious complications of joint replacement surgery. These risks are minimized by the of antibiotics and blood thinner medication. Please read more in the Appendix on Complications. 2. How long is the surgery? Approximately 2-2 ½ ho is reserved. Some of this time is preparation in the operating room. 3. Will I be asleep during surgery? Some patients h a general anesthetic, commonly called being put to sle Others have an epidural or spinal to numb the legs. Th is still some level of sedation with each method. These be discussed between you and your anesthesia care providers. 4. Who will perform my surgery? Your orthopedic surgeon and a team of operating room staff. 5. How long will the scar be? Usually about 8 long, vertically across the knee. This can vary from person t person. Ask your surgeon what to expect. 6. Will I need blood? You may need blood during or af your surgery. Please read more in the section Blood Transfusions 7. How long will the knee last? Most prosthetic knee last 10-15 years or longer. There are no guarantees an second replacement may be needed when the artificial surface loosens from the bone or the cup liner wears d over time.
8. Will I have any pain? As with any surgery, there will be some discomfort from the incision and placement of the prosthesis. Medication will be provided through an IV or epidural catheter initially. After the first day, your medication will be changed to an oral form preparing you for discharge. You may still have pain for several weeks as you heal but this should be different from the pain you had prior to surgery. Eventually, the prosthesis will relieve the pain and stiffness that led to your surgery. 9. Is there anything that will damage the new knee? Yes, please refer to the section Precautions. 10. How long will I be in the hospital? Average stay is 3-4 days, but may vary depending on your general health before surgery. Before leaving you should be able to: a. Walk safely with a walker or crutches. b. List precautions for your new knee. c. Perform activities of daily living (i.e. bathing, dressing, using the bathroom, etc.). d. Do your own exercises. 11. Will I need help after I leave the hospital? Yes. Your individual needs will be discussed with your case manager. The amount of assistance will vary depending on the preparations you made prior to surgery and your progress as you leave the hospital. 12. How long will I need a walker or crutches? This varies by each person, but the average use is 4-8 weeks following surgery. Thereafter a cane may be recommended. Your physical therapist will work with you until you are safe and confident with ambulating. Your physician will also check the healing process of the joint with X-rays and tell you when it is safe to discontinue the assistive device.
13. Will I need any special equipment? Yes. You may need a shower/tub chair and grab bars to make bathing easier and safer. Other devices that may be helpful are a reacher, a long-handled shoehorn, a sock aid, elastic shoelaces and a long handed sponge. 14. When can I resume my normal activities? a. Work: This time frame will depend on the type of work you do and your physical progress. The actual timing should be discussed with your orthopedic surgeon. b. Physical/recreational activities: Avoid high-impact activities and injury-prone sports (running, tennis, skiing, etc.) Low-impact activities such as walking, dancing, golfing, swimming, bowling and gardening are fine. c. Sexual activity: You should wait at least 3-6 weeks, or as directed by your physician, before resuming sexual intercourse. d. Driving: You may not drive until cleared by your surgeon usually at least 6 weeks.
B. Anesthesia 1. What types of anesthesia are available? The risks and benefits of each type of anesthesia as they pertain to your medical history will be discussed with your anesthesia provider before surgery. a. General anesthesia provides total loss of consciousness, a breathing tube is required b. Regional anesthesia provides numbness, loss of pain or sensation to a region of the body through a localized injection sometimes referred to as blocks, spinal, or epidural. Other medications may be given to help you relax and not be aware of your surroundings. 2. Who administers the anesthesia? Board certified or Board-eligible physician anesthesiologists and certified nurse anesthetists (CRNA) work together to oversee your anesthesia care. 3. Are there side effects? Nausea and vomiting are common side effects of anesthesia. Medications can be given to help prevent and treat this if necessary. Anesthesia staff will discuss risks, benefits, and side effects of the different types of anesthesia you decide upon. It is important to share all medical history with your anesthesiologist to include: any medications (prescription or over-the-counter), herbal or vitamin supplements, recreational drugs, smoking/tobacco use, alcohol use, previous complications with anesthesia (either yourself or an immediate family member) as these may all impact your treatment and recovery.
C. Pain Management As with any surgical procedure, there is an incision and a great deal of tissue manipulation that leads to pain and soreness post-operatively. Medications, positioning and exercise will help manage this pain while in the hospital and, over time, the pain will decrease. Pain medication may be offered through different methods. Your Orthopedist and Anesthesiologist will decide on the best methods to meet your individual needs. 1. IV (Intravenous): Puts fluids including medications into the blood stream through a small tube over a period of time. 2. PCA (Patient-Controlled Analgesia): The PCA attaches to an IV infusion and allows you, the patient, to push a button when pain level is increasing. The pump is programmed to only deliver a certain amount, regardless of the times pressed. 3. Epidural Pain Control: A catheter inserted by the anesthesiologist into the epidural space along the spine. A pump will attach to the catheter to deliver the medication. The epidural also has a patientcontrol setting. 4. Intra-Operative Injection: During the surgery, the Orthopedist injects pain medication directly into the surgical site. 5. Medication by mouth: Pain management medication may be started prior to surgery or soon after surgery. A side effect from many pain medications is constipation. Coupled with the reduction in activity due to surgery and pain, this could be bothersome for some individuals. To prevent the side effect of constipation and to promote healing of your wound, drink plenty of fluids and eat wellbalanced meals.
D. Potential Complications As with any major surgery, there are potential complications. Below is a list and description of some common complications. Bleeding Prior to surgery, lab work will be drawn to determine your blood levels are stable enough to undergo surgery. Daily labs will be drawn after surgery to monitor these blood levels. If your blood count becomes too low, a transfusion may be needed. Blood can be obtained from the local blood bank supply at the hospital. This is the quickest access to blood replenishment. Other options for transfusions would be an autologous or directed donation. Both of these options require more time and testing. An autologous donation is your own blood donated weeks before surgery that is saved for your use only if needed. If your surgeon suggested you donate your own blood for your upcoming surgery, you may be prescribed an iron supplement to maintain a healthy iron level in your blood. A directed donation is someone you select to donate their blood for you provided their blood is compatible with yours. The donated unit(s) would be reserved for you in the event you need it. The amount of drainage on the dressing or through the drain and lab values and vital signs will indicate the need for a blood transfusion.
Blood Clots Surgery may slow the blood flow in your body. When the blood is not circulating adequately it begins to coagulate creating clots. Thrombophlebitis or deep vein thrombosis occurs when the blood clots form in the large veins of the legs. Symptoms include swelling in the leg that does not go away with elevation, pain, tenderness, redness or warmth in the calf and calf pain while performing ankle pumps. If these signs of blood clots in the legs go unnoticed, the clot may dislodge and travel through the body and become stuck in the lungs causing a pulmonary embolus (PE) which is now an emergency. Signs of a PE include: sudden chest pain, difficulty and/or rapid breathing, shortness of breath, sweating, confusion and unexplained fever. The following treatments are steps to avoid or prevent thrombophlebitis: Blood-thinning medications (anticoagulants, aspirin) Elastic stockings (TED hose) Pneumatic compression device on feet Foot elevation Foot and ankle exercises Infection Infection occurs in a small percentage of patients despite efforts of prevention. Signs of infection include increased swelling, redness or pain at the incision; change in color, amount, or odor drainage; increased pain in hip; or fever greater than 101. Antibiotics are given during surgery and the day after to prevent infection. You may need to take preventative antibiotics for dental work and other potentially contaminating procedures for at least 2 years.
Hand hygiene is the single most important step in preventing the spread of infection. Please wash your hands frequently and before changing your dressing. E. Advance Directive We will ask if you have an Advance Directive. This is a means of communicating to your caregivers your wishes regarding health care issues in the event you are unable to communicate your wishes. If you have an Advance Directive, please bring a copy with you to the hospital so that they may be added to your medical record. Types of Advance Directives: Living Wills are written instructions that explain your wishes for health care if you have a terminal condition or irreversible coma, and are unable to communicate. Health-Care Proxy names a representative to make health-care decisions, if you cannot. A Health-Care Proxy may also be called a Medical Power of Attorney or Health Care Agent. Health Care Instructions are your specific choices regarding use of life sustaining equipment, hydration and nutrition and use of pain medications.
F. What to Bring to the Hospital Your Total Knee Replacement Guide Your medications in their original containers or a list with the name of the drugs, how much you take and when you take them including non-prescription medications and any supplements if these were not shared with the nurse during your pre-operative appointment Your insurance cards A copy of your Advance Directives A pair of well-fitting shoes suitable for walking Loose-fitting pajamas or a robe Personal hygiene items (toothbrush, deodorant, comb, etc.) Any medical support devices given at your pre-op appointment such as a walker or Incentive Spirometer Please do not bring: electrical items jewelry valuables cash or checks wallet with credit cards
G. Precautions DO NOT pivot or twist on your operated leg while standing or walking. Take small steps when you turn. DO NOT place a pillow under the operated knee. DO follow the instructions about how much weight you can put on your operated leg when standing and walking. DO use your walker or crutches until your Orthopedist or Physical Therapist instructs you to stop. DO complete your exercises as instructed by your therapist. DO hold on to the arms of your chair or the bed surface when standing and sitting. Avoid pulling on your walker. DO use the safety equipment recommended by your Occupational Therapist when bathing, dressing and toileting.
H. Physical and Occupational Therapy Physical and Occupational Therapy will begin either, the morning after or the afternoon of your surgery. The focus will be on getting out of bed, walking with a walker, activities of daily living (bathing, dressing, toileting, etc.), and exercise. We encourage your family/care supporters to attend the therapy sessions for training in how to safely provide support while in the hospital and after discharge. Your exercises are an important part of your Rehabilitation Program. The exercises will help you regain motion/flexibility and strength. The exercise sheets that follow may be modified for your individual needs. You should continue your exercises after your discharge from UM CRMC. The Physical Therapist you see after discharge will update your exercise program as you make progress. Continuous Passive Motion Machine (CPM): Your Orthopedic Surgeon may order a CPM as an adjunct to your exercise program. The machine is set up in bed and is designed to gently move your knee for range of motion. Your Physical Therapist will do the initial set-up and will routinely adjust the settings based on your progress. *Your Physical Therapist and Occupational Therapist can be reached at 301.609.4890. Physical Therapist Name Occupational Therapist
I. Home Safety and Activities of Daily Living Suggestions for home safety modifications to consider before returning home. 1. Have a light within easy reach or set up nightlights in the bedroom, bathroom, and hallways to maintain good lighting at night. 2. Arrange furniture to allow easy passage with a walker or crutches. 3. Have a firm and supportive chair with arm rests available to sit in. If the seat is too low, place a pillow in the seat of the chair to raise it to the correct height. 4. Check your home for cords, toys, pets, throw rugs that can increase your risk to trip and fall. Remove or relocate items as needed. 5. If possible have a cordless phone available in case of emergency. 6. Use a tub seat or shower bench when showering. 7. Use special devices for bathing and dressing: long handled sponge, shoe horn, sock aid. 8. Use a reacher for reaching and retrieving light objects from the floor or overhead. 9. Review your fire / emergency exit plan at home. Have a plan for a safe and unobstructed exit from your home.
J. Helpful Telephone Numbers Medical Center.301.609.4000 Medical Center/Toll Free.1.800.422.8585 Billing/Patient Accounts 301.609.4400 Discharge Planning..301.609.4189 Financial Counseling 301.609.4075 Gift Shop/Snack Bar 301.609.4348 Information Desk..301.609.4200 Laboratory Services...301.609.4270 Notary Services..301.609.4000 Nutritional/Menu Services..301.609.4330 Pain Management...301.609.4169 Pastoral Care Services...301.609.4189 Patient Information..301.609.4200 Patient Registration...301.609.4280 Physician Referral...1.888.332.4847 Quality Management...301.609.4310 Radiology Services...301.609.4170 Rehabilitation Services..301.609.4890 Safety and Security...301.609.4280 For more information on UM CRMC, visit our website: www.charlesregional.org
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