Most patients take as much time as they need to decide on if and when to undergo hip or knee surgery (the exception being the patients who need emergency surgery, as for trauma). After thinking about it, reading up on it, and discussing it with family and friends, patients who undergo joint surgery are usually comfortable with their decision, although most are understandably at least a little anxious about the surgery itself.
Scheduling Surgery
The next step is to contact the surgeon's office and let them know you are ready to schedule surgery. In our office, that usually means contacting your surgeon's medical assistant and letting her know that you want to schedule your surgery. She will check the medical chart to see what type of surgery was discussed and help you to pick a date for your surgery.
For joint replacement procedures, it is important to select a time when you can devote about 2 months to recovering. Although you will be up and about, getting out of the house, and driving by 4 to 6 weeks in most cases (and sometimes even sooner), it still takes a couple of months before most patients feel up to taking long trips or returning to physical work. Typical lead times in our practice (and for most busy joint replacement practices) usually are at least 4 to 6 weeks from the date patients call to schedule surgery (sometimes longer for busier times of the year - for example, many patients schedule surgery in January months in advance, and those surgery spots fill far in advance).
It turns out that several weeks are usually needed for preparation, and the usual lead time works well. There are several things that need to be accomplished before the actual hospitalization, and these are explained at the time of surgical scheduling.
Medical Clearance / Preoperative Evaluation
Because hip or knee replacement is an elective surgery, there is time to make sure that patients are in the best health as possible prior to the surgery. For this reason, in our practice (and most joint replacement practices) we ask patients to schedule a visit with their primary care provider a few weeks before the surgery to make sure that their heart, lungs, and other systems are in good shape for anesthesia and surgery. This usually entails a quick physical exam, some blood work, and usually an EKG to check heart function.
Many of our patients come from out-of-town or even out-of-state, and in those instances we have them see one of our hospital-based internists (or hospitalists) when they arrive in town for this visit. This ensures that we have adequate medical testing and history available for their other potential medical issues when they are hospitalized, and it also allows for them to be followed by the hospital internist during their hospitalization. For patients who live close enough for their primary care provider to follow them in our hospital during their stay, it is certainly preferable to have their own family physician perform the medical clearance.
Sometimes the medical clearance and preoperative evaluation turns up some issue that can be optimized, or may even have been unknown to the patient before testing, such as a high blood pressure, blood clotting disorder, diabetes, or cardiac arrhythmia. At least a few times per year, the preoperative evaluation discovers the need for a pacemaker or similar potentially lifesaving intervention that the patients may not have even known about. Most of these problems are easily correctable, and patients are then optimized prior to surgery to be in the best health possible.
Preadmission Testing (PATs)
There are also tests that need to be performed within a couple of weeks of the hospitalization. These are usually scheduled to coincide with the preoperative medical evaluation, so that the internist or primary care provider has the laboratory work available for their evaluation as well. The usual tests include a CBC (or complete blood count, which checks for many things, but particularly to see if a patient is anemic prior to surgery), coagulation studies (to ensure that the blood clots normally), and baseline metabolic testing (to check for kidney function, electrolytes, and blood glucose levels).
A chest x-ray and an EKG are also frequently obtained.
At our center, we also perform a series of special xrays during this visit which we use for templating, or determining the sizes of the components used. Frequently we also image the other bones around the joint being replaced, to check for other issues that may complicate the surgery. For example, sometimes an old fracture that has healed or an area of bowing may require additional preoperative planning to correct limb alignment during surgery.
Another important part of preadmission testing is to check for blood type and make sure that there is compatible blood available in the blood bank in case it is needed. Modern crossmatching actually checks far beyond A, B, AB, and O blood types, and usually a good match can be found before surgery in case it is needed. Many patients prefer to donate their own blood in the weeks before surgery, which can then be given back to them instead of donor blood. Still other patients may not be willing to accept any blood (e.g., Jehovah's Witnesses) and special arrangements are made. This entire topic of blood donation/management merits its own discussion and is discussed in the next chapter.
Joint Class
At our hospital, the preadmission testing, special xrays, and a short class on joint replacement all occur about 2 weeks before surgery.
The joint class is optional, but I have yet to have any patients tell me they regretted going to it. The class is about an hour long, with separate classes focusing on hip replacement surgeries and knee replacement surgeries. The class is usually taught by physician assistants, nurses, and/or physical therapists, and it serves to discuss the hospitalization, surgery, and issues after the surgery. (As you know since you are holding this book, there is actually a lot to know, and the class helps most people to absorb some of the volume of information that we have been discussing here.) Again, it is a good idea to take along any friends or family members who are interested so that they can hear the class information as well.
Short Term Rehabilitation Planning
Many patients undergoing routine hip or knee replacement surgery will be going directly home, often with arrangements made from the hospital for visiting nurses and/or physical therapists. However, some patients will benefit from going to a short term rehabilitation center for a short while after leaving the hospital and before going home.
The most common reasons for going to a rehabilitation center are social; e.g., a patient who lives alone or does not have adequate help at home during the day may need the extra help at a rehabilitation center before graduating to home. Other reasons are physical, such as having physical limitations (poor stamina or strength, significant obesity, neurologic problems, or other problems) that would make going directly home difficult. Patients having bilateral surgeries (e.g., both hips or both knees at the same time) also may benefit from short term rehabilitation.
In these cases, we will often discuss the option of short term rehabilitation placement with a patient before surgery and hospitalization. Since there are usually at least several weeks between the time surgery is scheduled and the actual hospitalization, I often recommend that patients visit one or more rehabilitation facilities near their home and pre-book with the facility if they find it to their liking. Most rehabilitation centers are glad to schedule tours and informative meetings before the surgery so that patients can decide if a particular facility is right for them.
Work and FMLA
Most patients have already considered that they will need a month or two away from work before deciding to have surgery, but it is worth thinking about before the hospitalization. Some employers have human resources directors available who can be quite helpful in explaining their company's policies for extended leave and short term disability. Some are able to plan on accommodations such as a temporary desk job or light duty to allow an earlier return to work.
Sometimes family members will want to take time off from work to care for a spouse or parent undergoing surgery. Many employers can facilitate this, with what is called the Family and Medical Leave Act (FMLA). After requesting time off under FMLA, employees may often need to submit some additional paperwork and may need to have the patient's surgeon sign employer forms. It is a good idea to explore this before the surgery and hospitalization if it is needed.
Consent
One final item that is important is the informed consent for surgery. In our state, as in most of the country, the state law requires some form of documented informed consent. Not only is it the law, but it probably is a very good idea.
The consent form for most hospitals essentially describes what the procedure is that you are having done, what location is involved (e.g., right knee, both hips, etc.), name of the surgeon(s) performing the surgery, and that you understand the risks and benefits of the surgery. It is never possible to fully explain all possible risks, so most surgeons list the general and most frequent complications that can occur. Other items on the consent form vary from hospital to hospital, but there usually is a provision to check off as to whether you would or would not be willing to accept a blood transfusion in the event that you need one.
In our practice, the consent forms are usually either signed in the office or mailed to the patient so that they can sign it and mail it back to us. If a patient has not signed the consent before the morning of surgery, then we will usually go over the consent form again at the hospital that morning.
Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.
