Patients usually arrive upstairs on the orthopaedic
ward within a few hours after finishing surgery
and their brief stay in the recovery room. Although
many of our patients who have had their surgery early
in the morning may be up and about in the afternoon
or evening, in general most patients rest the first
afternoon and evening after surgery. Pain medication
is given when patients request it, and ice is applied to
the surgical site. For most patients the first night is
uncomfortable but tolerable with pain medications and
antiemetic (anti-nausea) medications. After that, each
day gets easier.
Day 2 (The Day After Surgery)
On the morning of the second day, physical
therapy begins. In fact, we often have patients up the
evening of surgery if they feel up to it and the spinal
has worn off enough. The most important thing after
any joint replacement surgery is to get up and moving
as quickly as possible. The faster patients are up and
about, the faster they feel better, and mobilizing also
helps with other problems like preventing blood clots
and constipation.
Hip replacements have some precautions with
certain movements for the first couple of months after
surgery in order to prevent dislocation. In particular,
you should not flex the hip beyond 90º to 100º or cross
the legs until six weeks or so after the surgery (by
which time the tissues have healed and tightened up
around the joint). In contrast, anterior hip resurfacings
do not have any range of motion limitations or
precautions in most circumstances, because these
devices are very difficult to dislocate. Knee
replacement patients do not have precautions, but they
do need to learn how to properly begin walking and
moving. Physical therapy will reiterate the precautions
that apply to your surgery so that you don't forget.
Lab Tests
Lab tests are usually drawn the morning after
surgery, and one of the things that is checked is the
hemoglobin and hematocrit. These are measures of
anemia post-operatively and are used to help determine
if someone may need a blood transfusion or not.
Clinically, it is usually fairly straightforward to
determine who clearly needs a transfusion as these patients usually get quite lightheaded when they are up
and about. Other tests usually include basic metabolic
panels and electrolytes, and coagulation studies are
sometimes checked depending on the method of
anticoagulation being used.
All patients are on some form of blood thinner
(anticoagulation) to prevent blood clots after hip
replacement surgery (the next chapter is dedicated to
discussion of blood thinners and clots prevention). In
our practice, most first-time hip replacements (e.g., not
revisions or hip fractures) will be started on enteric
coated aspirin twice per day unless they are at higher
risk because of smoking, a history of clotting problems,
or bilateral surgeries, in which case low molecular
weight heparin (lovenox) may be used. If patients were
on warfarin before surgery (commonly for cardiac
reasons, such as atrial fibrillation), then they can
resume that after surgery. Note that different surgeons
may utilize different blood thinners, and there is a wide
variation on which methods are used.
Physical Therapy
During this first day of physical therapy, we are
principally concerned with teaching patients how to
start exercising and doing basic activities (such as using
a commode) on their own. Every patient will be
different in terms of how fast and how far they can
walk; it depends greatly on the physical condition of
the patient before surgery, how extensive the surgery
was, how anemic the patient is, what additional medical
problems the patient may have (e.g., lung disease,
morbid obesity, etc.), and other factors.
In general, we prefer for patients to walk at least
some short distance. Frequent breaks are used. As
patients get more proficient and confident with their new hip(s), they eventually can begin getting around on
their own using a walker or cane, but initially these
activities need to be supervised by nurses and physical
therapists.
Most patients are very apprehensive about getting
up for the first time. The discomfort after surgery
however is usually due mostly to the muscle and soft
tissue pain from the incision, and the majority of
patients are surprised to find that the replaced hip or
knee joint actually feels fine with weightbearing. There
is no longer the grinding, arthritic pain of a worn out
joint. The incisional pain gets dramatically better after
the first couple of days, and this can be helped
significantly with ice packs.
Diet
Usually most patients can begin at least with clear
liquids within a few hours after surgery. Diet will
gradually be resumed, but as a general rule of thumb, it
is a good idea to start slowly with bland things like
toast, crackers, and jello before progressing to meat and
potatoes!
If you feel nauseous, be sure to let your nurse
know. There are medications (like compazine or
odansetron) to counter-act nausea.
The pain medications used after surgery often
decrease appetite. Many patients may be eager to start
a diet after getting a joint replacement, but this is not
the time. Dieting can begin in a few months, after
tissues have finished healing and you are exercising
again. Even if you do not feel like eating very much, it
is important to keep drinking plenty of fluids. The
intravenous fluids can usually be discontinued once you
are taking plenty of liquids orally.
Although we do not use warfarin as a routine blood
thinner in our practice, some joint replacement centers
prefer it for all of their patients for post-operative
thromboembolic prophylaxis. In this case, certain
foods that contain a significant amount of vitamin K
should be avoided, and a nutritionist will usually help
educate you about what foods can interact with the
warfarin (collard greens, spinach, sweet potatoes, and
others). The vitamin K acts as a natural antidote for
the warfarin and cancels its effectiveness.
Dressings and Drains
In our practice, we typically try to remove dressings
and leave the incisions exposed to air on the day after
surgery. Sometimes there is still significant drainage
(which can sometimes last for days, particularly for
obese patients) which may necessitate the use of a
dressing.
In general wounds fare better when open to
air than with perspiration and a warm, moist dressing
without air. However, surgeons in other practices may
have different instructions about when to remove the
dressings.
Do not let anyone touch your incision without
washing their hands or using antiseptic gels. Most
hospital staff know this by heart, but it never hurts to
be vigilant because of the risk of infection. After all, it
is your incision.
Some redness and swelling is normal and to be
expected. It does not mean there is an infection.
Bruising is also not unusual.
Drains and catheters are usually removed on the
first day after surgery (not all patients will have drains
or urinary catheters, particularly those undergoing
short, first time replacement surgeries). Both may be
left for longer if there are medical reasons to do so. As soon as patients are taking good oral intake of fluids at
least and do not require transfusions or other IV
access, the IV will be discontinued.
Discharge Planning
Usually on the day after surgery one of the
discharge planners (or social worker in some hospitals)
will meet with you to discuss making arrangements for
aftercare. For patients who are going to a short term
rehabilitation facility, the discharge planner either
makes the arrangements or confirms them if you have
already prebooked with a rehabilitation center. They
also help to make arrangements for visiting nurses and
physical therapists at home and can also help with
straightening out any issues with insurance carriers.
Days 3 and 4
Physical therapy and getting up continue to get
easier. Again depending on the patient and the surgery,
some will begin practicing with a cane and others will
continue to use walkers or crutches. The most
important factor is simply getting up and moving.
We are watching at this point to be sure the
incision is healing properly, there are no medical
complications (blood clots, ileus, etc.), and that patients
are eating and voiding properly.
It is normal to be constipated for a few days after
surgery, and the laxatives and stool softeners that
patients are given will help. One of the most important
influences in return of normal bowel function is how
often the patient is up and about after surgery. Patients
who had spinal anesthesia will usually have a quicker
return to normal bowel function than those who had
general anesthesia.
Discharge
At this point, the majority of first time joint
replacement and resurfacing patients will be ready to go
home on the third or fourth day in the hospital, using
visiting nurse (VNA) and home physical therapy visits
until they are ready to go to outpatient therapy. Some
patients will go to a short term rehabilitation center,
typically those who have had more complex surgery,
had bilateral (e.g., both sides) surgery, have other
medical issues, or those that may live by themselves or
in a home situation in which they do not have adequate
assistance.
Most patients are able to travel in a regular car.
Moreover, most insurance plans do not cover an
ambulance ride to home or to the rehabilitation facility
unless there is a clearly defined (and documented)
medical reason for this. The discharge planners who
arrange for home physical therapy, visiting nurses, and
transfers to a rehabilitation facility can arrange for
medical transport, but unfortunately they cannot make
your insurance carrier pay for the services. Some
patients do elect to obtain these services at their own
expense if they feel they need medical transport.
Patients are discharged not only with their own
discharge instructions, but also extensive instructions
for either the visiting nurse/physical therapist or for
the rehabilitation facility. These include lists of
medications and dosages, weight bearing status,
activities to do and to avoid, problems to telephone us
about, when to follow up in the office (usually 3 to 6
weeks in our practice, depending on the procedure and
surgeon), and other instructions.
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.
