Part 1 : Preparation prior to surgery

Part 2 : The hospital admission

Part 3 : Returning home

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This pack may help answer some of your questions and prepare you for the road you are about to travel.

Dr Fleming highly recommends reading this after booking your surgery and again the week before your surgical date.

 

PART ONE: PREPARATION BEFORE SURGERY

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PREPARING YOURSELF PHYSICALLY

Becoming aerobically fit prior to surgery will aid your recovery. Dr Fleming recommends working with a physiotherapist/trainer well before surgery  to improve your fitness for surgery. If you have knee arthritis and have the means, please consider purchasing a stationary exercise bike. Start spinning on the bike well before surgery, this will get you into the habit of riding with a painful knee. Spinning will help your aerobic fitness and help you regain range of movement and strength.

PREPARING YOUR HOME

You will not be allowed to drive for 6 weeks  (insurers will not cover you in case of accident) if the joint replacement involves your right leg. If you drive an automatic and the left leg is being operated on, you may return to driving sooner should you feel confident behind the wheel and able to easily enter and exit the drivers seat.

Direct Anterior Approach Total Hip Replacement:

Dr Fleming usually  performs total hip replacement through the minimally invasive direct anterior approach which is an intrinsically stable procedure: therefore you do not need to modify your home toilet/chair heights.

Posterior Approach Total Hip Replacement:

If you are undergoing revision hip replacement or posterior approach, precautions will apply for 6 weeks following surgery. You will need to avoid sitting in low chairs and rotating the leg internally (knee inward) as this carries a dislocation risk.

 

An extend-a-hand (available from larger chemists or Bunnings), a long pair of BBQ tongs and a long shoe horn will make picking up light objects from ground level easier and can also be helpful for dressing.

Arrange for your pets to be looked after for the first 2 weeks or make sure they stay outside - you don’t want to be tripped up by your best friend!

Make your home as clutter-free as possible. You will be using crutches for the first 7 days 

Consider installing a hand-held shower head and a wall-fixed hand rail for stability.

 

Stock up:

• Easy-to-prepare food such as frozen meals.

• Projects to keep you occupied during your convalescence (e.g. DVDs /videos, organising photo albums). You will be limited in your ability to travel without support and may become bored if you have not planned ahead.

 

Purchase: Vitamin C 1000mg a day and standard iron supplements to take for the first 2 weeks after you return from hospital as this helps the soft tissues heal and the blood to regain its haemoglobin concentration after joint replacement surgery.

 

Carers need to be available for 6 weeks following surgery.

Arranging support at home: Please explore all options to ensure that you have someone with you.

Ideally, this should be day and night for approximately a week after your hospital discharge.

Standby shower assistance: Almost all patients will be able to shower themselves independently by the time they leave hospital, however, you will need someone nearby who can help dry your feet and back if necessary.

 

Meal Preparation:

Assisting with meal preparation is a key reason that we recommend you have someone stay with you.

• You cannot carry plates and other crockery while on 2 crutches.

• Standing at the kitchen bench to prepare and eat food is tiring.

• The person staying with you could leave sandwiches and a thermos within easy reach for you for lunchtime.

• Microwave ovens that are on the bench top (not on shelves) can be used for reheating pre-prepared food.

• There are gourmet dinner services which will deliver prepared food or fresh ingredients for you to cook at home without having to go shopping e.g. Hello Fresh or Marley Spoon.

• Home delivery of groceries is available – Woolworths will deliver to your kitchen bench (carrying your online order up your stairs for you!)

 

Support after discharge:

If you require Community Services or have any concerns about support after discharge, please contact your hospital's Pre-Admission Clinic or Discharge Planner prior to your admission.

 

Dressings: need to be kept as dry as possible as they are not waterproof - should they get slightly damp they will need drying with a hairdryer after a shower. Should they get soaked they will need to be exchanged for dry dressings to avoid wound infection - please call the ward you stayed in after surgery- they will arrange for you to have new dressings applied in the ward.

 

Transport: You will be unable to drive yourself home. Please arrange for someone to collect you when discharged.

 

Medications to cease:

Discuss this with Dr Fleming or your GP/Physician. Please cease anti-inflammatory medications 7 days prior to your surgery. Biologic medications for autoimmune diseases will need to be stopped before surgery (each has its own duration recommendation) to reduce the risk of infection.

DO NOT stop taking aspirin before the surgical date (only skip on morning of surgery).

You will need to stop taking Warfarin/Eliquis/Clopidogrel prior to the surgical date but it is VERY important that you discuss this with your cardiologist/surgeon/GP.

Stop taking over-the-counter medications a week before surgery - Curcumin, green lipped mussel extract, fish oil , Omega 3, flax seed oil, St John's Wort, high doses of Vitamin E and any other herbal supplements.                                                                                                                                                      

AVOIDING SKIN DAMAGE PRE-SURGERY

Any cut/abrasion in the relevant leg increases the risk of infection after surgery. Please avoid gardening for at least three weeks prior to your surgery. Should any skin issue arise prior to surgery please call the rooms and discuss this with Dr Fleming’s secretary.

THE DAY OF THE SURGERY - WHAT TO BRING

Toiletries, loose fitting comfortable night wear. Short leg pyjamas or shorts are recommended to accommodate for post-operative swelling and to provide access to your knee (knee replacements).

• A notebook to write down any questions as you think of them.

• A travel clock or watch

• A good book or magazine

• some of my patients have found a small plastic box that can hang on the edge of a table helpful to hold small things and spectacles/lip balm etc: available at KMART

 

FASTING TIMES AND MEDICATIONS

Dr Fleming advises his patients to drink 300 ml of isotonic sports drink (such as Gatorade or Powerade) 2 hours before your surgery time. This is a relatively new protocol that has been found to reduce post-operative dizziness and the risk of gastric reflux and aspiration - (expect the hospital administrators to get confused about this and advise you differently- follow Dr Fleming’s advice only please)

 

 

PART TWO: The day of your surgery

Your hospital journey will follow these stages

Admission – Pre-Surgery Ward – Anaesthetic room – Theatre – Recovery – Ward – Return Home

 

ANAESTHETIC

Dr Fleming prefers his patients to have a spinal anaesthetic and to sleep through the procedure aided by light intravenous sedation. At the conclusion of the surgery a cocktail of medications, including local anaesthetic, is injected into the region of the surgery. This helps to minimise pain, swelling and bleeding and allows us to perform the surgery with little or no opiates reducing the incidence of post op nausea/vomiting.

For knee replacements Dr Fleming typically leaves a small plastic cannula in the knee for the first night. This provides a site to ‘top-up’ with local anaesthetic the following day, providing excellent pain relief until the third day.

 

These techniques facilitate early mobilisation, which reduces the risk of post operative blood clots, helps you regain confidence in your gait, enabling you to walk up and down stairs and return home safely.

When you meet Dr Fleming’s anaesthetist please relate any prior anaesthetic experiences – both good and bad!

 

PAIN RELIEF

Surgery is a painful process. Some pain is unavoidable - the key to great outcomes is striking a balance, using the minimum dose of painkiller possible to make your pain experience acceptable, whilst avoiding complications from these medications. During your hospital stay, you will be able to be the judge of your own pain levels, helping us determine the appropriate mix of pain medication. It is not uncommon for people who dislike opiates to choose Panadol and an anti-inflammatory to manage their discomfort after Anterior Total Hip Replacement (knees less so!).

 

URINARY CATHETER

Dr Fleming avoids the use of urinary catheters as standard practice.

If for some reason one is required it is ideally removed at the earliest opportunity the next day.

If you have had difficulty passing urine/retention or have history of prostate problems/surgery please let the anaesthetist know when you enter the anaesthetic bay.

 

INTRAVENOUS DRIP

You will have a drip in your hand for the first day following surgery. This is for the 3 doses of intravenous antibiotic you will receive.

DAY-BY-DAY PROGRESS

 

DAY 0 - THIS IS THE DAY OF YOUR SURGERY

When your operation is finished you will wake up in the recovery room. The recovery nurse will be monitoring your blood pressure, vital signs and checking how you are feeling.

A mobile xray is performed. Once you have woken up sufficiently and your muscle recovery from spinal anaesthesia has begun (usually after 60 minutes) you will be transferred to your ward.

In the ward, you will meet the nurse and physiotherapist who will be looking after you.

Dr Fleming wants his patients to be capable of walking to the ensuite bathroom straightaway, with gentle assistance from the ward staff, provided your blood pressure is stable.

A short walk within the first couple hours following surgery is optimal. This reduces the risk of blood clots (DVT/PE) and paves the way for you to regain confidence and ability.

Apply the ice cooler to the surgical site regularly, to reduce swelling and pain. Your leg needs to be elevated when resting but please avoid sitting for more than 30 mins during the first 2 weeks following surgery.

Check with the physiotherapist if you are ready to train walking the stairs. The sooner this is achieved, the better your rehab will go.

 

DAY 1 – FIRST DAY AFTER YOUR SURGERY 

 

Today won’t be too painful as the local anaesthetic is active: Get up and go!

Physiotherapy: The aim is to start exercises and get you out of bed. The goal is to walk 3 circuits of the ward and become confident walking on stairs. Have a shower on this day, avoiding getting the dressings soaked. You will be allowed to sit out of bed in a chair for short periods.

Remember to ice in front and behind your knee (knee replacements). Be sure to ask for ice packs every 2 hours which should be applied long enough to cool the surgical site down completely. The use of ice packs, particularly for knees, helps reduce swelling and pain. Whilst icing your knee, perform calf pump exercises in bed counting 30 repetitions in each leg at least three times a day.

Additional tests:

• A blood test is taken to check if you need a blood transfusion.

• An X-ray might be repeated confirm the position of the joint replacement.

 

 

DAY 2

Today the pain will be worse than the previous day as the Local anaesthetic is waning and the surgical swelling will crescendo on this day.

The best thing you can do is to keep the swelling under control by elevating the surgical site (lying down in bed) and applying ice to the surgical area.

Be sure to take the minimum prescribed pain relief to make the pain acceptable. Only take the prescribed break-through pain medication if the pain is unacceptable. Please let the ward staff know if you are constipated as there are medications to help soften things up (This is due to dietary changes, pain killers and reduced mobility in hospital) and keep drinking fluids and eating prunes! Other measures which will assist are walking around the ward, eating fruit and drinking 2 litres of water a day.

Sit out of bed for 30 to 60 minutes at a time.

If you have had a hip replacement today is the day you will usually be returning home.

 

DAY 3 ONWARDS

Your goal is to increase your independence - master the use of Canadian crutches, walk up and down stairs independently, and shower without a helping hand. Keep aiming at walking 4 laps of the ward and use ice in the rest times.

Dressings are only changed if needed. Wound drainage may occur for 2 to 3 days and if this occurs the dressings will be changed prior to discharge.

If you have had a total knee replacement today is the day you will usually be returning home.

 

PART 3:  GOING HOME

 

Your discharge date will depend on many factors. When you can achieve the points below you can go home:

• walk safely

• walk the training stairs safely

• open your bowels and pass urine

• your pain is under control

As a guide, discharge is usually

• Day 3 after your knee replacement

• Day 2 after your total hip replacement

• Unicompartment (partial) knee replacements usually go home Day 2

• Revision surgery patients may need extra time.

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FOLLOW UP CARE

You will either be discharged home or to a rehab facility, as decided in conjunction with Dr Fleming.

Attend the follow-up wound check appointment with Dr Fleming, in his rooms, on the date given to you at the original surgical booking.

If you have had a knee replacement you will need to perform rehabilitation exercises daily at home for the first week post discharge. You will then enrol in an outpatient rehab, attending twice a week for 6 to 8 weeks, depending on your progress. Hydrotherapy is helpful only after the wound has been inspected by Dr Fleming at the 2 week appointment.

If you have had a hip replacement Dr Fleming prefers that you perform your own rehab in the form of gentle walks on flat ground, not more than 10 minutes twice a day for the first 2 weeks following surgery. After the wound check at 2 weeks post-surgery, he will guide you on the incremental walking time he wants you to be achieving.

 

THINGS TO WATCH OUT FOR

It is normal for your leg to be swollen for about 3 months after surgery then it will intermittently swell up to year after surgery following exercise. A knee replacement will remain slightly warm to touch compared with the other side for up to one year. The more you are up and around during the day the more it will swell. The swelling in your leg should be less in the morning when you get up, than it was the night before. It is normal for the operated knee to be slightly larger than the other side for up to a year.

• If the swelling has spreading redness in the surrounding skin or you feel unwell/fever call either Dr Fleming, through his rooms, or your GP to be assessed. 

If your calf becomes unduly swollen and painful, you will need to have an ultrasound to check that you do not have a deep calf venous clot (Deep Vein Thrombosis or DVT).

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A CLOSING NOTE OF ENCOURAGEMENT

Joint replacement can be a profoundly life changing operation- it will allow you to return to life without arthritic pain. It provides the ability for most patients to get back to daily activities, and some sports, with a smile. No one likes the prospect of surgery and rehabilitation that is required. Keep in mind the end goal, try to enjoy the process as much as possible! Dr Fleming and his team delight in the work they do and consider it a privilege to be able to help you to improve the quality of your life moving forward.