joint preservation, resurfacing and reconstruction orthopaedic … · 2020. 8. 11. · nurse or...

Joint Preservation, Resurfacing and ReconstructionOrthopaedicSurgery


CommunicationOur goal is to provide easy access to the team in order improve patient care.

Clinic: (972) 669-7179 Clinic Fax: (972) 669-7017 Physical Therapy: (972) 669-7189 PT Gym: (972) 669-7167

https://utswmed.org/doctors/joel-wells


Our MissionBuilding our legacy of excellence in orthopaedic surgery, finding cures and enhancing lives through patient care, research, innovation and education.


What Drives Us

Improve your quality of lifeHelp your joint painMinimize your post operative painMinimize post operative complicationsPrevent blood clotsProvide you with an exceptional health care experienceMaximize your recovery


The TeamSurgeon: Joel Wells, M.D., MPH Physician Assistant: Lanie Schrink, PA-C, MPHRegistered Nurse: Lauren YagerRegistered Nurse: Marina Pena Medical Assistant: Hipo EspinozaAthletic Trainers: Angie Frady/Amber BellSurgery Scheduler: Alexis Coffman Physical Therapist: Lauren Bryan PT, DPTPhysical Therapist: Emily Middleton, PT, DPTPhysical Therapist: Grant Myers, PT, DPT


Overview of Total Knee ReplacementThe knee joint is the hinge joint of the leg. It allows the leg to bend and straighten. It is made up of four bones: femur, tibia, patella, and the fibula.

During a total knee replacement surgery, the damaged part of your knee is removed and replaced.

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Overview of Total Hip ReplacementThe hip allows us to walk upright, keep our balance, and provides range of motion necessary for all tasks.The goal of a hip-replacement is to restore quality of life, improve pain, and function.Advances in technology have driven development of hip prostheses. Allowing longevity, better outcomes, and better satisfaction. During a total hip replacement, the damaged part of the hip is removed and replaced, with components that are sized and chosen for you.

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ComplicationsSwelling/Bruising Swelling is common. You may or may not have bruising possibly from your groin to your toes. Pain not relieved by surgery Dislocation This is the number one complication with hip replacement surgery. Wound infection/joint infection You are given pre, intra operative and post-operative antibiotics for prevention of infection. If

warranted, you may be sent home on oral antibiotics. Deep vein thrombosis (Blood Clot) The SCD’s combined with your prophylactic medication will significantly help to reduce this

risk. Failure of osseointegration – loosening of your hip replacementFracture By using your walker for the first 6 weeks after surgery will help to reduce this risk. Component wear Highly Crosslinked polyethylene currently- great profile with very good long-term results

Important to continue proper surveillance, follow up at 1 year, 2 years, 5 years, 10 years, 15 years, 20 years!


Scheduled visits before surgeryTwo clinic visits with Dr. Wells prior to surgery We want you to know our team, and know that we care and want to provide you the the best

outcome Pre Operative visit: Review and consent of surgery, receive shower soap and Bactroban

prescription, attend bootcamp, lab draws, hip-knee questionnaire complete, all clearances turned in to clinic.

Pre surgery testing: One week after Pre Op visit, usually the next Thursday, you will get a phone call from pre surgery testing. Look for call between 8 am and 12 pm. Medications will be reviewed and you will talk to the Anesthesiologist. If your health is more complex, they may ask you to come to Zale, 2nd floor for an in person appointment. They will schedule this at the time of your phone call.

MUST SEE: Primary Care Physician (PCP) for surgical clearance (if no PCP must obtain one prior to surgery)MUST SEE: Dentist for surgical clearance (if no Dentist must obtain one prior to surgery – we can refer you to one at UT Southwestern): Poor dental hygiene is a modifiable risk factor for infection. Case-by-case basis: may also need clearance from Cardiology/Rheumatology/Neurology/Infectious Disease/Geriatrics, etc. and our team will let you know if you need one of these.


Preparing for SurgeryPOSH: Perioperative Optimization of Senior Health

Provides comprehensive evaluation of older adults who are planning to undergo surgery. Designed to ensure surgery for our older patients is safe and that their recovery is smooth.Board certified physician led; performs preoperative assessment to anticipate risks related to surgery, and then develops individualized plan to optimize health status during surgical period; ensures best possible outcomes.All patients 75 and olderPatients 70 and over with one or more of the following: Polypharmacy (greater than 5 medications) Suspected or known cognitive impairment At least 3 comorbid medical conditions Unintended weight loss of > 10 pounds in the past year


Preparing for SurgeryHip or knee questionnaire research packet: This is to be filled out at your first visit and/or preoperative visit. This information is used to track your progress and for quality assurance.

Pre-operative exercises: You will be given individualized exercises at your pre-surgery Physical Therapy visit. Do the best you can to get strong and keep moving for a better outcome. Try to be vigilant in the month before your surgery.

Durable Medical Equipment (DME): You will require a walker and sequential compression device (SCD’s) - VenaPros). You will be contacted by representative within a week prior to surgery.

Please contact: Tyler from Matrix Orthopedics: (214) 449-4480 if you have not been called about the walker and VenaPros

The DME company will deliver equipment to the hospital, on the day of your surgery. If you have your own walker or VenaPros – bring them to the hospital

You will need your own walker for PT. You will wear the VenaPros home from hospital so do not send home early with family.

Medications: The medications will be reviewed with you during your pre-operative phone call. Please make sure your medication list is accurate, including the dosages.


Preparing for Surgery

Modifiable Risk Factors:Smoking and Tobacco Use Smoking and tobacco use has been shown to significantly increase the risk of post operative complications, especially that of

wound healing and infection.

We want to provide you with the best outcome; therefore all patients must stop smoking at least 8 weeks prior to surgery and 6 weeks postoperatively.

Nicotine screen – this will occur at least 2-3 weeks prior to surgery when you get your pre-operative labs drawn

Diabetes Control Hemoglobin A1C < 7.5, if greater than 7.5 we will postpone surgery and refer to Endocrinology

Healthy Weight (BMI = Body Mass Index) BMI < 35, If BMI > 40 will refer to Nutrition/PCP/Bariatrics. Significant Increased risk of infection and complications with BMI > 35.

Nutrition referral/Utopia Food and Fitness

MRSA Screen (all patients will be treated with nasal ointment regardless of results) All patients must be off any hormone replacement therapy 1 month prior to surgery and 1 month after surgery (Includes Birth

Control/Progesterone/Testosterone/Estrogen)

Proper Nutrition Hypoalbuminemia (Albumin < 3.5): Malnutrition, postpone surgery and referral to Nutrition

Optimize Nutrition Pre Operatively – Increase protein intake at least 30 days prior to surgery

Our goal is to minimize risk for complications to optimize your outcome!!!


Preoperative ChecklistYou have preoperative check lists in the Journey Guide including Home Readiness, 6 weeks, 3 weeks, 1 week, 2 days, night before and day of surgery.

This helps to determine any special precautions the team needs to take to ensure safe and optimal outcomes for every patient. Please give these to the Doctor, PA, or nurse.

You will also be given a list of things you can do in preparation to your surgery. Prepare your home, pack your bags, store throw rugs, prepare meals/frozen dinners, make pet

food and supplies accessible Discontinue appropriate medications, 1 month, 1 week, 1day, and day of surgery Call clinic if you have any questions


Three Days Before SurgeryAll patients must have COVID-19 PCR (nasal swab) testing 3 days prior to their surgery date.

A nurse from the pre-surgery testing office will call to schedule that for you when he/she performs your anesthesia phone call.

You can stay up-to-date on the latest COVID-19 information here: https://www.utsouthwestern.edu/covid-19/

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https://www.utsouthwestern.edu/covid-19/


Day Before Surgery Hibiclens Wash the night before and the morning of surgery. Do not use any lotions,

perfumes, or powders. Mupiricin (Bactroban) ointment, applied with Q tip, twice per day for 2 days before and

morning of surgery. You will continue this for 2 days after surgery. Stay well hydrated. Eat well-balanced meals which include protein. Nothing to eat after midnight. Please keep the meal light before midnight. You may drink

water up until 2 hours prior to surgery. (20 ounces total) Have bowel regimen ready at home

Metamucil + Colace + Miralax Expect call from team to verify time of surgery, The hospital will call between 2 pm and 5

pm the day before your surgery. This is to accommodate a very fluid OR schedule. Bring your walker and sequential compression devices (SCD’s) with you to the hospital.


Day of SurgeryArrive 2 hours before scheduled surgery at Zale Lipshy Pavilion, (Valet parking available for $5.00). 5151 Harry Hines Blvd; Dallas, TX 75390

Check in on first floor with hospital registration. Once complete, you will be escorted to the pre-surgery area on the second floor.

You will see the team with Game Ready for instructions, if you have rented this unit.

In the pre-operative unit, we will review your history and medications, start an IV in your arm, and the anesthesiologist will discuss your plan for pain management.

Dr. Wells and Lanie will review surgical plan and mark hip or knee, medications will be given for comfort to include antibiotics.

At this time, only one visitor is allowed to wait in the waiting room per patient.


Post Operative Expectations After surgery, Game Ready ice machine will be placed on surgical limb in the operating room and hips with

posterior approach will have a special pillow placed between your legs.

Dr. Wells will visit with your family and/or friends to update your progress after surgery.

You will wake up in the recovery room where you will be carefully monitored by nurses and an anesthesiologist.

Dr. Wells and team will visit you after surgery to check progress, discuss your surgery, and answer questions.

Your vital signs, IV fluids, and healing progress will be monitored frequently as well as pain level and meds.

Dressing: Your incision will be covered with an ABD that can be removed the next day if the incision is covered with Prineo mesh dressing. You may have a Prevena vac attached to a canister that will remain in place for one week or more. Specific instructions, both verbal and written, will be provided for the dressing.

A urinary catheter that is placed before surgery will be removed the morning following surgery if you require a catheter. Due to the shorter length of some surgeries, no catheter will be used which reduces your risk of infection.

Ice pack or ice machine and elevation will help keep swelling under control and help reduce pain.

The Occupational and Physical therapists will help you to get out of bed the same day as surgery. We expect you can, at least, stand at the bedside. For your safety, if you want to get up, please call the nurse or tech for help.


Hospital Stay and DischargeYou will be given a folder describing the protocol including dressing, SCD’s, implant information, and x-rays of your new hip or knee.

Expect Physical Therapy to come and get you out of bed 2 times per day. You may also get out of bed with nurse or tech assistance when you would like. We encourage this, but you must tell the nurse you want to walk. Do not get up without help.

To prevent a clot, wear your ted hose for 5 days after surgery and your SCD’s for 21 days after surgery on both legs.

Wear the SCD’s to sleep and when you are at rest during the day. Charge your SCD’s while in hospital because you will wear them on your way home.

Your prescription medications will be e-scribed to your pharmacy which we will verify.

Incision Care: Keep a close watch on your incision. Watch for drainage, rash, redness, or increased warmth. Contact

the Surgeon, PA or clinic.

Please call surgeon’s office with any concerns/problems at 972-669-7179, 24/7.


At Home InstructionsYou will be given discharge instructions verbally and in writing. These will be specific to your surgery and you will be able to refer to these at home, so keep them available.

Please take medications as prescribed. As your pain lessens, take less medication. Please do not take narcotic medication to “get ahead of the pain”. This causes nausea, constipation, fall risk, delirium and addiction.

Use your non narcotic medication to reduce that amount of narcotic medication that is necessary for pain relief.

Pain management techniques: Ice - for pain control and to reduce swelling – use machine or ice packs

Elevation - ”Toes WAY above nose”, at least 60 degrees, ramp the straight leg to reduce swelling.

Activity - movement and activity helps to lessen pain. Get up every 2 hours.

Distraction - focus on something other than your pain.


Narcotics Prescriptions

Narcotic prescribing law as of September 1, 2019

The new narcotics prescription law limits the amount of narcotics that can be prescribed for post operative or acute pain. Narcotic medication may be prescribed for 7 days. All refills require the patient to come to the clinic, in person, to receive a refill for 7 more days. We can only prescribe narcotic medication for 4 weeks. After that time, the patient must get narcotic medication from a primary care physician (PCP) or a pain management doctor.

We understand that this makes things a bit harder, and we apologize for the inconvenience.


At Home Instructions

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Home Health and Physical therapy will be set up for you at the hospital through the social worker/care coordinator. This person will come to your room and give you a list of HH companies to make a choice. If you live outside of the DFW or have a preference for HH or PT, please bring the name, address, and phone number of the facility with you to the hospital.

The Physical Therapist will come to your home 3 times per week for 6 weeks. They will teach you about exercise and hip precautions, evaluate your progress, watch incision for changes, and update the rest of the team on your progress.

During this time you will use your walker for 6 weeks with all walking. This is required for balance, healing, and gait mechanics. You will be weight bearing as tolerated unless otherwise instructed. We ask you to stay on the walker, rather than switch to a cane, to give your self time to get back to proper mechanics with walking.


At Home InstructionsConstipation Narcotic pain medication, decreased mobility and iron supplements can cause the slow down of normal

bowel movements. This is common so please use all three products in the bowel regimen. Stay hydrated- Water is best. Coffee, tea and soda can increase dehydration, so please limit the

consumption. You can lose your appetite so try smaller nutrient-packed meals more often and try for 40 mg of protein

per day

Prevention of Blood clots Wear your SCD’s (sequential compression device) while you are sleeping and in the day when you are

resting. You will wear these for 3 weeks after surgery. Wear the ted hose for 5 days after surgery during the day. Take them off at night. They help to reduce

your swelling. Take your oral DVT prophylaxis ( aspirin, Xarelto, Coumadin) as prescribed for 6 weeks after surgery.

Driving - Before driving, you must be: Off narcotic pain medication Able to bear full weight and walk without an assisted device Cleared by Physical Therapy

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Rehabilitation Expectations

GOALS Reduce Pain Promote Healing Maximize Outcomes

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Pre-Surgery

Acute Care

(Hospital)Home Health Outpatient


Rehabilitation Expectations

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Pre-Operative PT

• Maximize Post-Operative Outcomes• The stronger you are going in – the better function you should have coming out• Motion is Lotion

Home PT

• Promote Tissue Healing• Incision• Muscular and Tendinous Tissue

Outpatient PT

• Maximize Functional Goals• Activities of Daily Living • Job Related Activities• Recreational Activities


Physical TherapyPre-Op PT Visit is part of our protocol to optimize your outcome – the stronger and more mobile you are prior to surgery, the chance for good outcomes is improved.

In this visit you will receive: A comprehensive evaluation, including functional outcomes testing A tailored home exercise program to perform prior to surgery (clarify timing, duration

and frequency) Gait and assistive device training, home training including gait belt and transfers as

needed Review of precautions specific to your planned surgery type Education regarding expectations for after surgery


Home Physical TherapyA therapist will be coming to your home for approximately 4-6 weeks

Stay on the walker for 6 weeks – you will be weight bearing as tolerated (unless told otherwise) until the follow up visit with the surgeon Safety Healing Balance Proper gait

Keep progress in the middle of the road Too much = sore Too little = stiff

Doing well means you are on target – don’t progress too far too fast

Use pain as your guide - NOT no pain, no gain


ConsiderationsAssistive Device

Weight bearing Weight bearing as tolerated WITH Walker/Assistive Device until 6 week check up After 6 weeks weight bearing as tolerated (WBAT) WITHOUT assistive device with guidance of

PT

Walker (given at hospital)

Crutches(given at hospital) Cane


Hospital Hip Kit

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Reacher

Sock Aid

Long Handled Sponge

Long Handled Shoe Horn

Leg Lifter


Additional Considerations

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(Don Joy for purchase)

Elevated toilet seat

Other Medical Equipment – not covered by insurance

Shower benchTub bench

Ice Machine(per patient request)

(Game Ready for rental)


Total Knee Expectations

Minimize Swelling DVT prevention Improved range of motion (ROM)

Range of Motion Expectations End of Week 1 – 90° 0-120⁰ as soon as possible! Expected: at least as much motion as pre-operatively Full Extension is critical for normal walking

Recovery happens quickly! 3 month outcome is good indicator of how you will do, recovery will slow from 3-6 month

Gait Work with home therapist for weaning from assistive devices – quality is important

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Leg Positioning

Resting with your leg straight helps you reach your recovery goals. Elevation- helps reduce swelling Heel prop- helps regain knee extension ROM

Do not rest with your knee bent It may feel more comfortable, but it will make reaching your ROM goals more challenging and painful.

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Hip Precautions


Global Hip PrecautionsFirst 6 Weeks:• 6 weeks weight bearing as tolerated, heel first contact WITH rolling walker at all times

Driving: NO driving until:(1) full weight bearing(2) OFF narcotic pain medication(3) cleared by Physical Therapist

Patients 25 years and younger should utilize a hip abduction brace and will be20 pounds partial weight-bearing with assistive device

Select older patients/revisions will also be 20 pounds partial weight-bearing with assistive device


Global Hip Precautions

First 12 Weeks:NO straight leg raises Do NOT extend operative hip past neutral, including end range bridging and

terminal stance in gaitDo NOT flex the operative hip > 90° (do not sit on low surfaces, be cautious

when bending forward to put on shoes and socks)Do NOT internally rotate the hip (let the toes roll in – especially when your

trunk is leaning forward)Do NOT adduct the hip (cross the leg past the center of your body)Do NOT push range of motion


Outpatient Physical Therapy

Home Therapy must be complete and discharged prior to your first outpatient appointment – this is because of how insurance pays for services

Attendance in outpatient PT typically occurs between 4-6 weeks post op

What you will receive: Evaluation of current functional status Update to home program Plan for continued therapy


Outpatient Physical Therapy at Richardson/Plano Location

If you plan to complete your outpatient PT with us at the Richardson Plano location, please let us know prior to surgery. This will allow you to secure your spot at your preferred time.

Please call the clinic to schedule at (972) 669-7189 Schedule starting at 6 weeks post-op Schedule 2x/week for 6 weeks

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ExercisesWalking is the best therapy! Must be of good quality – NO limp Minimal, ideally NO pain

Tailored exercise by the physical therapist to target Gluteus Muscles (buttocks) Quads & Hamstrings (thighs) Balance Encourage good function in everyday and recreational activities

Return to Activity


Commonly Asked QuestionsWhy should I exercise before surgery? The better condition your muscles are in prior to surgery the easier it is to improve after surgery. Learning

some of the exercises prior to surgery helps you to become comfortable with them.

Will I need a walker, crutches, or cane? Yes, we want to allow time for the limb to heal as well as ensure good safety, balance and strength. You will be

on some device until your post-operative visit with surgeon.

Will I need any other equipment at home? You may need a shower seat or raised toilet seat that will need to be obtained before you come to surgery. You

will be given information on where to purchase these. A reacher and other equipment for activities of daily living will be provided a the the hospital.

Will I need PT at home? Yes, PT at home is a key factor in recovery. The number of sessions is based on your progress, typically home

health is 4-6 weeks and outpatient PT an additional 4-8 weeks.

Are there any activities that I should avoid initially? It is important to keep the hip moving but you should return to your previous activities gradually. Typically if

there is a specific activity you were doing prior to surgery you should be able to return to that activity by 12 weeks with the help and guidance of your physical therapist.


Commonly Asked QuestionsHow long will my new hip/knee last and will I need to have my hip/knee replaced again in the future? Current research shows that prosthetics can last 20-30 years. This depends on how you care for your hip/knee

replacement. It is very important to ensure you make all your follow up appointments (6 weeks, 4 months, 1 year, 2 years, 5 years, 10 years, etc.)

How much time will the surgery take? Approximately 1 ½ to 2 hours for an uncomplicated procedure.

Who will be performing the surgery? Dr. Wells will be performing the surgery, Lanie PA-C and resident will be assisting.

Will I be awake during the surgery? If you have general anesthesia, you will be intubated and asleep. With spinal anesthesia, you will be given

medication through your IV to put you to sleep.

Will I be in a lot of pain after surgery? If you have spinal anesthesia or a block, your legs will be numb up to 6 hours after surgery. Your pain will be

controlled with IV and oral pain medications.


Commonly Asked QuestionsWill I notice anything different about my hip/knee?

The pain in the hip/knee will have a different character. The groin and arthritis pain will be gone, and you will have surgical site pain that is much less than your arthritis pain.

Will I need a blood transfusion after surgery?

This will depend on your blood loss during surgery, your state of health, and any comorbidities you have. We will monitor you and discuss with you if transfusion is necessary.

How long will I be in the hospital?

The team plans carefully that you may be able to go home the next day after surgery. This will depend on certain factors and youwill stay until it is safe for you to go home.

Can I go directly home, or do I have to go to a rehabilitation facility?

Most people go home after surgery. There is certain criteria that must be met for insurance to authorize an inpatient rehab facility.

After leaving the hospital, when do I see my surgeon again?

You will hear from Dr. Wells, one of the nurses and Lanie after surgery. You will follow up with Dr. Wells/Lanie in clinic at 6 weeks for evaluation and x-ray.


Commonly Asked Questions

When can I return to work? The best situation is to return to work after 6 weeks of recovery. If you need any paperwork for work for yourself

or your partner/spouse, please bring it by the office or fax to us.

When can I go up stairs? You may use the stairs from the beginning. Go “up with the good (non-surgical)– down with the bad (surgical)”

leg. Be sure to use a railing for balance and assistance.

When can I drive? Right Surgical Leg – 5-6 weeks, when you are no longer taking medication for pain, you can walk comfortably

without support, and you are clear with current treating physical therapist. Left Surgical Leg – 4-5 weeks, above criteria must be met.

Will I always have one leg longer/shorter than the other? There is a chance there will be a subtle difference but often this initial discrepancy is due to the soft tissues. The

muscles must adjust to your new joint– this is a long process and not a complication to worry about in the first several months. Often there are changes in body mechanics and function.


Questions Regarding Presentation InformationIf you have any questions regarding information provided in this presentation, please feel free to contact us.

MyChart is the preferred contact method.

If you need to reach any of our medical staff, please send the message to Dr. Wells and/or Melanie Schrink, PA-C and then direct the message to the appropriate staff member you are trying to reach.

If your question is related to physical therapy, please contact Lauren Bryan, PT, DPT.


Thank You!

joint preservation, resurfacing and reconstruction orthopaedic … · 2020. 8. 11. · nurse or...

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