Don’t let joint pain slow you down

Welcome to Prisma Health! My name is Shea Garbett, and today we're going to talk about joint replacement surgery. We know it can be intimidating anytime you go in for surgery, so we want to make your journey as smooth as possible. Today we're going to hear from experts: Dr. Brad Presnell, Dr. Jeff Hopkins, and our nurse practitioner, Pat Family-Foreign.

My name is Shea Garbett, and I'm the Director of Marketing Strategy for Prisma Health. Thank you for being with us today to talk a little bit about joint replacement and what to expect before, during, and after. Can you tell us a little bit about yourself and what you do?

My name is Brad Presnell. I'm an orthopedic surgeon at Prisma Health Orthopedics. I specialize in hip and knee replacement, and I've done specialty training in orthopedic surgery to do joint replacement. How would a patient know if they need placement?

Generally, people come in because they're having pain. So that is the primary driver in deciding whether you want to have surgery or not. A lot of people ask me, 'Am I a candidate for a joint replacement? Do I need a joint placement?' And really what I tell them is, you never need a joint placement, but you may want a joint placement if the pain is now to the point where it's interfering with daily activities. Simple things like walking around the neighborhood with your spouse, walking on the beach, playing golf, working in the yard - those kinds of things that are everyday activities that now become difficult because of pain in your hip or knee. So, would you say really when your pain starts to affect your quality of life, maybe it's time to start thinking about surgery?

Exactly, it's not a life-threatening problem; it's a lifestyle problem. So we tell people, you have to decide when it's a significant enough problem, then you want to consider surgery for improvement in your quality of life. Thank you.

So, Dr. Presnell, once I have decided that I'm ready to have a joint replacement surgery, what happens from there?

So in the office, once we've had the discussion about surgery and you've decided it's the right time for you to have your hip or knee replaced, sort of the process in the office is we have a surgery schedule who come in and talk to the patient, and they'll start that process. Number one, we'll talk about scheduling the date, but also, there are a number of things we want you to do prior to surgery. We want you to visit your primary care physician and get a really what I would consider just a physical, your yearly physical. That's what we describe as a pre-operative clearance, but it's just a visit with your primary care physician to make sure all your medications are correct and all your medical issues are stable. If you see a cardiologist, we may want you to see the cardiologist and have him evaluate you or her prior to surgery to make sure all your heart issues are okay. There may be some other specialists that will want you to see a pulmonologist, maybe one that we'd like for you to see just to get an okay from them, an assessment from them that surgery is okay. They may have some recommendations what we need to do around the time of surgery. Another thing that seems kind of odd is we require a dental clearance, and the reason for that is we just want to make sure we're assessing all those things that could affect your post-operative recovery. Anything that might be at risk for infection. So dental infections could possibly create an infection around your hip or knees. We want to assess that before surgery.

We have booklets that provide information about the surgery, what to expect in the lead-up to surgery, the pre-op visit, and guides for your primary care physician. We also have general information about joint replacement that you can read at home. We recommend taking antibiotics before dental procedures, especially for the first year after surgery, to reduce the risk of complications. After a year, most people don't need to continue taking antibiotics for basic dental procedures. Before the surgery, we'll ensure that your diabetes is well-controlled and that your hemoglobin A1c is at an appropriate level to minimize the risk of complications. We'll also ask people who smoke to stop and those who are significantly overweight to lose weight.

We'll provide you with a walker and show you how to use it correctly to ensure that you can get around your home safely when the therapist starts to work with you. The case manager will arrange for you to get your own walker at home. We recommend an elevated toilet seat or a bedside commode to make it easier to get up and down off the toilet. You'll have a waterproof dressing that stays on for one to two weeks, allowing you to start showering immediately.

Thank you for joining us today to talk about what we can expect with a joint replacement surgery.

Thank you for joining us today to talk a little bit about joint replacement surgeries and the pre-op that goes on before you actually have the surgery. So if you would just tell us a little bit about yourself and what you do, my name is Patricia Family. I'm a nurse practitioner. I work with joint replacement surgeons, and I see all of the patients before they have a hip or knee replaced in order to make sure they are medically optimized and ready to proceed with their surgery.

So when I come in for a pre-op visit with you, what types of things are you looking for? How do we know that I'm healthy enough to have the surgery?

When you first come into the pre-op Clinic, the nurses will greet you and take your height and weight, along with some vital signs. They'll review your medication, so we do ask that all patients bring all of their medications that they're currently taking to the pre-op visit so we can actually look at the bottles and confirm the doses. After that, the nurses then go through a pre-anesthesia questionnaire to assist the anesthesiologist for when they meet with you the morning of surgery. Then the nurses will review your medical history for the anesthesiologist prior to me seeing you.

While the nurse is interviewing you, I will be reviewing your chart, looking at your medical history, the information that your medical doctor has provided, along with your dental history and any sub-specialists, such as a cardiologist or a pulmonologist. After I review all those records, along with lab work and EKG, I then determine if there are any additional studies that we need, such as an A1C or a chest x-ray that may not have been done.

What are red flags that you may be looking for as you review my medical history?

Red flags that I'm looking for include the A1C, as I just mentioned, to be sure that your diabetes is well-controlled. Your A1C has to be less than 7.5. Other red flags that I'm looking for is that your blood pressure is under good control within an appropriate range. If it is too high, say greater than 100-160 millimeters of mercury, we may have to send you back to your primary care physician to have your medications adjusted so that your blood pressure can get under better control. Other red flags that I'm looking at is your weight. We do have a weight limit or a BMI limit for surgery. If you are near that limit or over that limit, we may have to postpone surgery until you're able to get your weight under better control. People that have a high BMI tend to have more complications, such as infection issues with mobility, etc.

I'll also be looking at your pulmonary status, particularly if you have any COPD or other lung diseases. I'll be listening to your heart and lungs. If you haven't had a chest x-ray within the past year and you do have any lung history, we'll go ahead and send you for a chest x-ray while you're at the pre-op visit. If you're on any inhalers, we'll ask you to bring those to the hospital so that you'll have them for post-op use. As far as other medications, the hospital is able to provide those during your stay. So, there's a lot going on at the pre-op visit. How long does that usually take? It can take anywhere from one to two hours. We try to make it as quick as possible, but since you have to meet with the nurse before I have the chance to see you, sometimes it can take a little bit longer.

One other thing I'd like to mention is your smoking status. If you are a smoker, we ask that you stop smoking at least four weeks before surgery. While we would love for you to quit completely, we understand that that's not desirable for everyone, but you must stop smoking four weeks before surgery and up to 12 weeks after surgery. Again, that's to limit any risk of complication or problems with wound healing.

For surgery, you'll meet with the anesthesiologist. The surgeon will then meet with you and mark the appropriate extremity. At that point, when you're ready to go back to the OR, your care partner can go on up to the waiting room and wait for you there. Following surgery, you go to recovery, and some of our patients go home from there. Some of our patients spend the night. We do ask that you have a care partner (family member, friend) spend at least a few nights with you so that you're not home alone after this surgery. We have a discharge nurse who will be contacting you a week or two before surgery, and she will arrange your home health physical therapy. We do have you work with physical therapy several times before you go home from the hospital, and that's whether you're going home the day of surgery or the next day. Therapy will work with you, and we do have some therapy goals that we'd like you to meet. Our discharge nurse will arrange home Physical Therapy to follow up in your home for several weeks after surgery. She'll also look at your equipment needs to see whether you need a walker or a bedside commode. All of our patients will need a walker for at least two weeks. Most of the hip replacement patients will need a bedside commode to either use next to their bed or to use on top of their commode at home. Knee replacement patients will also need a walker for a minimum of two weeks as long as they have a toilet riser. They don't necessarily need a bedside commode, but that's certainly an option for them to use as well. Since you mentioned therapy in the hospital, I think people may be surprised to learn that they will be up and moving the same day as surgery. Yes, so therapy will get you out of bed the day of your surgery and have you walk. If you're spending the night in the hospital, you may just walk in the room and maybe to the bathroom or to the doorway and back and sit up in a chair for a few hours. If you're going home the day of surgery, they will work with you a little more extensively on walking and going up and down stairs. If you're spending the night in the hospital, the following morning, therapy will come and get you, and then they'll take you down to the therapy room where you will do a little more walking and then be able to go up and down steps at that point. So now I've decided that I'm going to have my joint replacement surgery, and I have been in to see you for my pre-op visit. What actually happens next during the pre-op visit? We provided you with some scrubs to use, as I mentioned. That's an antibacterial scrub called chlorhexidine. We ask that several days leading up to surgery, you use these scrubs during your shower. We recommend that you do one two days before surgery.

The day before surgery and the morning of surgery, if that does not fit with your schedule, then it will be the last three showers that you take prior to surgery. How you use these is you actually get in the shower, shower normally using your own products, as you would your own body wash or soap as well as your own shampoo and conditioner. Completely wash up, then step out of the stream of water. Go ahead, open the chlorhexidine scrub and scrub the surgical site. If it's a hip, we usually have you do your waist down to your ankle. Same thing with the knee: your waist, your ankle on the affected side. Make a good lather with the chlorhexidine scrub and then rinse it off. And at that point, you can discard that scrub and move on to the next one with your next shower. The night before surgery, we ask that you not eat or drink anything after midnight, unless you were instructed to take certain medications with a little sip of water. Other pre-op instructions that we would like you to follow is no shaving your legs for seven days prior to surgery. And one of the reasons is if you would have any nicks or cuts on your legs, we would not be able to do surgery on that extremity. And after going through all of this preparation, I know that is not something you would want to happen on the day of surgery to find out that you can't have surgery because you shaved your legs and you have a cut on your leg. Now, when you come in on your morning of surgery, please don't wear any lotions, powders, perfume, fingernail polish. You'll be accompanied usually by a family member or a friend, and they can stay with you in the pre-op holding area until it's time for you to go to surgery.

As far as medications, we typically provide most of your medications, although we will ask you to bring any inhalers or eye drops to the hospital for post-operative use. We also ask that you bring a CPAP machine if you have sleep apnea. As far as other items you may want to pack to bring to the hospital, most of our patients will bring their cell phone, so don't forget your charger. We also ask that you bring basic toiletries such as a toothbrush, hair comb, change of underwear, or change of clothes. Typically speaking, most people are able to wear the clothes that they wore into the hospital home from the hospital.

Since they're not in them very long, the day of surgery we do ask that your clothing be loose fitting and not restrictive so when you're working with the physical therapist, you'll be able to bend your knee and move about without any restriction on your extremity. We do ask that you leave valuables at home, so any type of jewelry, money, your ID, if you need to bring that to registration and your insurance card, you can ask your care partner to hold while you're in the hospital. But you don't need any money, jewelry, or other valuable items. I'd leave a laptop at home, just bring the basics.

So, what about shoes? You mentioned that you'll be up moving around after surgery. What kind of shoes are best for that? So, it's best to have a shoe with a non-skid sole and with the back on it. So, obviously, sneakers or tennis shoes are ideal. A lot of people, particularly after hip replacement surgery, don't want to have to tie shoes. You can also find slip-on tennis shoes that will usually do the trick. But we do ask that you avoid any type of sandals or flip-flops.

So, you've mentioned I'll need a care partner the day of my surgery. How will this person be updated on my status? How I'm doing in surgery? When it's time for you to go to surgery, your care partner will be directed to the waiting room, the surgical waiting room. There is an information desk there and they'll be provided with a beeper. There's also a board in the waiting room and they can follow your progress to see when you have moved from pre-upholding to pre-anesthesia to actually the operating room and then to recovery room. If your care partner would like to go to the cafeteria, they can do that and the beeper will alert them if it's time for the doctor to talk to them. They can also go to the information desk in the waiting room at any time and ask for updates. At that point, the surgery lasts anywhere from one and a half to two hours, so typically, it's a pretty quick process and is over before you know it.

What happens when you're in the recovery room afterward?

At that point, the anesthesia has stopped and you gently wake up. Some people wake up very hungry, some people not so much. Some people are still a little groggy. The anesthesia that's used on the majority of our patients are spinal anesthetic along with a sedative that helps you sleep during the surgery. When you wake up, you still might feel numb from the spinal anesthetic from the waist down. Usually, the sedative wears off fairly quickly and you wake up and feel pretty good from that point of view. And how long are you in recovery after surgery? It varies anywhere from about a half an hour to a couple hours. That's dependent upon several things: one, whether you're going home the day of surgery, and then two, the bed availability on the floor. If your surgery is later in the day, you may have to wait to go upstairs to the orthopedic floor. So how do you decide if you're going to stay overnight or if you're going home after your surgery? The doctors will make that decision with you. If you have multiple medical problems, we'll want to keep you overnight just to monitor you. If you don't have any other medical problems other than arthritis and you don't take any medications, you may be a candidate for going home the same day. So it would be good just to plan to stay overnight, have your toiletries with you, bring everything you need. That's always a good idea because even those who plan to go home the day of surgery, sometimes they're not able to meet the therapy goals or they have a slower time having the anesthesia wear off their lower extremities, and we end up having to keep them overnight anyway. So after surgery, once I'm discharged and I'm at home, how do I take care of myself? I'm sure I'll have a wound, obviously. The dressing on the wound, how does all that work? Most of our patients are sent home with an aqua cell dressing that covers the incision. Aqua cell dressing is a waterproof dressing that looks like a big band-aid and covers the entire incision and stays in place for one to two weeks.

This dressing is waterproof and can get wet, so you may shower with it in place and just pat it dry. You don't need to remove the dressing unless instructed. At that point, when you do remove the dressing, you will just have your incision line. It should be healed to the point where it does not need to be covered with anything else. If you notice any drainage, redness, swelling, or have a fever or chills, we do want you to notify us. If there's any drainage coming from the wound, just cover it with a dried dressing and notify us at that point. Most of the surgeons use dissolvable stitches, but there are times when visible sutures or staples may be used.

Once I'm home after the surgery, how long do I need to have someone there to care for me? Ideally, we'd like someone there for about a week. And it's not so much that you need care. By the time you go home, you will be able to take care of your own needs, such as getting up and down in and out of a chair, on and off a toilet. You will need help with meal preparation. We don't want you spending long periods of time standing. You'll be doing exercises several times a day and, in between your exercises, meal time, personal care time. We want you to plan your day so you have episodes where you're sitting with your leg elevated and ice on the incision. You also have your family member or your caretaker to help manage the ice, whether you use an ice machine or ice packs. They can help change those out on a regular basis to make sure you have something called against that incision.

We've talked about returning to normal activities. I think one activity people may have questions about that aren't comfortable as asking how long after surgery should you wait to resume physical intimacy with your partner? We do ask that you wait about four to six weeks before resuming any type of sexual activity. And that will just allow the joint and the incision time to heal. We'll provide you with some written material. This is a guidebook that we use that just provides some general guidelines into getting back into a normal relationship.

Pat, thank you so much for joining us to answer some questions about pre-op and getting ready for surgery. I'm sure our patients will find this very helpful. "Oh, you're most welcome, and I look forward to seeing the patients in pre-op.

Hi Dr. Hopkins, thank you for joining us today to talk about joint replacement surgery. If you could just tell us a little bit about yourself and what you do?" "I'm Jeff Hopkins, I'm one of the total joint surgeons here at Prisma Orthopedics. I moved here about 11 years ago from Los Angeles. That's where I did my fellowship and then I was in Kentucky before that and part of this practice for the last 11 years focusing on hip and arthroplasty or joint replacement." "So once I'm home from surgery, what does that recovery look like?" "Most patients, like we said, are going home either day of or day after surgery. Therapist will come work with patients in the home. We use a waterproof Band-Aid that's designed to stay on anywhere from 10 to 14 days and so that allows showers. We don't like hot tubs, swimming pools, bathtubs, that kind of stuff for about four weeks after surgery so no submerging water but showers are fine. Day of surgery, if you really want to get a shower. With regards to activity, I don't like folks driving a car anywhere from three to four weeks. There's some data out there that shows we maybe don't have neuromuscular control or the strength to operate a vehicle safely during that early interval and so it means having transportation around. I would expect pain and swelling after surgery that just comes with the territory and so patients go home with what we call a multimodal regimen meaning a bunch of different types of medicines to target the different things that cause pain after surgery. So typically people are going to go home with the Tylenol and that we do on a scheduled basis, some element of a narcotic pain medicine and that varies from patient to patient depending on their pain tolerance and if they're on pain medicine before surgery, etc. Usually, we'll send people out with an anti-nausea medicine. Unfortunately, a lot of these medicines can make people sick on their stomach and so a nausea pill can be helpful. We encourage everybody to do a stool softener. Unfortunately, with the narcotics and the pain management comes constipation after surgery. That's a pretty common thing and so we recommend people do just an over-the-counter stool softener, drink plenty of fluids. Those things can help as far as keeping your GI tract moving. We're doing anti-inflammatory for patients that can handle them. Again, that helps with the pain and the swelling after surgery. We recommend cryotherapy or ice. So, I think cold can help and patients are getting ice packs in the hospital. Most folks will keep that on as long as they can stand to do it. You need to watch the skin and that it can be too cold, so give the skin a little break.

I've seen a couple folks with frostbite over the years. The first couple weeks, certainly after knee surgery, are typically pretty rough. I would encourage against overactivity and I tell everybody just look at sort of how you feel and how your leg looks. If the leg is massively swollen and it's so big and bulky you can't get out of bed the next day, then that's your knee's way of saying you've done too much. And similarly with the hip, if you're so swollen you can't move and there's pain in the buttock and down the leg, that kind of stuff, that's probably an indication that you've done too much and you need to back off a little bit. I rely heavily on the home therapist and the outpatient therapist to kind of keep tabs on that, and they do a very good job of telling patients, 'hey, you need to pick it up a little bit, you're being a bit of a slug' or 'hey, let's pump the brakes a little bit, you're doing too much and you're getting big and swollen'. Because what we don't want is for patients to get swollen and then they start to drain and we start to worry about wound infections and those things after surgery. So what type of complications should we be on the lookout for after surgery? Infection is the biggest one that I worry about, for sure, because it is catastrophic when it happens. It means more surgery to try and fix it. It can be very difficult to eradicate an infection, and so in the short term after surgery we want people to be vigilant and look after their incision. And fortunately, the therapists do a good job, they come to the home of watching that and they have a very low threshold of cost and say, 'hey, Ms Jones' incision doesn't look good, she needs to come in and be seen.' But certainly on the patient, the family member's side, washing the incision, if we see wound drainage that's concerning. Redness and swelling are super common after surgery, the surgery is traumatic to the tissues and so to be swollen is common. We get that question all the time and I tell everybody out to a year you can have some swelling. Now in general, it's going to look better at six weeks than it does at one week and certainly better at six months than at six weeks, but there is a progression that most folks go through with regards to swelling. We worry about blood clots, patients or prophylaxis with typically it's an aspirin for most patients nowadays. We see that in the face of a modern therapy protocol, meaning we get people up and moving quickly. Aspirin tends to be a good enough prophylactic agent to prevent blood clots. There are certain patients who have increased risk for quads patients with a history of clots or clotting disorders, bleeding disorders, those types of things. We usually will do a little bit more aggressive anticoagulation in those patients, but by and large, the majority of folks nowadays are getting just baby aspirin twice a day for about six weeks after surgery.

I know many people wonder and I'm sure it's different for everyone, but how long does it typically take to get back to yourself and your normal day-to-day activities? I think it's different depending on hips versus knees. Hip patients tend to get better faster; it tends to be a less painful operation. The hip is, in my experience, the more forgiving part of the body with regards to post-surgical pain, and a lot of patients are really aggressive with their therapy and activity after the fact. And I backed off a little bit on my therapy protocols over the years, and then there's been some evidence come out recently that said maybe the anesthetic techniques have gotten too good, that people feel too good too quickly, and we're not giving the body the chance that it needs to heal after this significant traumatic event in the form of the surgery. So, I want people to take it easy the first month after hip surgery, and then at the four-week point, if they want to start ramping it up, I think that's fine. With knees, again, the first two to four weeks, typically pretty rough for most patients. Somewhere in that two to three month range is normal as far as getting back on the golf course or the people that do sedentary type work. I'd say somewhere in that six-week range is pretty common as far as being able to do that. As we've seen over the last couple years, a lot of folks are able to work from home now, and so that's changed things a little bit with regards to return to work, but by and large, if you're going to an office sedentary type job, somewhere in the four to six week range is pretty typical. A more physically demanding job, people that are going to be up on their feet for 8, 10, 12 hours at a time, that kind of stuff, that's usually more in the three-month range for people. If you're feeling comfortable doing that when people go back to work, even in a sedentary job, they're going to be sore, there's going to be pain that comes with that. The best case situations where people have really been active, I still don't think it completely mimics your return to work, and so you're going to expect some aches and pains along the way, and swelling, and those things tend to fade out. I tell everyone out to a year, as far as it being sort of as good as it can be. It's very rarely an overnight phenomenon where people just wake up one day and all of a sudden they feel great. It's usually a progression where they're feeling better at six weeks than one week and certainly better at six months than six weeks. Dr. Hopkins, thank you so much for being with us today to talk to us a little bit more about joint replacement surgery and what we can expect. I know that our patients appreciate having this information. Thank you for taking the time to sit down, talk about it. Our goal is to try and have folks educated and prepared for surgery. We recognize it's a big decision, and we genuinely appreciate the people who made the choice to see us and are honored to serve as Physicians and surgeons for the patients. I encourage everyone to read up and learn about the surgery and know about it. Think it absolutely affects outcomes, and we're privileged to have patients choose us as their surgeons. Thank you for joining us for joint education. We wish you a speedy recovery and the best of luck on your journey.

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- I'm Phillip Wessinger,

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I'm an Orthopedic Surgeon and have been an

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Orthopedic Surgeon with Prisma Health for the last 27 years.

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What led to my procedure really started back

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in my late teens and in early college.

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I was an athlete and very active,

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and with that comes the injuries that you get

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when you're an athlete.

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Had several knee operations early on,

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in my understanding and doing this for a long time,

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pretty much destined me to

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needing a knee replacement at some point.

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I did the things that we advise patients to do.

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I tried to keep my weight down.

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I tried to keep my activity levels at a level

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where I kept my strength and range of motion.

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I used any inflammatory medications.

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I use braces, I use the injection therapies that we do,

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and all those things worked well for me up until

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the last year or so,

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as I saw my function start to deteriorate,

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became evident that my conservative treatment

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was no longer going to be adequate.

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And I realized that what I've been told

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I needed a long time ago

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was coming to fruition.

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- Dr. West singer had severe arthritis in his knee.

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He failed what we call Conservative Treatment.

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And then he required a knee replacement.

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The knee replacement is a retread

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of the surfaces of the joint,

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which removes the arthritis changes.

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In his case, we used a robotic system,

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which is referred to as CORI.

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I think some people get the impression

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that the robot does the surgery.

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The robot is actually a tool that we use that I think

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enhances our ability to do the procedure more predictably.

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The CORI system uses inter-operative mapping,

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which actually makes a three dimensional image

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of that patient's joint.

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And from that we're able to better do

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their surgical procedure

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- In relationship to my postoperative experience,

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the first couple of weeks is slow.

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I use crutches for approximately two weeks,

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obviously had to use pain medicine that

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was needed in order to do physical therapy

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and participate with the things I was

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being asked to do by the therapist.

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After two weeks, transitioned over to a cane

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and used a cane sort of as needed as I moved around.

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But certainly by the four week mark,

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I was doing pretty well,

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so much so, that I was back in office

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and by six weeks was back in the operating room.

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By eight weeks,

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I was back a hundred percent doing what I do.

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- There's a lot of different

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diagnosis that can cause knee pain.

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For example, a person could have arthritis,

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which we perform the Total Knee Replacement for,

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but there could be other things such as a meniscus tear.

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There could be different causes of inflammation in the knee.

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So if you're experiencing symptoms in your knee,

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probably a first thing to do is be evaluated

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by a primary care doctor.

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Usually they're going to obtain x-rays,

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you may need an MRI scan,

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and then they can determine if you need to see a specialist,

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like an orthopedic surgeon.

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We also have non-operative orthopedist in our office

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who can do that preliminary evaluation.

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- When I described the excellence of the care I received,

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everyone treated me as if I were a novice

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with regard to this.

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And I took that as, not only a compliment,

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but it gave me real confidence

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in the way my patients are taken care of.

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Every piece of information was given to me as

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if I'd had not had any previous knowledge

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with regard to how this should go.

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That just demonstrated the commitment

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to excellent care and good communication that our staff has.

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And I got great confidence from that because it does require

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that teamwork and expertise for us to have the outcomes

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that we have.

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