Total joint arthroplasty, sometimes known as total joint replacement, involves the cutting and resurfacing of bone and replacement with a metal implant.
As with any surgery, there are risks inherent with this procedure. The major risks for this procedure are the risks associated with anesthesia, infection, nerve damage, fracture, and blood clots in the legs and lungs. With Dr Mullen’s minimally invasive technique there is minimal blood loss, there is no need to pre-donate any blood, and only very rarely does a patient require a transfusion.
What do I need for surgery?
Some patients will be sent for blood work and an EKG before surgery. If a heart condition needed to be addressed within the prior year, a letter from your cardiologist describing your condition should be faxed to Dr Mullen.
At your office visit prior to surgery you will sign a consent form and Dr Mullen will electronically send in prescriptions for the two medications that you will use AFTER surgery. The first is for Aspirin 325 mg taken twice daily to thin your blood after surgery. The second will be for a pain pill. You can pick up both of these before surgery, but they are not to be taken until after surgery is completed.
You will need to get a walker and bring it with you to the facility for surgery. It needs to be the kind with two wheels in the front and no wheels in the back. Walkers with four wheels and hand brakes are dangerous and less appropriate for use immediately after surgery.
What medicines should I stop taking before surgery?
Plavix (Clopidogrel), Effient (Prasugrel), Pletal (Cilostazol) and NSAIDs (Advil, Aleve, Aspirin, Diclofenac, Ibuprofen, Motrin) need to be discontinued 10 days prior to surgery.
Over-the-counter vitamins often have ingredients that may thin the blood and must be discontinued 7 days prior to surgery.
Coumadin (Warfarin) and Brilinta (Ticagrelor) need to be discontinued 5 days prior to surgery.
Eliquis (Apixaban), Xarelto (Rivaroxaban) and Pradaxa (Dabigatran) need to be discontinued 4 days prior to surgery.
Failure to stop taking these blood thinning agents at these recommended times puts you at significant risk for excessive and potentially life-threatening bleeding, and may result in cancellation of your surgery. If you have any specific concerns with regards to your blood thinners, please address them with Dr Mullen and his office team no later than at your pre-operative appointment.
What do I do the night before surgery?
Drink plenty of liquids. Stock your home with easy to prepare meals for a few days.
In order to reduce the chance of infection, we ask you to perform a pre-operative skin prep. Please shower and scrub every day the week preceding surgery and make sure you shower the morning of surgery with regular soap.
You may take your pre-approved medicines the morning of surgery with a sip of water, but may NOT eat or drink anything else the day of surgery. No mints, no gum, no tic tacs… nothing.
When do I need to get to the surgical facility?
You will report to the facility about 2 hours before the surgery is scheduled to start. That time is needed for administrative check in, escort to the preop area, changing into a hospital gown, have a nursing evaluation, get an IV, and get a preoperative IV antibiotic infusion through that IV. You will meet your anesthesiologist to both answer and ask questions. Anti-nausea medication can be delivered before surgery through the IV.
What kind of anesthesia will I get?
A short acting spinal anesthesia is typically the safest. This allows for better postop pain control as well as less nausea and a lower complication rate than a general anesthetic. If a spinal anesthetic is contraindicated for some reason, the anesthesiologist will discuss your options with you to make an informed and consensual plan. Regardless of the type of anesthesia, you will not be alert during nor remember the surgery.
Adjunctively, if getting a knee replacement, your anesthesiologist will give you a Nerve Block immediately after surgery. This ‘block’ will numb the nerve in your upper thigh that supplies sensation to a large part of your knee. This minimizes pain, wears off within 12-20 hours, but may leave your leg feeling ‘heavy’ until it wears off.
How long does the surgery take?
You will arrive at the facility at least an hour and a half before the surgical start time. Once family and friends are eventually shown to the waiting area, you will get some intravenous sedation, be transported to the operating room table and then be safely anesthetized. You will then be comfortably positioned for your surgery, your skin sterilized, and sterile drapes applied. This all takes under an hour. Dr Mullen institutes a series of safety checks and then will perform your surgery. The actual surgery takes about another hour. You then will spend about 90 minutes in the Recovery Room, get dressed, and walk down the hallway before going home. So you will be at the facility for many hours before going home.
How will my pain be controlled?
Your anesthesiologist will give you medicines while you are in surgery to keep you comfortable. So will the nurse in the Recovery Room. The spinal anesthetic is short acting but the nerve block last many hours. Oral pain pills will be available to you as needed.
Let Dr Mullen know in advance if you have a preference for any particular pain medicine that works best for you. ALL narcotic pain medicine can result in nausea. This is an undesired adverse side effect, but is not an allergy. This can ideally be combatted by finding and using a narcotic that sits well in your particular stomach. If you are someone who gets nauseated with many different narcotic pain meds, we can use and anti-nausea medicine with your pain pill or just use over the counter pain analgesics like Tylenol instead. This may be a wise strategy if the nausea of a pain pill is more distasteful than the pain itself.
Do I walk on my leg right away?
Yes. The day of surgery. You will put all of your weight on your surgical leg while you stand and walk. You will walk down the hallway with your walker before going home.
When will I go home?
Same day surgery for joint replacement is a plan reserved for patients with confidence, a strong upper body, and demonstrable proficiency with a walker. Not everyone needs a hospital stay after a joint replacement surgery. Remember, you are not sick. When you are mobile enough to get in and out of bed, up from and back into a chair, and up and down the hall, you can go home.
Wouldn’t it be safer to stay in a hospital or go into Rehab?
Not necessarily. Studies have shown an increase rate of infections and medical complications in patients who stayed in the hospital or went to Rehab. If you are not sick and can get around safely, you don’t need to be in a hospital.
However, not all patients are good candidates for the outpatient program. Using a hospital is still a good idea if you have multiple serious medical conditions, are at high risk for complications after anesthesia, or if you are not strong enough in your arms and other leg to ambulate safely.
Where will I do my Physical Therapy?
After your outpatient joint replacement you will do outpatient PT. You may begin as soon as the first day after surgery. You will do outpatient PT 2-3 times per week for 6 weeks. Dr Mullen knows many clinics and therapists and can help you choose a PT clinic that does good work, is near your home, and takes your insurance.
Do I get a “Motion Machine”?
CPM or Continuous Passive Motion machines are not typically used after an outpatient knee replacement. Studies show that your eventual final range of motion will likely not be influenced greatly by the use of a CPM. CPMs are sometimes used for patients who either had to stay in a hospital after surgery or in patients who are at particular risk for stiffness after surgery.
How do I keep from getting a DVT, or a ‘blood clot’?
Many things can help, but DVTs do occur sometimes. Early full weight bearing and frequent walking is the most important and effective way to prevent DVTs. Sequential Compression Foot Pumps are used when not walking while in surgery. You will be started on Aspirin twice daily to chemically thin your blood right after surgery.
If you already take a daily blood thinner as part of your typical medical regimen, please discuss this with Dr Mullen before surgery.
When may I shower and change my bandage?
Dr Mullen will apply an Aquacel or Mepilex antimicrobial foam adhesive bandage to your leg after surgery. On knees, an ACE wrap on top of this adhesive bandage may be removed the day after surgery. You may then shower with the adhesive bandage on, dabbing it dry afterwards. However, under no circumstances should the wound be dunked or submerged under water for 6 weeks.
7 days after surgery you will peel off the adhesive bandage. You will then see your wound. You may still shower and now get the incision wet, but only let soapy water run along the incision briefly before patting it dry. Keeping your incision clean this way is a good idea and can help prevent infection. Your shower should be brief. Don’t linger. After showering you should cover the wound with a piece of gauze and either tape for a hip or an ACE wrap for a knee.
Do not apply any ointments or creams to your incision. You are still not allowed to dunk or submerge your incision under water for 6 weeks. Water exposure in this manner can seep into the incision and cause a terrible infection. That means no bathtubs, hot tubs, Jacuzzis, swimming pools, or water therapy for 6 weeks.
When may I drive?
It is illegal to drive under the influence of narcotics. Once you do not need narcotics, and only after you feel physically able to accept the responsibilities that come with driving a car may you return to driving. That turns out to be an answer that changes patient to patient.
When will I be seen after surgery?
Your next appointment in the office is usually scheduled for about 15 days after surgery.
How long will I be out of work?
Your return to work is dependent on the type of occupation you have. Patients with sedentary jobs may be able to return 2-4 weeks after surgery. Patients with a physically demanding occupation may be able to return 8-10 weeks after surgery.
Do I need to take antibiotics before dental cleanings forever now?
Dental infections or bad teeth can be a source of infection for a joint replacement even after the surgery is completed. For this reason it is wise to advise your dentist that you have had a total joint replacement surgery. For any dental procedures, including cleaning of your teeth, you should consider antibiotic prophylaxis. Conflicting evidence exists regarding their necessity; however, most doctors agree that anyone with any medical condition that increases any risk of infection should use pre-dental care antibiotics. This is generally a single oral dose of either Amoxicillin 2 grams or Cleocin 600 mg one hour before dental procedures. Other infections in the body, such as boils or bacterial infection, could also represent a source of problems for a person with total knee replacement. For this reason, if you have any infection you should consult your family doctor promptly so that proper treatment can be carried out.
Are my expectations realistic?
Total knee and total hip replacement surgery are major surgeries and should not be undertaken lightly. It is wise to keep in mind when considering this surgery that even the best total joint replacement is not as good as your body was when it was healthy. The goal of the surgery is to relieve your pain, if not totally, then at least somewhat. It is also the goal with this surgery that you will maintain reasonable stability and flexibility as well.
Even when you feel much better you must keep in mind that this new joint is a mechanical device. Just like any mechanical device, including your automobile, there can be problems or failures. In general, total joint replacements can last many years. As with any medical procedure, there is no guarantee.
Even if you feel much better following your surgery it is wise that you avoid activities which require high impact to the leg or hard contusions to the joint. While permitted, they may shorten the lifespan of a joint replacement.