Total Joint Replacement Program

The musculoskeletal system includes bones, joints, muscles, ligaments, cartilage, and tendons — all working together to allow us to move.

Stress, injury, and aging cause wear and tear of the system. This can lead to osteoarthritis, also known as degenerative joint disease. When we lose the smooth gliding movement of bone over cartilage, pain, swelling, stiffness, and instability often occur.

Joint replacement — called arthroplasty — is often the best method to relieve severe osteoarthritis and to help a person regain freedom of movement.

Joint replacement surgery is one of the most successful surgical procedures available. Many individuals wonder why they waited so long to choose surgery and regain movement. Some say it is like getting their life back. Surgery gives them back their freedom to return to normal activities.

About 700,000 total knee replacements and 400,000 total hip replacements are done in the United States yearly. Women outnumber men two to one. The typical age is between 50 and 80 years of age. Many younger people have joint replacement surgery to improve their quality of life.

THE KNEE

The knee is the largest joint in the body. The knee joint includes these three bones: femur (thigh bone), tibia (leg bone), and patella (knee cap).

Ligaments hold the bones of the knee joint in place. These ligaments work with muscles, bones, and tendons to allow the knee to bend and straighten.

These joint surfaces where the femur, tibia, and patella touch are covered with articular cartilage, a smooth material that cushions the bones so that they glide smoothly. Fluid-filled sacs (bursae) cushion where soft tissues glide across bone. A thin, smooth lining (synovial membrane) secretes a clear liquid called synovial fluid. Synovial fluid lubricates the joint. This fluid reduces friction and allows smooth motion. 

With osteoarthritis, this cushioning is missing, making movement painful.

Total Knee Replacement

Total knee arthroplasty is a surgical procedure in which injured or damaged parts of the knee are replaced with artificial parts. 

During the procedure, your knee is in a bent position so that all surfaces of the joint are fully exposed. The articular cartilage and a small amount of bone are removed from the end of the tibia, femur, and undersurface of the patella. 

The surgeon takes measurements to fit your new prosthesis — artificial parts — and smoothes the rough edges of the bones. The artificial parts are made of cobalt, chrome, and titanium, and a high-wearing plastic called polyethylene. The artificial parts are cemented into place by bone cement (methylmethacrylate). 

Your new knee will have cobalt chrome cap on the end of the femur, a titanium plate on the tibia, and a polyethylene spacer. A polyethylene “button” may be placed on the undersurface of the patella. Before closing the incision, the surgeon bends and rotates your knee to test and balance it to be sure that it is the right fit and works correctly.

THE HIP

The hip joint is a ball and socket joint. The head of the femur (thigh) bone is the ball and the acetabulum (pelvis) is the socket. It is designed for stability and for a wide range of movement, including flexion, extension, twisting, turning, and bending.

Next to the shoulder joint, the hip is the most moveable of all joints. When standing, the entire weight of the upper body is passed through the pelvis to the legs.

Total Hip Replacement

In total hip arthroplasty, an artificial hip is designed to work like a normal hip joint.

A cup, usually made of polyethylene plastic with a titanium backing (or shell), replaces the worn hip socket. A ball, usually made of cobalt chrome metal alloy, replaces the worn head of the femur bone. A metal stem joins the ball to the existing thighbone. Bone cement may or may not be used to hold the stem in place. These three parts (cup, ball, and stem) work together to provide smooth, comfortable movement like a healthy hip joint.

Putting the Pieces Together

The surgeon will choose the best way to be sure that the artificial pieces are securely fitted to your bones. The choices are:

• Cemented: Methylmethacrylate is used like grout to hold the parts in place.
• Non-cemented: When cement is not used, a titanium mesh is used. Your own bone will grow into this mesh.
• Hybrid: A hybrid joint uses both cemented and non-cemented pieces. The femoral part will be cemented into the thighbone and the acetabular cup will be press-fitted into position using the cementless approach.

You will stand on your new hip as early as the day of surgery. Your doctor will decide how soon and how much weight you should put on your leg.

Joint replacement surgeries can be performed as an outpatient or an inpatient procedure. The decision on whether you are admitted as an inpatient or you are sent directly home after your surgery (outpatient is dependent upon many factors, including your insurance and medical history). Your surgeon will determine which procedure is best for you.

During the pre-admission process, your status as inpatient or outpatient may need to be modified. Any modification and reasoning will be discussed with you.

THE PRE-ADMISSION PROCESS

Doylestown Hospital’s orthopedic care team will help prepare you both physically and emotionally for your total joint procedure.

After a physician evaluates you for surgery, you will be given a pre-admission packet with important information and forms. Please bring this folder to all of your appointments.

As part of the pre-admission process, you will be contacted by the hospital staff to setup your pre-admission testing and pre-admission nurse call. 

Pre-admission Testing

A pre-admission testing session will also be scheduled for you. This will include testing and a physician assistant appointment. You will receive a phone call from a nurse prior to your preadmission appointment. During this phone call, you will discuss your other medical conditions and medications. You will also be given preoperative instructions.

The nurse will need to know all of the medicines you take (including vitamins/ supplements and over the counter medicines).

You will need to schedule appointments for your surgical clearances. These include your family doctor, dentist, and cardiologist and other doctors, if necessary. (You will be instructed as to which doctors you need to see — see folder). Please schedule all needed clearance appointments as soon as possible. You will be given a prescription for the nose medicine at your preoperative appointment with the physician assistant.

Education

You will need to view the online education program prior to your preadmission appointment. This program is extremely valuable and will help you understand:

• What will happen at the hospital
• The rehabilitation process
• How you can return to active living as you recover from surgery

Please click here to review additional information. DoylestownHealth.org/ TotalJointReplacement. 

You may have some questions about your surgery and care. Later in this booklet, you will find a list of frequently asked questions. There is also a list of questions you may want to ask those caring for you while you are in the hospital.

Don’t be afraid to ask — our orthopedic care team is here to answer your questions while providing the best care available.

You will receive an email requesting that you complete a survey about your health status, pain, and how well you are able to do certain tasks. The survey will come from the following email: DoylestownHospitalOrthopedicInstitute@ortechsystem.com. Please complete the survey as it will assist us in planning for your stay.

Prior to surgery, make sure to refer to the checklist in your folder for things that must be completed.

DAY OF SURGERY

The orthopedic team will be ready for you when you arrive at Doylestown Hospital for your surgery.

Before coming to the hospital, remove all your jewelry and leave any valuables at home. You do not need to bring any of the equipment you will use at home unless instructed to do so.

When you arrive at the hospital, please report to the Same Day Surgery (SDS) unit on the 2nd floor above the main lobby.

Prior to surgery, the team will make sure you are ready. Your nurse will review your medical history, then the anesthesiologist will discuss your anesthesia.

Anesthesia

General anesthesia acts on the brain and nervous system, similar to a deep sleep. It is usually given intravenously and/or by breathing it in.

Regional anesthesia involves numbing a specific area of the body without acting on the brain or nervous system. Because you will be conscious, you will be given sedatives (medicine) to relax you and put you in a light sleep. 

There are two types of regional anesthesia:

1. A spinal block, where the anesthesia is injected into the fluid around the spinal cord in the lower part of your back. This fast, numbing effect lasts for a few hours. 
2. An epidural block, where a small tube (catheter) is inserted in your lower back to give local anesthetics over a longer period of time. The epidural catheter is placed closer to the skin and farther from the spinal cord. Epidural anesthesia can be continued for one to two days after surgery for postoperative pain relief.

Your anesthesia needs will be carefully matched to your medical condition and the details of the surgery. Your response to anesthesia will be closely monitored. Be sure to share with your anesthesiologist your current health history, including any reactions to medicines and past experiences with anesthesia. 

The anesthesia option video can be viewed at DoylestownHealth.org/ TotalJointReplacement. If you have specific questions about anesthesia, let the pre-admission nurse  know and she will set up an individual meeting for you.

Depending on your medical history, your surgeon may require you to meet with anesthesiology prior to surgery. If this is the case, you will receive a phone call from the anesthesia department. 

Getting Ready for Surgery

All dentures, contact lenses, glasses, hearing, aids, and hairpieces will be removed and safely kept for you. 

An intravenous (IV) catheter will be placed into one of your veins and IV fluids and antibiotics will be given.

Any hair on your surgical site will be clipped. An antibacterial scrub will be done. 

Before you arrive for your surgery, your team of experienced anesthesia and operating room staff who are experts in total joint surgery will plan and prepare the operating room suite. This team will stay with you during the entire surgery, providing for your safety and privacy while you are under anesthesia. 

As the time for your surgery nears, you will meet your nurse anesthetist and and anesthesiologist. Your medical chart will have already been reviewed by the team to be sure that all important information is noted, including the permit for surgery, the history and physical findings, and other medical reports. 

For your safety, your team will ask you to confirm what surgery you are having. They will also ask you your name and date of birth several times throughout your stay.

Next, you will be taken into the operating room suite. The room will be a bit chilly; warm blankets will be applied.

In the room, you will notice one or more of the team members in what look like space suits. During your surgery, the surgeon, nurses, and assistants will wear these suits to protect both you and the staff from any potentially harmful bacteria or viruses.

The nurse anesthetist will place monitoring equipment to check your blood pressure, blood volume, oxygen level, and the rate and rhythm of your heart before, during, and after surgery.

Total joint replacement surgery can take anywhere from 45 minutes to two hours, depending on the procedure.

Rehabilitation Begins When Surgery Ends 

After surgery, you will be taken to the post-anesthesia care unit (PACU) to begin your recovery.

Your vital signs (temperature, blood pressure, pulse, blood oxygen level, and respirations) will be closely monitored. You will have a special dressing over your incision.

An X-ray may be taken while in the PACU to check the positioning of the knee or hip prosthesis in this early phase of your recovery. 

After your initial recovery from anesthesia, your care will continue on the surgical unit if you are staying overnight. There, you will meet with other members of the orthopedic team as you continue your road to recovery. 

Keeping circulation and blood flow to and from your legs is of utmost importance.

One of the major risks for patients who have joint surgery is a problem called deep vein thrombosis (DVT). A deep vein thrombosis is when a blood clot forms within a deep vein in the thigh or calf. Surgery-related changes in circulation and activity, as well as individual risk factors, contribute to a clot’s formation. 

Our team has measures in place to help prevent this from happening. These may include:

• Anti-embolism stockings (TED stockings). These are elastic compression stockings used to help circulation. You may wake up from surgery with these on your legs.
• Foot pump. This is a foot wrap connected to a small machine that applies pressure to the bottom of the foot, helping blood flow. Depending on your medical condition, these may be recommended for you at home.
• Medicine prevention. The use of aspirin or an anticoagulant medicine such as Lovenox or Warfarin (Coumadin) may be started. (See the “Medicines and Pain Control” section.)
• Early movement and rehabilitation several times throughout the day. Walking helps keep the blood flowing. You will be prompted to do your ankle pump exercises. Therapy will start the day of surgery. Based on your medical history, you may be instructed to wear portable compression devices at home.

Planning for Discharge

Your plan for discharge will be based on how you progress with therapy. Your hospital stay will likely only be one day. Most of our patients are able to return home at the time of discharge. 

If your orthopedic team feels you are not able to return home, another plan will be put in place.

After discharge from the hospital, the majority of our patients go to outpatient physical therapy. Home care may be ordered for you based on your personal needs, functional level, and insurance. If choosing therapy at Doylestown Hospital please call 215.345.2894 to schedule your appointment.

For patients not staying overnight, they will return to the same day unit, where they will receive physical therapy prior to going home. They may receive home care or go directly to outpatient therapy. 

First Steps in Rehabilitation 

Your incision may have staples or surgical glue. A special dressing will be placed over your incision to promote healing. This will stay in place for seven to 14 days. Your nurse or therapist will take off the dressing for you or you will be instructed to take it off yourself. It is common to have swelling and black and blue coloring on your operated leg. Ice packs may be used to help with the swelling and ease the pain.

If you have staples in, you will be discharged with them in. A nurse will take out the staples, if you are receiving home care. Otherwise, you will need to make an appointment at the surgeon’s office to have them removed. 

You will begin your normal diet as soon as you are able. “At Your Request” is a bedside service for meals of your choice, unless you have other dietary limits. You may also order meals for family members at a cost.

Therapy will begin the day of surgery. The therapy sessions are specific to your needs. They may be exercising at the bedside, sitting at the side of the bed or in a chair, or walking. You are an important member of your orthopedic team. The team will support you as you take the first steps after surgery until you take your steps to leave the hospital.

Your orthopedic team includes:

• Orthopedic surgeon
• Physician assistants
• Nurses
• Physical therapists
• Occupational therapists

You may also have contact with pharmacists, dietary, and/or housekeeping staff. 

Physical therapy (PT) will show you exercises to strengthen your muscles, increase movement, and help you get up and walking. Training on stairs will be done if needed.

Occupational therapy (OT) will help you return to your activities of daily living (ADLs), such as bathing, dressing, using the toilet and shower, and homemaking activities. You will dress in your street clothes during your stay.

You will learn how to use the special equipment recommended by your therapist, so that you can do as much as possible for yourself. 

All total joint patients use a walker with two wheels after surgery and progress to using a cane at home. The therapist will encourage you to walk with a pattern of placing one foot in front of the other.  

ANTICOAGULANTS (BLOOD THINNERS) 

An important part of your recovery is anticoagulation medicine to thin the blood and help prevent blood clots. Aspirin and Warfarin (Coumadin) are our most commonly used medicines to prevent blood clots. 

An anticoagulation medicine is prescribed for several weeks after surgery unless you have health reasons not to take them, such as stomach ulcers, blood disorders or allergies. If you are on a medicine other than aspirin, blood work will be done daily while in the hospital to help your doctor know how the medicine is working. Your dose of medicine may change based upon your blood work results. 

It is normal for you to have swelling in your operative leg. If you have increased calf pain, swelling, redness or feelings of warmth, notify your nurse/surgeon immediately while in the hospital or at home. These could be signs of a blood clot.

If you get short of breath or have chest pain or extreme fatigue, tell the staff while in the hospital or get to the nearest emergency room if you are at home. In either case, these could be signs of a blood clot in the lungs that needs emergency testing and treatment.

After you leave the hospital, your doctor will manage your anticoagulation medicine dosage, testing, and results. While taking anticoagulation medicine, you need to be more careful when using anything that may cause bleeding, such as shaving, sharp knives/scissors, or a hard toothbrush.

While you are taking the anticoagulation medicine, you may be more prone to bruising and bleeding. If you have any of the following, call your doctor right away:

• A nosebleed
• Change in the color of your urine or bowel movements
• Bleeding in your gums
• A cut that won’t stop bleeding
• New bruises that get larger

Certain foods, especially green, leafy vegetables, can affect your anticoagulation medicine levels.

You do not need to drastically change your diet. However, you should keep a similar amount of green leafy vegetables in your daily diet.

Talk with your doctor about taking over-thecounter medicines or drinking alcohol while taking the medicine.

PAIN CONTROL

When you have pain, your body becomes tense. You will heal better when you are relaxed. Pain control relieves your discomfort and helps in the healing process. Your doctors use a multimodal pain management plan. They use small doses of several medicines that all work in different ways in order to decrease side effects and control your pain. You will get pain medicines before, during, and after the surgery.

Every person’s level of tolerance for pain is different. We use a pain scale of 0-10 to measure and treat pain. A “0” means no pain and a “10” means that it is the most severe pain you have ever had.

No matter what type of pain control is ordered, it is normal to have some pain while healing. Your doctor will help choose which medicine is best for you.

Side Effects

Side effects of pain medicines can include nausea, dizziness, dry mouth, itching, drowsiness, trouble focusing, constipation, and/or diarrhea. Most side effects can be treated and are not a reason to stop your pain medicine. At the hospital, stool softeners and laxatives will be given to prevent constipation and should be continued even after you leave the hospital. 

Your Part in Pain Control

Your health care team wants and needs to know about your pain. Pain medicine is usually ordered on an “as needed” basis, every four to six hours.

So, if you need it, ask for it. 

• Take or ask for pain medicine when pain first starts.
• Take pain medicine before activity. Ask for pain medicine at least 30 to 60 minutes before therapy.
• Try relaxation techniques to help with pain control.
• Tell your needs to your health care team.
• Use ice – 20 minutes on, 20 minutes off. You will receive an ice pack when you leave the hospital. 

Pain medicines are not usually needed for a long period of time. As you heal your need for pain medicine will change. Narcotics (strong medicines) will be ordered right after surgery, changing to non-narcotic and over-the counter medicines. Anti-inflammatory medicines may be added. 

If at anytime in your recovery, your pain is not manageable, you need to contact your surgeon. If you run out of narcotic medication and you feel you need additional medicine, you will need to call the surgeon’s office.

TIPS FOR YOUR RECOVERY

• Use your adaptive equipment as shown (raised toilet seat, hip kit, rails, shower chair, etc.).
• Use your assistive devices as shown (walker, cane).
• Schedule and keep your follow-up appointments with your surgeon, primary care doctor, and therapists.
• To help strengthen your operative leg, do your exercises and keep a routine. Your therapist will give you a written exercise guide with pictures
• Conserve your energy. Pace activities. Rest in between.
• Avoid low chairs and beds.
• Resume physical activities gradually.
• Resume household activities.
• There is no limit on the amount of times you can go up and down stairs.
• You may sleep on your back or on your side with a pillow between your knees. Your therapist will instruct you in proper sleeping positions.
• Sexual activity can be safely resumed around four to six weeks after surgery.
• Talk with your surgeon about when you may drive.
• You may return to work and volunteer activities when cleared by your surgeon.
• When your therapy ends, keep walking! You may want to join an aquatics (pool) program.
• If you plan to travel by plane, your surgeon will give you a special card stating that you have an artificial joint. Your prosthesis may cause sensitive metal detectors to alarm.

What should I do in the weeks before my surgery? 

Check your Hip and Knee Replacement Surgery Pathway in your folder and make sure that you complete all the tasks.

Get plenty of rest and eat balanced meals.

For 24 hours before surgery, do not smoke or drink alcohol. (For help to stop smoking, see the brochure in your preadmission packet.)

Prepare for a safe return to your home by safeguarding your house.

• Make sure that your furniture and railings are sturdy.
• Remove any throw rugs and secure loose edges of carpet.
• Clear walking paths of any electrical cords or other objects.
• The night before surgery follow the instructions that you were given at preadmission testing for showering using the antibacterial soap and wipes.
• Keep a light at your bedside.
• Consider light-sensitive automatic nightlights to place in rooms/hallways.
• Organize your kitchen by storing cooking utensils and food in areas that are easy to reach and close to your stove and refrigerator.
• Consider grab bars in your tub or shower.
• Stock easily prepared foods, such as canned, frozen, or microwavable meals for use after surgery.
• Obtain safety devices such as slip-proof treads for the bath or shower, or grab bars for the bath and/or toilet.
• Think ahead about care for your pets. You may need some help with them.
• Buy the equipment that you will need before you come to the hospital.
• Three days prior to surgery, follow your shower and nose medicine guidelines.

What should I do the day before my surgery?

The hospital will call you after 2 pm the day before your surgery to tell you what time to come to the hospital (they will call on Friday if your surgery is on Monday).

• Follow the eating/drinking guidelines that you were given.
• Remove toenail polish for circulation checks.
• Follow the shower guidelines in your folder.
• Follow the nose medicine guidelines in your folder.

What should I bring to the hospital?

We will review and update your medical history before surgery. Bring a list of all your prescription and over-the-counter medicines and supplements (including dosages). 

You may bring any personal items, including any toiletries or cosmetics. Pack comfortable clothing to wear while in the hospital. Bring supportive shoes with non-slip soles. Shoes without ties are easier for hip patients. 

How long will my surgery take?

If you are scheduled to have inpatient surgery, it will take approximately four hours from the time you arrive at the hospital, have surgery, recover in the Post-Anesthesia Care Unit (PACU), and get settled in your hospital room. Outpatient surgery is also about four hours from arrival to discharge home.

How do you ensure my safety?

Doylestown Hospital is committed to patient safety. To provide a safe environment for all of our patients, we follow these safety guidelines:

• We ask you your name and date of birth many times during your stay.
• We use a “Time-Out” in the operating room, a process that confirms the right patient, procedure, and site.
• We give antibiotics before, during, and after surgery.  
•  We screen for infections before surgery.
• We have specially designed infection control procedures.
• We have specially trained orthopedic staff that care for you in the operating room and on the orthopedic unit.
• We have special air-flow design in the surgical suites.
• We adhere to required frequent hand washing and sterilization by staff.
• We use special wipes before surgery.
• The operating room staff wears sterile attire.

Where should my family or friends wait during my surgery?

The waiting area is located on the 2nd floor of the hospital’s Main Lobby atrium, outside of the Same Day Surgery Unit.

After my surgery, if I have questions related to my surgery who should I call?

For any issues, call the surgeon’s office; they answer calls 24 hours a day. In the case of a medical emergency, you should call 911 if necessary or go to the closest hospital. If you receive care at another hospital, please let the surgeon know when you are able.