Pre-op Class

Dr. M requires all of his patients attend the joint replacement pre-op class; for me, that class was this past Thursday (two days ago).  The class is about two hours long.  Here is the basic overview: the first hour (minus a few introductory minutes) was Dr. M telling the patients about both hip and knee replacements (both types of patients attend the same class), showing us models, telling us what to expect, and (again) explaining the risks.  After Dr. M, we heard from a physical therapist who gave a basic overview of the exercises we will be doing in the hospital and some general info.  Next, we heard from an occupational therapist - but her presentation had no relevance for the knee patients, just the hip patients (gadgets to help them get dressed).  Third, a nurse from the anesthesia and pain management team explained the regional nerve blocks as well as the pain management "cocktail" we will be given after surgery.  Finally, a nurse from the surgical team gave some instructions as to what we need to do before the date or surgery and provided some information on discharge planning.

Now for more detail...  Dr. M showed us the knee joint pre-op, showed how the bone is removed, and showed how the components are inserted.  He then took questions.  I found out that I will be in the hospital for 3 days and 2 nights; since my surgery is Wednesday, I will be going home Friday (barring no complications).  I learned that he uses plastic dissolving stitches internally rather than the traditional sutures or staples; his reasoning is not cosmetic (although it reduces scarring) but rather that it gives a water-tight seal so that the patient knows that if there is drainage to call in (rather than telling a patient to call about "unusual" drainage when the patient has no idea what's normal).  This also means that when the wound is dry, I can shower!  No waiting two weeks to get a real shower - so exciting!  (Though it doesn't help me in getting TO the shower which is on the second floor of my home.)  Dr. M also told us that we will have some sort of strip over the incision and we can just let it there until it falls off (or until the 2-week appointment when he will take them off).  Of particular interest, he mentioned that he does not use CPM (continuous passive motion) machines.  He told us that he was trained to use them, but during his fellowship at Duke they didn't use the CPM machines and he saw no difference.  There was no improvement for patients on the machine but there is some risks.  He told us about two different patients: one patient had a spinal and could not feel his legs so when his foot was rubbing against the side of the machine, no one knew and he eventually had to have the leg amputated (an ulcer formed on the outside of his foot, got infected, and wouldn't heal); another patient's machine was set to the wrong specifications which bent her knee too far, damaged the parts, and she wasn't able to have a revision due to the massive tearing of tissue.  On another, similar, note, he also warned us to make sure we have a pillow under our heels - we will have a regional nerve block and won't be able to feel pressure sores in the making and the heels are very vulnerable.

Dr. M also discussed what he considered the biggest, most important risks.  1) Death - There is also a risk of death when undergoing surgery.  2) Infection - We learned the average rate of infection (over one's lifetime) is about 1-2% but the rate doubles for diabetics and increases exponentially for people with Hepatitis C (about 20% risk).  Infection can be hard to detect because the knee won't necessarily turn red or swell, but can often just cause pain; since a joint replacement is painful as is, it can be hard to determine the reason for the pain.  If infection is suspected, a blood test will be performed - if the blood test is positive, the doctor will test the joint fluid.  If there is an infection, they usually need to remove the metal parts for three months and then do another surgery to put them back in.  Usually just washing out the joint doesn't work because the bacteria (the risk of infection is of a bacterial infection, not a viral infection) can live in the bio film on the components; Dr. M analogized to fighting with you back against a wall - it's easier to fight when you can only be attacked from the front.  It is this risk of infection that requires patients to take antibiotics before a trip to the dentist (even for routine teeth cleaning) or before a colonoscopy (though I have a while before I need one of those!) or really anything where bacteria could get into the bloodstream.  It is also important to go to the doctor right away with a urinary tract infections, pneumonia, or any other sickness resulting from bacteria (i.e. not the common cold or the flu which are both viruses).  3) Fracture - The drilling and bone sawing required can cause fractures within the bones.  The risk is about 1-2% and are generally treated with screws or cables (in the case of a large fracture of the femur during a hip replacement, the doctor may use plates and screws as well).   4) Loosening of the parts - The plastic parts wear down and can eventually loosen; it is estimated that this will be 10-20 years down the road but the time may be shorter for younger patients who will generally be more active.  However, the plastics used now have shown some potential to last longer than expected.  But, when you are 26, it is pretty much a certainty that the parts will wear out within my lifetime (provided a live a long, healthy life).  5) Blood clots - Any person who remains sedentary can get blood clots, especially in the legs, but when you have just had surgery and have limited mobility, the risk increases.  A blood clot that forms in the leg is called a deep vein thrombosis; this is very painful and will cause swelling.  The clot can dislodge and travel through the body, causing more damage or even death; if the clot goes to the lungs, you can have a pulmonary embolism which is the blockage of the main artery of the lung or one of its branches.  The blockage of blood flow to the lungs will cause difficulty breathing and chest pain; a minor embolism will leave the patient short of breath but a larger embolism can cause sudden death.  In fact, pulmonary emboli are the biggest risk of death following a knee replacement.  To prevent blood clots, patients are encouraged to walk as early as possible, wear compression socks, use leg pumps (which use air pressure to squeeze the lower legs to improve blood flow) at least 20 hours per day, and take blood thinners.  Dr. M prescribes Lovenox which is an injectable blood thinner - we will learn to give ourselves a subcutaneous injection in the stomach once per day; Lovenox has less complications than the well-known coumadin (or warfarin) - you don't have to worry about various foods that counteract the drug and there are less risks of internal bleeding, etc.  We will use the Lovenox for 3 weeks, followed by 3 weeks of aspirin.  6) Limp - A persistent or permanent limp can develop due to range of motion issues or misalignment.  7) Instability - Any revision of a joint can result in less-than-perfect stability.  8) Persistent pain - For me, however, I'm already in persistent pain so this doesn't seem like much of a risk.  9) Loss of motion - Scar tissue can build up in the joint and prevent the patient from achieving a good range of motion (usually a patient should expect to achieve full extension -0 degrees- and should be able to get about 130 degrees bending).  If scar tissue becomes a problem, the surgeon will put you under anesthesia at about six weeks post-op and manipulate the joint, forcing it to bend and extend to break up any scar tissue.

On to a cheerier topic - the physical therapist told us that we will be up and walking within 24-hours and will have two sessions of physical therapy per day (while in the hospital).  We will be told to do certain exercises on our own about five times per day.  Knowing me, I'll probably do them even more than required.  First of all, I want a speedy recovery - I only have four weeks before school starts up again.  Second, the requirements are for someone much older than myself.  I can push myself harder than that...  The therapist also told us that it is expected that we will have full extension and about a 90-degree bend before leaving the hospital.  The occupational therapist didn't have much to say to the knee patients but did tell us that (since they want us bending as much as possible) we don't get any fun gadgets to help us get dressed; we also learned that the morning after surgery, occupational therapy will be in to make use get dressed, to show that we can start to become self-sufficient.

As I mentioned, a nurse from the anesthesia and pain management team also talked to us.  She explained that knee patients will get two sets of regional nerve blocks - one will be for the femoral nerve and the other will be for the sciatic nerve.  The nerve block is a series of injections placed very close to the nerve to cut off sensation.  A perfect nerve block will make the leg completely numb while an imperfect block will knock out much of the pain but you will still feel some discomfort.  We were also told that we would start a drug "cocktail" - there will be three "pain" medicines: Oxycontin (or, generic, oxycodone), Celebrex (anti-inflammatory), and the maximum dose of Tylenol.  We will stop the Oxycontin after 3-5 days after leaving the hospital, the Celebrex about 2 weeks after leaving the hospital, and the Tylneol about a week after leaving the hospital.  We were also told that we would be given two pills to counteract the side effects of the pain meds - a drug to help deal with nausea caused by the three drugs and a stool softener to prevent the constipation often caused by narcotics.

Finally, the nurse from the surgical team explained a night-before cleansing wipe routine (we were given six large germicidal wipes that we clean different areas of our body with so that, when all are used, our entire body will be cleaned; the wipes are to be used at least two hours after bathing and are said to reduce the chances of infection).  We were also told that we needed to make an appointment for our first physical therapy outside the hospital, to get clearance from both our primary care physician and dentist, and to get blood and urine lab work done.  The nurse started talking about discharge planning but I had to head to my anesthesia appointment (or so I thought...); I wasn't worried about missing anything since the information is in a packet and I know that I won't need to consider a skilled nursing care facility or nursing home.  I am lucky enough to have a mother who doesn't work and lives close by; I will be living with my parents for the week or two after surgery until I can take care of myself enough to go home (my husband will also be staying there). 

Anyway, so off to anesthesia I go...  Only to be informed that my 11am appointment had been changed to 1:30pm and I wasn't notified.  Luckily I thought to ask to get my scripts for the lab work; after filling out a form and waiting for a practitioner to check it over, I got my scripts for a chest X-ray, urinalysis, and blood work.  Because I had just gone to the bathroom, I chose to do the X-ray first which was quick and easy.  Then it was off to the lab - of course they wanted to do the urine sample first so luckily I had been drinking lots of water.  Finally it was time for blood work.  Blood and needles don't bother me...  I don't like to see the needle go into my skin, but other than that, I'm usually good.  But I didn't take into account that all I had to eat was a granola bar almost 6 hours prior to blood work (it was lunchtime).  The girl taking my blood was a student and she had some problem getting any blood to come out (I have the bruise to show for it); I'm not sure whether it was the lack of food, the amount of time the blood draw was taking, or a combination, but I started to feel it...  I was getting light-headed and dizzy as she put the bandage on my air.  Then I heard this pounding and it sounded like I was listening to everything through water.  I've never passed out before but I knew I was about to if we didn't do something quick - she escorted me to lie on a bed, then gave me an icepack to put on the back of my neck.  Just lying down for a few seconds seemed to solve everything - by the time she came back with some juice, I was ready to sit up and leave.  But, lesson learned, just like you don't donate blood on an empty stomach, don't get blood work done on an empty stomach!  So after that near-disaster, my mom (who was nice enough to come along for all of this) and I grabbed some lunch before heading back for that rescheduled anesthesia appointment.

I think I'm the anesthesia team's dream...  I have no health problems (besides the knee), no problems with anesthesia, no drug allergies besides Synvisc (a knee injections), no food allergies, and no latex allergies.  I have had so many surgeries that I know where the best spot to put my IV is and I know to ask for anti-nausea medicine and Demerol in the recovery room.  (I will be sad that, since I'm inpatient, my family won't be able to be with me in the recovery room.)  Anyway, so the anesthesia team did a basic physical, asked a bunch of questions, and gave me my final instructions (no food after midnight, take a Pepcid the night before and a Pepcid in the morning, no jewelry or make-up, and wear my glasses instead of contacts).

All that was left was getting the clearances from my primary care physician and my dentist... But this proved more difficult than expected!  First, we headed to the dentist.  But I'm bad and haven't been in two years so before they would sign, I needed an exam!  But this was Thursday - six days before surgery, two of which are the weekend and two are the days of my finals!  Well, luckily, one of the hygienists was able to squeeze me in for an exam, but not a cleaning, so I got my form signed.  But next we headed to the primary care physician's office.  Well, I hadn't been there in over a year (last time was for a sinus infection) so they won't sign it either.  To make matters worse, the last several doctors (of P.A.s) that I saw don't work there anymore!  Oh, and did I mention that the office was about to close for the day and wasn't open on Friday or Saturday because they are moving locations?  With no hope of getting that clearance, I had to call Dr. M's office and beg for a waiver.  Luckily they called me the next morning to tell me that since my anesthesia appointment went really well that they would not require the clearance but would send all the info to my primary care physician for him to review and if he had any concerns he can call them (which I'm sure he won't since whoever reviews it probably has never even seen me).

So, where am I now?  I'm four days away from surgery and I have everything set up - all of my appointments are done and all of my forms are filled out.  I just need to get through my two finals on Monday and Tuesday!  Then comes the last minute planning (until I know what time my surgery is on Wednesday, I can't plan for someone to take care of my dogs) and packing.  I need to pack a bag for the hospital and I also need to pack a bag (or two) for my one-to-two week stay at my parents!  I'm almost ready and can't wait to get the hard part over with...