Overview: Getting Ready for Surgery

Learn about what to expect through the process of managing your hip and knee problems

Initial Consultation

Your initial consultation with your surgeon is very important as it forms the basis for your treatment. On your first visit, we will take a comprehensive medical history, with special emphasis on your hip or knee problem. A thorough and relavant examination will be conducted by your surgeon to rule out other conditions that may be causing your symptoms. Most likely, ancillary studies such as X-rays will be requested to complete the evaluation if you have not had any previous and recent radiographs. We greatly encourage that you prepare for this visit by bringing with you the following:

• Referral letter from your Government Dispensary for CGHS or other Panel patients
• Photo ID Card issued by CGHS, DGEHS, TPA , PSU or other corporate Panel
• Any previous X-Rays, MRI studies, bone scans or other studies of the region involved
• A list of your current medications (with dosages).
• Any family members or friends you may want to have present to help in the discussion and decision making process.

By the end of the initial consult, we would have discussed with you the pathology or orthopaedic condition that causes you symptoms, the treatment options, and the pros and cons of each alternative treatment. Depending on the complexity of your condition, we may also ask for further tests. While we firmly believe in non-operative management of most hip and knee disorders, in some situations, either because of the basic nature or severity of the orthopaedic condition, we may recommend an operative approach. In these situations, the procedure is also discussed. You do not have to make a decision to proceed to surgery during this consult. While some patients are very much decided to have an operation even before the consult, many reserve the decision for a latter time after discussing it with friends and relatives.

Information sheets will be provided for patients to increase their knowledge regarding their condition and specifics of the operation and post-operative rehabilitation. You are encouraged to go over the materials prior to surgery and bring them with you as reading material on your hospital admission.

Follow-up Consultations

Reasons for a follow-up consult may vary. Mostly, it is to monitor for efficacy of non-operative treatment options. On some occasions, you may need to ask further questions that had not come up during the initial consultation. It may also be to indicate a decision to proceed to an operative treatment and to book the procedure.

Selecting a Date for Surgery

Selecting the exact date for surgery must be done after some thought. You must be both physically and mentally prepared for surgery by the designated schedule. Also, it must be a time where you may take some time off to recuperate after the procedure. Equally important is the availability of any family member or support groups at home a week or so after the surgery to help in your rehabilitation. It is preferred that somebody looks after you during this time. Enough time must also be given to have the necessary blood work done and proper evaluation by a physician, cardiologist or other specialists if necessary.While many of these things may be accomplished sooner, most bookings are filled to about a fortnight or so from the day you make a decision to proceed with surgery.

Permissions / Financial approvals / Pre-authorization

The Financial approvals have to be completed before Hospital Admission. Our TPA desk will help you in obtaining pre-authorization by processing required forms and documents and guide you regarding permission process from Government Panels. Patients paying out of the pocket for procedure need to credit required amount before admission or pay at the time of admission through cash or cards. Common documents required for Preauthorization intimation are

• Photo id: copy of Aadhaar card or PAN or Voter id etc.
• Copy of card issued by TPA / Insurance provider
• Copy of current prescription (TPA may ask for past treatment records)
• Copy of X-Ray or Radiology Report
• Copy of past and present Health Insurance policies

Pre-authorization intimation does not necessarily mean approval. TPA or insurance provider may raise certain objections/ queries. Our TPA desk and doctors assist you in addressing these queries. Approvals are generally received within 24 hours and may be complete or partial or may warrant co-payments depending on your Insurance Policy Terms and conditions. Cash less facility for inpatient treatment is subject to receipt of approval or permission letter.

Hospital Admission

For patients undergoing total joint replacement, admission on the afternoon before the surgery date is preferred. This allows for Dr. Dua or Dr. Khatri to have a final evaluation of you before the surgery and enables you to ask any final questions before the procedure. Also, you may be given you first dose of the anti- biotic after skin testing the night before surgery.Before going in to hospital, prepare the following items to bring in for your stay.

• Permission or referral letter issued by Dispensary / DGEHS / competent Authority
• Medical insurance card issued by TPA, Photo ID card issued by CGHS, DGEHS, PSUs and other Government panels.
• Photo ID card like Aadhaar / PAN / Voter id etc.
• All Investigations, X-Rays, medication record and prescriptions
• Comfortable footwear with non-skid soles
• Your favorite pillow, if you wish
• Reading materials

Anesthetist will also have a final evaluation before surgery and will be more than willing to answer any queries that you may have. The anesthetist will discuss with you the options for anesthesia. While we prefer using a Combined spinal Epidural anesthesia with or without light sedation or general anesthesia in most of the total joint patients, your specific needs and medical conditions may lead the Anesthetists to recommend alternative options. The final decision in the type of anesthesia to use will be made by you and the Anesthetist. Surgical, Anesthesia and Special consents are provided to you after admission. You are requested to read, understand, seek clarifications and duly sign the consents.

Setting an Appointment with the Anesthetist and PAC Investigations.

We prefer our patients to be seen by an anesthetist prior to surgery. This usually happens when you are decided to proceed with the surgery. These specialists may order further ancillary tests and will assess your fitness for surgery. You also undergo a battery of tests including blood work, Urine test and specialized tests like 2D / Dobutamine stress ECHO to ascertain your fitness for surgery (List Attached). Investigation results are shared with the anesthetist and they may also make recommendations that would be crucial in making the operation as safe for you as possible.

The Night Before Surgery

The nursing staff will provide you with an iodine scrub and will request you to take bath and scrub the operative site to decrease the chances of infection. You will be served with a dinner after this you will have to refrain from having anything to eat or drink for six - eight hours before surgery. An intravenous line will be inserted to provide you with water, electrolytes, and some glucose. We also recommend that you do not smoke or drink an alcoholic beverage within 48 hours of your surgery as these may increase anesthetic risk.

The Morning Before the Operation

Take your morning medication (as advised by anesthetist) at 6 AM with a sip of water We recommend that you relax while awaiting transfer to the operating theatre. Watching television and reading a good book may help keep your mind off the operation. You will be given some pre-operative anti-anxiety medications if you need them.

The Operation

You will be brought down to theatre around 30 minutes before your operation. This gives the anesthetist time to induce you. For most first time replacements, total operative time will range from 60 to 90 minutes. Revisions may take considerably longer.

The Immediate Post-operative Period

After surgery you will wake up in the recovery room. Most patients are comfortable and are pleasantly surprised about being "pain-free". Hip patients will find an abduction brace / pillow positioned between their legs to keep the extremities in a "safe" position. Patients with a higher risk for clots (see Deep Vein Thrombosis) will have a pneumatic compression device on their extremities to lessen the chance for thrombosis. Once it has been determined that you are stable enough, you will be discharged from the recovery room into the ward. In some instances, the Anaesthetist may request you be further observed in the Intensive Care Unit (ICU); this may not mean a serious or life- threatening situation. Instead, this is done to closely monitor patients with advanced age and potentially serious pre-existing medical conditions and lessen the chance for post-operative problems. You are orally allowed 3 hours after surgery. Assisted in-bed side turning is recommended. Sitting upright may be restricted till 24 hours after spinal epidural anesthesia in few patients.

Pain Control

We believe in the need for excellent pain control. Adequate pain control is achieved with combination of modalities like Local injections during surgery, Continuous epidural injection, oral analgesics, Intravenous injections and Transdermal patches. Frequent Ice packs on knees also help in reducing pain and swelling. Aim is to provide near complete pain relief and enable you to start with your physiotherapy and rehabilitation as soon and smooth as possible. Some patient may need bladder catheterization for urinary retention.

Other Drugs

We routinely use antibiotics prior to and after surgery to lessen the chance for infection. We will also maintain you on an anti-clotting agent while you are at hospital and after discharge. Mostly, fevers often mild are common in postoperative period and not considered as a source of major concern. Epidural catheter is removed and Intravenous medications are discontinued on day two after surgery.

Drugs are also ordered for nausea, constipation, and sleep. Diabetes, Hypertension, cardiac or other chronic medications are started in consultation with specialists. Feel free to talk to your nurse about what we can do to make you as comfortable as possible.

Suction Drainage Tubes

In few cases suction drainage tubes are placed deep in the wound and into the joint to remove oozing blood that may collect after surgery. These tubes are removed the day after surgery.

Operative Wound Care

Wound care is very important in infection control. Wounds must be kept dry and we will change dressings as required. However, as long as the wounds remain dry, routine dressing change is just done after removal of initial bulky dressings.

Subsequent changes are minimized unless dressings are soaked or if your surgeon opens up the dressings to inspect the wound.

Physical Therapy

We believe in the importance of good post-operative rehabilitation. We work with Full time dedicated Physiotherapist and his associates, a group fully equipped to get you up and about at the soonest possible time. Many of our patients are able to take a short walk on next day of the surgery while the rest are able to do so the following day. The physiotherapist will instruct you on the amount of weight bearing and range of motion that you may perform. They will also give complete instructions on necessary precautions to protect the surgery. Lastly, the physio will help you get back to doing daily activities, such as getting in and out of the bed on your own, toilet and shower on your own, and go up and down the stairs on your own. Once you can accomplish all these activities and your observation parameters are good, the team may decide that you are fit to be discharged from hospital. This is usually accomplished at 5 to 7 days after surgery.

We encourage you to continue your exercises at home and try to be up and about as much as you can. You may require engaging a physiotherapist for home visit to supervise the exercise routine. Again, common sense is key, as your body will tell you if you are doing too much. Rest as much as you have to and do not overdo it.

Preparing Your Home

In general, no drastic modifications need be done to your home. However, as with any patient, it would be common sense to put rubber mattings on slippery areas such as the toilet and bathing area. It is also preferred that toilet seats be raised to prevent extreme flexion for hip and knees. Railings are preferred in strategic places in the house while loose rugs and carpets that may slip are discouraged. Specific instructions will be given by the physio prior to your discharge.

Things to Watch Out For

It is not uncommon to develop some swelling of the knee, foot and ankle in the weeks after surgery. If this occurs, you should elevate your leg on pillows when you are not up and about. However, should sudden swelling of the calf associated with tenderness and pain on doing foot pumps be experienced, it would be best to give us a call to rule out clot formation. Chest pain, shortness of breath, or cough may be signs of an embolism, do not hesitate to call us if you suspect this. Fever, drainage or redness on the wound, and increasing pain on the joint may signify an infection. Early evaluation and treatment is the key to a good outcome. Again, do not hesitate to call us if you are worried.

First Post-operative Follow-up Visit (suture removal)

We normally use absorbable suture for wound closure and dont require removal. Still, we like to see you about 20 days after surgery to remove suture if any and have a check on your progress. After suture removal, suture line is left open and can be cleaned with soap and water after one day delay.

Second Post-operative Follow-up Visit

The next follow-up is about 8 weeks (2 months) after surgery. You will have a new x-ray taken before this consult. We will evaluate the surgical wound, your gait, extent of pain relief and recommend strengthening exercises should your rehabilitation be lagging. Depending on your status, you may also be given clearance for most activities such as driving, regular work, lying on your side, and completely weaning from any walking aid.

Third Post-operative follow-up Visit

The next follow-up will be 6 months after the surgery. Again, an x-ray will be taken.

Yearly follow-up

We are extremely interested in having an idea how our patients are doing. We therefore encourage patients to see us yearly to assess your latest condition and pick up any possible problems with your surgery. This enables us to advise you promptly, prevent progression, and solve present problems immediately before they become severe. Although mainly to assess your orthopaedic condition, yearly follow-ups are also meant to update us of your other medical and social concerns. Our practice is dedicated in sustaining the healthiest possible doctor- patient relationship.

Long Term Care of your Joint Replacement

Even with the latest technology, no implant design is known to last forever. Annual visits to our rooms will ensure early detection and prompt management of these problems either through activity modification or surgery.

Joint replacements must be treated with care. High impact activities such as jogging and running, jumping, and strenuous sports must be avoided if possible. Lifting heavy objects should not be done. You must also try to watch your weight. The heavier you are, the more stress you put on the joints. Although an occasional twinge now and then may be normal for patients who have undergone surgery, persistent and progressive pain may signify loosening of components or a delayed infection. You must call the rooms to book an appointment if you have any of these symptoms. You must also be aware that any infection in other parts of the body may seed into the artificial joints via the bloodstream. Thus, any form of infection must prompt a visit to your doctor for immediate management. We also recommend prophylactic antibiotic coverage for any dental work after your surgery. Always inform your dentist of your replacement and insist on coverage. Any other surgery, especially of the gastrointestinal tract, must be preceded by antibiotic coverage. Lastly, do not allow physicians to inject steroids into your artificial joint as this may also predispose it to infection.