2012

US CENTER FOR SPORTS MEDICINE DR. COREY G. SOLMAN, JR.

[PREPARING FOR TOTAL KNEE REPLACEMENT: IMPORTANT INSIGHT FOR PATIENTS] Information regarding the expectations before, during and after surgery to return patients to their QUALITY of LIFE

The NORMAL KNEE AND ITS INTACT JOINT SURFACES

The ARTHRITIC KNEE

The Loss of articular cartilage (craters, potholes, pitting, and pealing). To correct this condition

surgically the bone is spared and the cartilage is removed utilizing engineered jigs.

The TOTAL KNEE

More accurately described as “Resurfacing of the arthritic compartments of the knee. It is a

misnomer that the surgeon cuts your thigh bone and lower leg bone off and the replaces it with the

metal and plastic.

This pictures demonstrates all the components and the knee cap button that is cemented

to the back of the patella. All off the metal and plastic have a nice smooth surface to glide

upon when bending and straightening the knee.

Patella Button

Femur component

Polyethylene Plastic Space

Tibial Component

Preoperative information:

Schedule appointment with Primary Care Physician

1. Lab work (CBC, BMP or CMP, PT,PTT, UA)

a. Results sent to our office

2. Possible Diagnostic Tests (EKG, Stress test, Chest X-ray): Good for 6 months

a. Results sent to our office

3. Letter of Medical Clearance sent to our office

a. Primary Care Physician

b. Cardiologist if under their care

c. Pulmonologist if under their care

4. Dental Hygiene

a. Imperative to prevent infections into bloodstream that may affect Total Joint Replacement

b. Routine Dental work

i. antibiotics prior to procedure for life ( 1 hour prior to procedure and 1 hour after)

ii. Script either from Dentist or our office

iii. Typically write for Amoxicillin or Clindamycin

iv. The earliest to consider elective dental work would be 6 weeks post op

5. Urinary Tract Infections

a. If susceptible may require long term antibiotics to prevent infection of the Total Joint

6. Risk of Operative infection

a. 1% in general

b. Increases with number of medical co-morbidities (Diabetes, Obesity, Hypertension, Kidney disease,

Vascular insufficiency, Depressed immune system)

c. Increases if performing bilateral procedures (not 2X but 4x or greater).

Day of Surgery:

Arrive at Hospital scheduled time and go to admissions and then to pre op area to review medical history, assess all labs

are in order, IV placement, possible EKG.

You will then be transferred to the Pre-op Holding area

Surgery will take approximately 60-90 minutes.

That does not account for the time it takes: 1. The OR staff to roll you to the OR suite 2. Transfer you to the operative table 3. Anesthesia putting you to sleep (of course that is not the same thing as the unfortunate event for pets)

and waking you after surgery 4. Applying your postoperative dressing 5. Transferring you back to your bed 6. The OR staff rolling you to recovery area

Once in recovery you will remain there until you are stable (breathing and maintaining oxygen saturation in your blood, blood pressure stable, and pain managed) prior to going to your assigned room. That time frame is approximately 1-1 1/2 hours.

After you are discharged from recovery and are wheeled to your room you should expect:

1. Nursing to ask you many questions 2. A continuous Passive Motion Machine will arrive (hospital property) and you may also receive the one

that will be going home with you from Joe (Kinex Company). 3. Hopefully, a successful femoral block will keep your pain under control, the nursing staff will be

monitoring and administering either oral or IV pain medication a. While the block is effective you DO NOT put your weight on that leg unless you have the

immobilizer on! Why you ask….You will fall down because the block keeps your quadriceps from firing and contracting and therefore you cannot hold your body weight.

4. A bulky dressing on your surgical knee along with a drain that will collect excess blood. This prevents a very swollen painful knee that keeps you from bending or performing exercises.

5. Remain in Hospital 2-3 days for swelling, pain management, medical management, and physical therapy.

Physical therapy will come to your room:

1. Instruct you in basic knee exercises 2. Walk with you on the floor with the walker and immobilizer (as long as block is functioning) 3. Encourage you to BEND your knee (Initial goal is 90 degrees) by hanging over the side of your bed,

sitting in the chair, or performing heel slides. 4. We discourage prolonged seated positions with your knee extended!

a. This will increase stiffness and pain along with apprehension to flex knee

MOTION, MOTION, MOTION= Positive Outcome, Possibility of Blood Clots, Faster Return to your Quality of Life

The CPM (Continuous Passive Motion) Machine

1. Dr. Solman’s Protocol is 0-50° for 6 hours a. There is no particular regimen for 6 hours; you can break

it up into whatever time intervals that works for you. 2. It is ok to sleep with the CPM 3. As tolerated, we ENCOURAGE you to increase the range of

motion with the hand held control: SO ↑ from 50°to 52-55° and see how it feels for a few cycles. If you find it easy and you are not experiencing increased pain continue to increase the motion within tolerance.

4. You will go home with the Machine from Kinex, or one will be scheduled to be delivered to your residence.

5. The average duration is 2 weeks of use

Discharge to Home

1. Home Nursing a. Evaluates your incision to make sure there is no signs of infection b. Removes staples

2. Home Physical Therapy a. Will come to the home and work on swelling, range of motion, strengthening and gait (how you

are walking) b. Progress from walker to cane when able

3. Blood Clot Management a. Xarelto for 12 days or Lovenox for 14 days b. Some patients may require Coumadin, Blood draws and

variations in amount of medication taken will be monitored c. After completing the above medication you will then take a 325mg Aspirin daily

until you are 6 weeks post op d. Ted Hose Stockings x 6 wks

4. Pain Medications a. It is the Patient’s Responsibility to watch the amount of narcotics you are taking and call for

refill in a timely manner. b. Refills are approved during the week up until noon on Fridays. Refills are not called in over the

weekend c. It is important to be pain managed to perform exercises d. Exceeding the prescribed amount of narcotics has the potential for serious impact on an

individual’s liver function because the amount of Tylenol consumed. e. Signed Narcotic Agreement

Follow Up with Dr. Solman

1. Post op appointment approximately 2 weeks after surgery 2. Make sure you have scheduled follow up appointment 3. At first visit expect:

a. See Dr. Solman or Physician Assistant (PA) b. Staples removed if not already c. X-rays will be taken d. Evaluate swelling, range of motion, pain management e. May be transitioned from home physical therapy to outpatient physical therapy f. You can initiate driving if on a cane

i. Practice in parking lot ii. Avoid pain medication because you will be impaired while driving

4. Follow up intervals for office visits a. occur monthly up to 3 months post op b. Based on progress may follow up at 6 and 12 months post op and then at 1-2 year intervals

thereafter. c. Will obtain X-rays at first visit and year anniversary, as well as, yearly thereafter to keep a

baseline on the prosthesis and patients bone quality. Will perform more frequently if patient is experiencing post operative issues.

Preventing Knee stiffness and Scar tissue formation (Arthrofibrosis)

1. MOTION! MOTION!MOTION 2. MOTIVATION! MOTIVATION! MOTIVATION! 3. Staying on top of your pain medication for the first few weeks so that you are able to perform your

exercises 4. Once incision is healed if patient has access to a pool…. exercise in the water is encouraged to enhance

motion (Patient is only 10% body weight in the water) 5. Your knee replacement is solid as it can be prior to going to recovery area…It’s your swelling, motion,

and strength that are now the focus! 6. If stiffness & pain are problematic after 6-8 weeks post op the patient may undergo:

a. Closed Manipulation under anesthesia i. Requires return to the Operating room a Femoral Block is

placed to allow for 18-24 hrs of painfree movement ii. Manually Force Knee through ROM gradually to break through

scar tissue, subsequent intra articular cortisone injection iii. Walker & Knee immobilizer until Femoral Block has worn off (24

hours) iv. Immediate Same day return to physical therapy to maintain

range of motion and subsequent daily PT for approximately 7-10 days

Prosthesis Expectations:

1. Longevity of prosthesis (15-20 yrs) a. Weight Management b. Bone(quality of the bone)/Cement Bonding c. Avoiding impact activities

2. Activities a. Kneeling (limited by the scar tolerance not the implants) There is a knee sleeve that

allows patients to kneel and eliminates the scar pain b. Gardening c. Doubles Tennis d. Walking e. Skiing-no moguls

3. Sounds/Stiffness/Pain a. On occasion patients hear and feel the prosthesis metal on plastic components moving

within the knee…..THIS is Normal, it is a mechanical knee at this point, or it may be scar tissue

b. Stiffness is a trade off for the Osteoarthritis pain prior to surgery i. Weather changes still may be noticeable

ii. Geographical locations may cause more or less stiffness c. Pain should be eliminated from the Osteoarthritis standpoint. Other issues that may be

creating pain include i. Scar Tissue formation (Arthrofibrosis)… MOVE! MOVE! MOVE!

ii. Weakness in quads (Mechanical pain)….STRENGTHENING EXERCISES!!! iii. Bursitis/ITB syndrome from correcting deformity of arthritis which may impact

how you walk (Pes Anserine Bursitis or Iliotibial Band Syndrome.)…STRETCH,NSAID,CORTISONE INJECTION, POSSIBLE SURGICAL Bursectomy

iv. Saphenous Neuritis is an irritation of the sensory nerve around the knee…..referral to specialist for possible injection versus removal of the nerve

Resources:

www.biomet.com (Vanguard prosthesis)

http://global.smith-nephew.com/us/LEGION_TOTAL_KNEE_SYSTEM.htm (Legion prosthesis)

http://stlouishomehealth.com/St. Louis Home Health

http://www.xarelto-us.com/

Narcotic Agreement Patient Name:______________________________ Date: ___________

Pharmacy Name:________________________ Pharmacy Number: ___________________

“This agreement is between the above named patient and Dr. Corey Solman. It is agreed that narcotic medication will be given by your orthopedist to you only if the following terms are met: 1) You must take the medication we prescribe exactly as instructed by the provider.

2) You cannot increase your pain medication without the EXPRESSED consent of the prescribing physician

3) If at any time you are obtaining pain medications or attempting to obtain such drugs from another source

WITHOUT our knowledge, you will be DISCHARGED from our care. You will also be released if you are found to

be taking illicit substances.

4) You must designate ONE pharmacy for your narcotic pain medication if you are found to be having multiple

pharmacies or other physicians prescribing narcotic medication unbeknownst to your currently treating

physician is grounds for discharge from our care.

5) In order to continue to receive medications, you must MAKE and KEEP scheduled appointments with Dr. Corey

Solman.

6) Narcotic prescriptions WILL NOT be refilled early 7) Pain medication should be kept in a safe place. If they are LOST, STOLEN, DESTROYED or accidentally dumped in

the sink or toilet, or eaten by the dog, they will not be renewed until the scheduled refill.

8) Phone call regarding medication will be made Monday through Friday prior to 2 pm to give office staff ample

time to call in all patient requests. NO drug refill requests will be granted AFTER hours or on WEEKENDS, unless

the patient is immediately post op.

9) EFFECTIVE 10/1/2012: Narcotic refill requests must first come from the patient’s pharmacy.. No longer will calls

be taken in the office for pain medication refills.

10) If at any time you are concerned about your medication or side effects of your medication, you may call the

office or through the exchange after hours.

11) You understand that these medications may create a physical dependence and you are willing to ACCEPT that

responsibility.

12) The physician will be decreasing your narcotic medication in a stepwise progression to a lower potency in a

reasonable time frame based on your diagnosis. If managing your pain is beyond the scope of practice you will

be referred to pain management.

13) State law prohibits the driving under the influence of opiate medications.

14) If requested by your insurance carrier, all information will be released to the company. If required by the Drug

Enforcement Agency regulations, your diagnosis may be revealed at the pharmacy. We may contact ANY

pharmacy or physician regarding your medications.

15) You understand that the medications that are prescribed for you are for your use ONLY. You understand that

State and Federal laws prohibit the sale of or sharing of prescription medications. Such behavior will not be

tolerated and result in our office notifying the DEA. This will also be grounds for discharge from care.

16) Post operative and chronic pain issues will be managed for a maximum of 3 months. IF Narcotics are needed

beyond this point, you will need to seek out your primary care physician or a chronic pain management

physician. The office can assist in finding a chronic pain management specialist in your area.

17) By signing this agreement, you are agreeing to ALL of the above terms. You understand the expectations as a

patient regarding the use of the prescribed medication. You understand that failure to comply with any of them

may result in your dismissal from Professional Athletic Orthopedics.

Patient Signature Date

Physician Signature Date

Femoral nerve blocks

1. Total Joint Replacement or Manipulation under anesthesia: Anesthesia will perform a femoral nerve block prior

to total knee surgery or if you are subsequently undergoing a manipulation. This block will last approximately 12

hours (each person is different). After you are discharged, you will go to physical therapy the same day to focus

on knee range of motion. You WILL need your walker! You will be Non-Weight bearing on the affected lower

extremity. DO NOT attempt to walk or bear weight through your leg. The femoral block will keep your

quadriceps muscles from firing, your leg will collapse under you and YOU WILL fall down. There is no need to

try and prove the block wrong or you will RISK potential SERIOUS injury.

2. After Knee Surgery: if you are inpatient, do not attempt to use the bathroom without assistance if your block is

working (inability of your leg to activate your quadriceps muscles when you stand and attempt to bear weight).

Please notify the nursing staff far enough in advance of the need to use the restroom, this will prevent you from

becoming frantic about urgency or a possible accident!

3. If you are outpatient, you will be going home the same day. If the nursing staff allows you privacy to change into

your clothing don’t forget you can’t stand on that leg. So, don’t try put your pants on and expect the leg that you

had the femoral block to hold your body weight. Instead, please sit on the side of the hospital bed and put on your

clothes for your SAFETY!!!!

4. If you are a manipulation you should schedule your physical therapy for the same day of manipulation, but in the

afternoon. Also, schedule future appointments daily thereafter for 4-6 visits if able.

5. Please sign below acknowledging that you have been verbally instructed in the above procedure, understand the

procedure, and are aware of the risk of not adhering the above guidelines.

Patient Signature: _________________________________________Date:________________

My Questions to ask the Doctor………

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