Total Joint PREP Class Knee Replacement

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Presentation transcript:

Total Joint PREP Class Knee Replacement T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center

Goals for you and your family attending this class Recognize knee replacement is a reliable operation to relieve pain and restore function. Describe what to expect of the knee replacement procedure. Discuss the risks of knee replacement surgery.

Goals of your knee replacement Improve your quality of life Relieve your pain Restore function (knee movement, alignment) Increase activity

Knee Arthritis Loss of cartilage leads to narrowing of the joint space. See the bone spur formation?

Knee Arthritis As the cartilage wears, bone spurs develop which can cause stiffness

Surgical Technique -Resurface the bony surfaces with metal and plastic -Balance the ligaments -Restore alignment and motion (straighten the leg)

Metal and plastic are used Implant materials Metal and plastic are used The metal is usually a cobalt-chrome alloy. The plastic is UHMWPE or “poly”.

Implants -The end of the femur is capped with a metal component. -The end of the tibia may have a metal plate or plastic. -A plastic spacer goes between the metal cap and plate.

Implants If the back of the kneecap is worn, it is resurfaced with a plastic button

Surgical Technique Incision Made in front of the knee, usually from above the kneecap down to bump on shin bone Length of the incision depends on the thickness of soft tissue Surgeon will make the incision long enough to see the area around the knee Surgical techniques continue to improve as technology advances Surgeon will use techniques to spare muscle

Day of Surgery Your surgeon will meet you in SurgiCenter to initial your knee and answer final questions. Family can wait with you in the SurgiCenter. You will go to the Operating Room (OR) first, then to Recovery (PACU). Surgery lasts 1-2 hours, recovery 1-2 hours. Finally, you will go to the Med-Surg Unit 4500.

Post-op Therapy Physical & Occupational Therapy is important for a good outcome. Your participation will improve your result You may have a machine that bends the knee – called a CPM. Therapy starts the day after surgery Get you out of bed Bend the knee! Straighten the knee! Walk with a walker

Other Doctors Additional Doctors take care of non-orthopedic issues (such as high blood pressure or diabetes). If you have an Internal Medicine doctor here they will see you after surgery. If your regular doctor does not see patients in the hospital, a Hospitalist will see you after surgery. If you are not getting a medication you think you should, please ask.

Blood Clot Prevention You are at risk of a blood clot after knee surgery. You will receive medication (warfarin or aspirin) after surgery to prevent blood clots. TED hose should be worn for 3 weeks after surgery, you may remove these at night. SCD (calf squeezers) are used when you are in the hospital and should be worn whenever you are in bed.

Risks of Surgery Blood Clots High risk (>20%) if no treatment Clots can go to the lungs and be fatal Your risk is reduced to <1% if treated with medication, squeezers Getting out of bed and walking helps to prevent blood clots

Risks of Surgery Infection You will get antibiotics at the time of surgery and for 24 hours after surgery. Surgeons, assistants and scrub techs wear “spacesuits”. Using all precautions, risk of infection is ~1%. Infection may occur months or years after surgery. An infection may mean removal of your implants.

Risks of Surgery Blood loss Tourniquets are used during surgery. There may be some bleeding into the knee after surgery. Your surgeon may use a drain in the knee and give you some blood back. Your blood count will be checked each morning after surgery. If you have symptoms from a low blood count, you may need a blood transfusion.

Risks of Surgery - Stiffness It is painful to move the knee after surgery and some people get stiff. You need to work hard to prevent stiffness. Work on both getting the knee straight (0 degrees) and bending the knee (90 degrees.) Goal is more than 90 degrees flexion by the first week If you have limited motion at 6 weeks, your surgeon may need to perform treatment under anesthesia.

Risks of Surgery Need for Revision We encourage patients to wait as long as possible before knee replacement. Implants wear with time… ~90% of implants last 12 years Revision surgery may involve changing the plastic or changing one or both metal parts. Revision surgery is more challenging with a more difficult recovery.

Risks of Surgery Medical Complications Surgery is a stress to your body. Heart and lung problems, stroke, stomach problems, constipation all may occur. A physical with your regular doctor and an EKG are required before surgery. Despite precautions, unforeseen medical complications may still occur.

Risks of Surgery Anesthetic Complications You will meet the Anesthesia providers the day of surgery. They will discuss anesthetic options such as; general, spinal, epidural, nerve blocks. Nausea and vomiting are common but more serious side effects or complications may occur. Please tell the anesthesia provider of any past experience with anesthesia.

Summary Knee replacement is a reliable operation to relieve pain and restore function. As with any operation, there are associated risks. All of the precautions we take are to minimize risk and provide for a “routine” operation. The purpose of this talk is to provide you with information about knee replacement.

Questions or Concerns?

Patient Resource and Education Program Joint PREP Class Patient Resource and Education Program Welcome to our Joint PREP class. PREP stand for Patient Resource and Education Program. My name is__________________ from the Orthopedic center. I will be hosting today's program. Today our presenters will be Dr._____________ one of our Orthopedic Total Joint Reconstruction surgeons Myself ________________Physical Therapy ________________ Occupational Therapy ________________RN Case manager/Social Services_________________ There will be time after each presentation to ask questions. We have pens if you would like to take notes. There is a space for notes in the back of the Mayo total joint booklet in your folder. There will time to ask questions after each presenter. We will be having a break after the nursing presentation. Restrooms are located outside the door on your left. At this time I'd like to introduce Dr.__________________ As we greet the pts. & family/friend as they arrive, point out the refreshments, give them a name tag and have their family/friend make their name tag. Check and see if they brought their folder and if not give them a new one.

Goals for you and your family Discuss steps to take to get ready for the surgical procedure. Discuss what to expect of the surgical experience. Identify what you need to do to achieve the best outcome. Recognize why it is important for you to participate in your plan of care. Thank you Dr. ________________ As we continue this afternoon we will : Read slide bullets

Plan Ahead Finish any planned dental work at least 2 weeks before your surgery date. Plan for your return home. Identify who will take care of you after surgery. Plan for about 2 weeks. Simplify meals. Plan for 2 weeks of easy or no preparation meals. Prepare your home now- take notes today and get started! There are things you can do to prepare for you surgery. Finish any planned dental work at least 2 weeks before your surgery date. Have your teeth in healthy condition. Bacteria in your mouth may enter your bloodstream and cause infection in the new joint If you have current work being done plan to finish before your surgery. Plan for your return home Identify who will take care of you after surgery. Plan for about 2 weeks. This is 24 hours every day of the week. If you do not have someone who is able to care for you after surgery social services will discuss options with you. Simplify meals. Plan for 2 weeks of easy or no preparation meals. Prepare your home: If upstairs bedroom: prepare room on main floor, or arrange things to go upstairs only once a day. Remove throw rugs and clutter from traffic paths Arrange bedroom for extra space to get in/out of bed with assistive devices Place sturdy chair that is easy to get up from. Prepare your home now- take notes today and get started

Plan Ahead Appointments: Regular doctor for pre-surgery; Blood work, EKG, Physical exam, discuss medications. Surgeon for final discussion and update. Stop smoking – talk to your regular doctor to get help. Call your surgeon if you get a fever, cold, infection or rash before your surgery date. Read slide. There is a stop smoking brochure in your folder for more information.

What to bring to the hospital Loose comfortable clothing Comfortable nonskid walking shoes Personal items Copy of your advanced directives Insurance cards Medication list, inhalers, C-PAP mask Any assistive devices you have Prepaid long distance calling card (optional) Your Total Joint Replacement information folder Loose comfortable Clothing: Jogging suits or sweatpants Comfortable non-skid walking shoes: Velcro closures or elastic laces are handy. Personal items; toiletries, books, magazines Copy of your Advance Directives Insurance cards Medication list, inhalers, C-PAP mask Any Assistive devices that you already have. Bring your walker, or crutches. Prepaid long distance calling cards (optional) Your Total Joint Replacement information folder from class. We will be using this folder though out your hospital stay

What not to bring to the hospital Valuables/Jewelry Credit cards, check book or large sums of money Your medications (except inhalers) -All Valuables/jewelry, even your wedding band if it comes off easily -Credit Cards, check book or large sums of money -Your medications- except inhalers

The day before surgery A SurgiCenter nurse will call you to: Review your medications Tell you what medications to take and not take the day of surgery Update your health history and review allergies Review eating, drinking and smoking restrictions Give hygiene instructions Tell you what time to arrive at Luther Hospital A SurgiCenter nurse will call you to: Review your medications Tell you what medications to take and not take the day of surgery Update your health history and review allergies Review your eating, drinking and smoking restrictions Nothing to eat, chew or smoke after midnight. No mints, hard candy or chewing gum Your surgery may be delayed if you eat anything after midnight May have clear liquids up to 2 hours prior to the time of surgery: Water Clear juices without pulp such as apple juice, Clear broth, Clear Jello, Black coffee or tea, Popsicles Give hygiene instructions Take a bath or shower the evening before or the morning of surgery.. Shampoo hair - it may be a while before able to do this after surgery. Do not shave your surgical site. Tell you what time to arrive at Luther hospital

Day of surgery Take medications at home as instructed. Check in at Luther Hospital Registration Desk. Read Slide

Day of Surgery (continued) You will be taken to the SurgiCenter You will be asked your name and date of birth by everyone who has contact with you – this is done for your safety. Family and Friends are welcome. Try to limit to 2 people on day of surgery. Read Slide Family/friends Will be allowed to stay with you until you are taken to surgery.

SurgiCenter Nursing admission in the SurgiCenter- We will ask you many questions and discuss your: Medical history Plan of care Rights and Responsibilities Safety Anesthesia visit Surgeon visit Nursing admission in the SurgiCenter- We will ask you many questions and discuss your: Medical history Plan of care Rights and Responsibilities Safety In the SurgiCenter If you do have jewelry, remove and give to your family/friend. Dentures, glasses and hearing aids may stay in place until you are taken to surgery. Anesthesia staff will: Discuss the type of anesthesia available for your procedure Perform a brief examination Start IV Surgeon will: Review the consent for your procedure and will sign your surgical site Answer your last minute questions.

SurgiCenter (continued) If ordered for your surgery: blood work, x-rays, clip hair at the surgery site. Your personal items are stored and later taken to your hospital room. Leg squeezers (SCDs Sequential Compression Devices) and TED hose are applied. READ SLIDE (Picture of SCDs on next slide)

Leg Squeezers – SCDs This is a picture of the leg squeezers

Going to the Operating Room The Surgery RN will take you to the operating room Family/Friends Will be directed to the main lobby Family Lounge They should register with the volunteer and will be given a beeper and contacted when the surgery is finished

Operating Room (OR) Monitors Antibiotics Anesthesia Surgical scrub Foley catheter Time in operating room area OR Staff will communicate to your family if the surgery is 2-3 hours Staff will hook you up to equipment that will monitor heart, lungs, breathing and blood pressure throughout the surgery. You will be given an antibiotic through your IV. Anesthesia will be given to you Once you are asleep: An antibacterial scrub is done to your surgical site; this may leave your skin with a bluish or brownish color that eventually washes off. A catheter will be placed in your bladder You will be in the operating room area about 3 hours. If the surgery is taking longer than 2 hours and not expected to finish soon, the Operating Room staff will try to call your family in the Family Lounge to let them know of the change in time.

Recovery Room/Post Anesthesia Care Unit (PACU) You will be in recovery for about 1 hour. You will have Monitors and Oxygen on Your nausea and pain are monitored and controlled When you are ready, you will be transferred to a hospital room. When you are ready and nausea and pain are controlled (not eliminated), you will be brought to your hospital room. You will be in the PACU Recovery Room about one hour to make sure you are stable.

Arrival in your Hospital Room You will have… Oxygen – to help breathing and healing A foley catheter – to measure urine output An IV – to give you fluids and medication Incentive spirometer – to encourage you to take deep breaths to prevent congestion in your lungs. A pulse oximeter – a device that fits on your finger to measure blood oxygen level Read slide Show incentive spirometer. This is used to encourage you to take deep breathes. (Pulse Oximeter is on next slide)

Pulse Oximeter This is a picture of the pulse oximeter monitoring your oxygen level

Arrival in your Hospital Room (continued) We will check on you, take your vital signs Start your Nutrition Activity as you tolerate Work together with you to keep you safe. Help you with control of pain and nausea When settled in your room, the nurse will listen to your heart and lungs check color, movement, and feeling in your surgical leg tell you about your room and equipment used for your care. Nutrition - Sips of water and/or ice chips --- then clear liquids if not nauseated Activity Bed rest May stand at bedside if your doctor orders Staff will reposition you every 2 hours to prevent pressure sores Keeping you safe You will need to tell us your name and birth date before receiving medicine or having a procedure i.e. blood tests We will continue to help you with control of pain and nausea

Pain Management Read slide While you have an IV in you may have a Pain pump. This allows you to safely give yourself pain medication through your IV. Only the patient should push the button for pain medication. You may begin to take your pain pills by mouth when you are able. Ask your nurse for pain medicine before your pain becomes too intense

After Knee Surgery We will care for your skin and incision You may have a drain in your knee incision area You may have a Cryo Cuff or ice pack on your knee You will have a continuous passive motion (CPM) machine We will care for your skin and incision You may have a drain in your knee incision area You may have a Cryo Cuff or ice pack on your knee A CryoCuff is a device filled with cold water and placed on your knee to minimize swelling. (Show ) You will have a continuous passive motion (CPM) machine CPM will be used to gently move your knee while you are in bed. (Picture next slide)

Continuous Passive Motion Machine (CPM) Your leg rests in the lambs wool cradle as the CPM gently bends your knee.

You are a Partner in your care! Post operative day ONE Blood work Medication Pain control *Anticoagulation – Warfarin Catheter and drain removed. Nutrition as you tolerate Activity-Physical Therapy and Occupational Therapy Work together to keep you safe. You are a Partner in your care! Blood work - Blood will be drawn daily Medication for Pain Control – Continue using pain scale to rate pain Anticoagulation with warfarin Catheter and drain removed Nutrition If not nauseated, you will progress to your usual diet Activity Physical therapists and Occupational therapist will begin working with you Up in chair for lunch and supper Staff will continue to reposition you every 2 hours while you are in bed. Keeping you safe Call for assistance/Do not get up by yourself! White Board Plans for each day in the hospital will be on a white board in your room so you know what to expect each day. It will also be used as a communication tool for the nursing staff, Physical Therapy, Occupational Therapy and you and your family.

Post operative day TWO plan The person who will be taking care of you after you go home needs to come to the hospital to learn about: Safety Incision care Activity – Physical and Occupational Therapy Medication for pain control and anticoagulation The person who will be taking care of you after you go home needs to come to the hospital for about 2 hours to learn: Safety Incision care Activity – Physical and Occupational Therapy Medication for pain control and anticoagulation Once you have began taking pain pills you may want to ask your nurse to bring pain pill at each meal (to prepare for therapy) and at bedtime You may have problems with constipation, do what works for you or ask to keep taking stool softener and/or laxative if no bowel movement after surgery.

Day THREE/Discharge day. Prepare for discharge to home or transitional care unit. The person who will be taking care of you after you go home needs to come to the hospital again to learn about and get discharge instructions for: Incision care TEDS and how to keep swelling down How to take pain medications correctly Anticoagulation – Warfarin and blood work Antibiotic coverage card When to contact your Surgeon You are a Partner in your care! Day THREE/Discharge day Prepare for discharge to home or transitional care unit. The person who will be taking care of you after you go home needs to come to the hospital again to learn about and get discharge instructions for: Discharge Instructions - Staff will go over discharge instructions Incision care: we will provide you with a kit to take home with all the supplies you will need. (Show Kit) Ted hose to decrease swelling- on during the day, off at night – for 3 weeks. Medications: You will be given a list of medications you will take at home Blood work: lab draws twice a week for warfarin for 3 weeks Antibiotic coverage card: Will be given to you at discharge- show this card before having any dental work You will be instructed of when and how to contact your surgeon for concerns

Elevation of your leg Elevate knee above hip and toe above knee to decrease swelling and pain Read slide ( Use pointer or point to the knee and toe elevation)

After Discharge A person to care for you will need to be available 24 hours a day to: assist you at home the first two weeks drive you to appointments encourage you in your therapy and progress Read slide above…

Bathing You may shower when your incision is dry (no drainage) Place a new dressing on the incision after shower Do not submerge the incision in a bathtub, pool, hot tub, etc, until the incision is completely healed Read slide You can shower and allow soap and water to run over the incision and either air dry or pat dry.

Driving Talk with your surgeon about when you will be allowed to drive again. You must be: off narcotic pain medicines to drive able to sit in car comfortably able to move foot from gas to brake pedal easily You need a valid driver’s license! Practice in a safe area. Read slide

At your appointment we will: A Follow-Up Appointment with your surgeon will be made 10-14 days after surgery At your appointment we will: Remove your staples Give you care instructions about your: Incision Bathing TEDS Assistive devices Medications – warfarin and pain control Joint replacement - dental procedures and antibiotics Read slide

Questions or Concerns?

Start getting ready for surgery. Make your plans. Watch the Total Joint Replacement Video at www.luthermidelfort.org Click on Medical Services, then Orthopedics Center Thank you! Read slide and refer to web site card Take a 10 minute break. Rest rooms Water to drink After Break PT OT RN Case Manager After class THE END Thank everyone for coming If you have any question that come up after you leave today refer to the cards inside your folder for numbers to call…..

Joint PREP Physical Therapy Total Knee Replacement

Home Preparation Become familiar with exercise handout If you have a walker, practice using it and make sure you can get through your house with it.

Physical Therapy Your therapy will start the day after your surgery Activities include getting into a chair, walking and working on the exercises Therapy will continue twice daily until goals are met or you are discharged from hospital

Includes in/out of bed, getting out of a chair, walking and stairs Therapy Goals Independence with mobility Includes in/out of bed, getting out of a chair, walking and stairs Independence with an exercise program to continue at home

Therapy Goals Cont’d Learn appropriate use of walking devices such as walker/crutches Can bring your own to hospital to make sure it’s sized correctly and get familiar with it’s use

Goals Continued Your family member or friend should be available on the 2nd or 3rd day after your surgery to become familiar with the exercises and any assistance that you will need at home.

Range of Motion Gaining full knee extension (straightening) Is KEY!

Goal is 90 degrees of flexion (bending) by the Range of Motion cont’d Goal is 90 degrees of flexion (bending) by the end of the hospital stay

Range of Motion CPM (continuous passive motion) You will use this machine while in the hospital

Exercise after Discharge WALK! Continue with exercises from hospital Outpatient PT if ordered by your surgeon

Questions or Concerns?

Rehabilitation Services Joint PREP Occupational Therapy

Why Occupational Therapy? Your occupational therapist (OT) is trained in the field of rehabilitation and is concerned about your safety in performing activities of daily living

Activities of Daily Living Your OT will show and teach you ways to safely do your daily tasks Dressing Bathing Toileting Your goals for OT include: Increased Independence Increased Strength Increased Mobility

Adaptive Equipment Reacher Sock aid Long-handled shoe horn Your OT will help you order/purchase adaptive equipment if it is needed to assist you with dressing and bathing Reacher Sock aid Long-handled shoe horn Dressing stick Elastic shoelaces Long-handled bath sponge Tub/shower chair or transfer bench Raised toilet seat

Before surgery… Prepare your home with safety in mind Remove throw rugs and clutter from traffic paths Rearrange your kitchen so you can easily reach often-used items Install grab bars in bathrooms

In the hospital… Occupational therapy will begin the day after your surgery You will be seen by your OT once a day

Day One Your OT may… Learn about your home set-up and help available to you at home Begin home safety instruction Discuss home equipment needs Instruct you in an upper body exercise program

Day Two Your OT may… Practice with adaptive dressing equipment Order dressing/bathing equipment as desired Review upper body exercise program

Day Three Your OT may… Work with you on safety with room maneuvering Help you practice getting in and out of a tub with the use of a tub bench or chair Encourage you to participate in a bathing/dressing session to determine the level of assistance you may need

When you leave the hospital… Keep SAFETY in mind! Stay ACTIVE and INDEPENDENT!

Questions or Concerns? Thank You!

Social Services and Case Management Joint PREP Social Services and Case Management

Department Role Social Services and Case Management staff can assist with: -Insurance concerns -Home Health Services -Skilled Nursing Care -Community Services and referrals -Power of Attorney for Health Care -Counseling and Advocacy

Insurance Assistance Once you and your Doctor decide you will proceed with surgery you should : -Pre-register at the front counter -Notify your insurance company -Get your insurance company’s approval.

Insurance Verification continued Insurance plans vary in what is required to authorize your surgery. Our insurance notification may not be enough. Some plans require you to call too. Many Medicare Advantage plans require prior authorization. Your insurance company may take 15-30 days to complete this process.

During your stay Doctor decides when you are ready for discharge to the next level of care. The next level of care might be: home with or without Home Care Nursing home Rehabilitation Hospital Transitional Care Unit/Swing Beds

During your stay The usual hospital stay is 3 nights and 4 days. Talk with your Case Manager about services you want after discharge as soon as possible. Check your insurance to see if it limits who you can use.

Options for continuing care once you can leave the hospital Transitional Care Units or Swing Beds Skilled Nursing Facilities Home Care options Home with outpatient services.

Transitional Care Units Bloomer, Barron and Osseo Transitional Care Units are owned by Luther Midelfort . Other Transitional Care units include Durand, Stanley, Spooner, Hayward, and Medford to name a few. Medicare pays for your transitional care stay like it would if you went to a nursing home.

Continuing Care Discharge Options Transitional Care Units (also referred to as Swing Beds) provide continued skilled nursing and rehabilitation care after your hospital stay. Can provide closer medical monitoring and more intensive rehabilitations therapies than regular nursing homes.

Nursing Homes (skilled nursing facilities) Area nursing homes offer a range of services from short term rehabilitation stays to long term medical and residential care. Eau Claire area skilled nursing facilities include: Clairemont Dove Oakwood Villa Syverson

Other nursing homes include but not limited to: Chippewa Manor-Chippewa Falls Wissota Health and Regional Vent Unit-Chippewa Falls Cornell Care Center- Cornell American Lutheran Home-Mondovi/Menomonie Hetzel Care Center-Bloomer Dunn County Health Care Center Colfax Area Nursing home-Colfax Dallas Health Care-Dallas Pepin Manor-Pepin Spring Valley Nursing Home- Spring Valley

Medicare Skilled coverage Medicare requires the following to pay for your nursing home or transitional care stay: 1. You have a skilled nursing or rehab need (PT/OT) 2. You participate in therapies and show progress. 3. That you have a qualified 3 day stay at a hospital.

Home Care options Medicare will pay for home care services: -if you are homebound -if you have skilled nursing needs. -if you have skilled therapy needs. Medicare does not pay for: Help with meals, grocery shopping, etc. Shopping Personal Care (bathing, dressing, etc.) Housekeeping services

What are Advance Directives? Written documents that tell your Doctor what you want for care when you are unable to speak for yourself. Allow you to describe the type of medical treatment you would like to receive or not receive. Allow you to identify the person you wish to be your decision maker if you are unable to make your own decisions.

How do you get an Advance Directive? Luther Hospital Social Services Luther Hospital Chaplaincy Your personal attorney

2 types of Advance Directives Declaration to Physicians or Living Will The Power of Attorney for Health Care

Power of Attorney for Healthcare With this document, you appoint a family member or friend to follow you wishes and act as your health care agent. Your Health Care agent will make decisions for you only when you are unable to make your own. This document is recommended because it is much more flexible that the Living Will and gives health care providers a person to discuss your wishes with. This document also lists what you want in different situations when you are unable to speak for yourself.

Safekeeping of Advance Directives You should always keep the original document. Copies can be given to family members. A copy can be brought to your doctor’s office or to the hospital to be kept in your medical record. It is important that you discuss your wishes with family and friends close to your. Decision making becomes easier when these discussions have taken place and your wishes are clear.

Questions or Concerns?