Arbor Orthopedics

What to Expect

Surgical preparation: This is an elective surgery and we require a medical doctor to evaluate you prior to the surgery and ask that he or she be available to follow you while you are in the hospital.

Labs: There are numerous labs and tests that are needed to evaluate the risks of surgery. These include blood tests, chest x-ray and an EKG heart test. Sometimes other tests are needed for patients with a history of heart problems.

Pre-surgery evaluation:

Our office: We will see you a few days prior to the surgery to go over the plan and make sure all of your questions have been answered.

Pre-op clinic: The hospital will need to see you to complete paperwork, to review labs and give you instructions.

The day of surgery: The instructions as to when to stop food and drink will be given to you at the hospital during the pre-op visit. Once in the hospital an IV will be started for medication such as sedatives and antibiotics. The skin will be prepared in the surgical area. The anesthesiologist will discuss the plan and answer questions.

The surgery generally is about 1-1/2 hours in length but the time in the operating room is much longer. First the anesthetic is administered then you will have a catheter placed in your bladder as it will not work well for awhile after the surgery. Next you will be positioned on the operating table. Your skin of the entire lower extremity will then be prepared with a solution that kills bacteria. The leg will then be draped with special sterile materials and, finally, an impervious sticky drape is used to cover the skin and prevent contamination of the instruments as they are used during the surgery. After the surgery a tapeless dressing is applied. Dr. Carn feels it is very important not to have tape applied to the surgical area as it is associated with blistering and pain. Therefore, you will have special wrap, compression type of dressing which holds the sterile dressing in place over the incision. Also, a cold pack will be applied as part of this compression dressing to minimize swelling and pain.

Once in the recovery room you will be made comfortable in your hospital bed. X-rays and laboratories will often be obtained to monitor your progress. The total time from holding area to recovery room is 2-1/2 or 3 hours.

After Surgery

Deep breathing and wiggling is very important to prevent problems even in the recovery room when the patient is first waking up.

Most patients are mobilized the day of surgery by getting them out of bed and having them walk at least a bit. This promotes circulation and improves bowel and lung function.

As the days go on the confidence in the use of the operated extremity quickly increases and within a few days patients are able to take care of themselves. Those who have good help at home can go directly to their normal living environment. Those who do not have sufficient help or have other factors such as multiple joint arthritis, age or medical problems may be best treated in a rehabilitation facility for another one or two weeks.

It should be noted that Medicare protects the right of Medicare patients from early inappropriate discharge. Dr. Carn has always respected the patient's rights as well as when it is appropriate to discharge the patient and does not feel it is appropriate, in only very few selected patients, that they be discharged within the first day or two after surgery. The average length of stay is anywhere from 2 to 4 days averaging about 3 (Medicare patients will be given a form by the hospital describing their rights as a patient as it relates to discharge from the hospital). (See section on "Standard of Care").

Dr. Carn will evaluate you every day while you are in the hospital and once you are discharged or transferred, then he will see you at about four weeks after the surgery for the first set of x-rays and to evaluate your progress.

Knee replacement is a bit more difficult than a hip replacement as the amount of physical therapy and exercise needed to obtain the best result is much greater. A knee replacement requires that the patient be vigilant in the postoperative exercise routine. Ninety five percent of the success of a knee replacement is what the patient does at home. A physical therapist often will be utilized and can provide guidance and direction but, again, it should be emphasized that the majority of the therapy is what the patient does at home and not for the short periods of time spent with the physical therapist.

Controversies in Total Knee Replacement

The biggest development in total knee replacement is the quality of materials available. This results in very long-term predictable use of the knee after having a knee replacement. The tried and true proven method of fixing the parts to the patient is using bone cement. In some patients placement of parts without bone cement has been shown to work well but the results of non-cement knee replacements need to be compared to the standard of care which is a cemented total knee.

A small incision surgery is not the standard of care in knee replacements. Early studies by the developers of such approaches show good results but studies done by less biased observers show the complication rate to be higher with minimal incision total knee replacements.

Computer guided knee replacement may at some point be shown to be helpful in knee replacements but the current studies do not support it as being as good as the standard of care having mechanical guides for alignment. The problems include increased surgery times and placement of numerous holes in the bone for the computer guides. Both of these can be associated with increased problems after surgery, for the current standard of care in knee replacements does not include computer guided alignment.

Informed Consent

The patient must know the risks, options and long-term considerations prior to having a hip or knee replacement surgery. It is exceedingly important that the patient understand what the standard of care is of any surgery but in particular with hip and knee replacement. There are surgeons who perform what they feel may be best for the patient but is not standard of care and is truly a developmental procedure or a developmental implant. Therefore, I think it is very important that the patient ask about whether or not this is a standard of care implant or a developmental implant. If the technique is "one of a kind" or if these are "new and improved parts" then I advise the patient to be cautious.

Most important would be to ask the following questions:

• Are the parts and the surgical technique standard of care for hip or knee replacement?
• What is the method of fixation of the parts to my bones?
• How many of these surgeries have been performed across the United States in the last ten years using these parts or surgical techniques.
• What is the surgeon's experience, in particular with this technique and with this implant? (Make sure that this is specific for what the surgeon wants to place in you as he may have extensive experience with hip or knee replacement but very little experience with this particular part or technique).
• What is the planned type of bearing surface; how does it compare and if it is not standard of care how does it compare to the very well substantiated standard of care in hip and knee replacements?
• What is your rate of complications; specifically with regards to infection and phlebitis or clots in the legs? (Note that most surgeons do not have specific information on their own complication rates but only their best estimate).
• Ask the physician how long they have been practicing at the facility that they plan on doing your operation.
• Ask the physician what their experience is and how long they have been performing the surgery that they plan on performing on you.
• Sometimes it is helpful to ask about actual training if the planned surgery is something a bit more difficult or unusual.

Be aware of physicians who have done very few of the planned type of surgery. Be aware of physicians who are willing to "give it a try" even though it may be something different or not standard of care. The most important aspect of informed consent is to truly have a good rapport and good trust with the surgeon who plans on performing the surgery.