- Before Surgery
- Day Of Surgery
- Immediately After Surgery
- After Discharge & Recovery
- Taking Care Of Your Joint Replacement
What Is Joint Replacement?
Joint replacement surgery removes the worn-out cartilage and underlying bone and replaces the area with implants that provide a new wear resistant surface. The vast majority of individuals who have joint replacement surgery experience a dramatic reduction in joint pain and a significant improvement in their ability to participate in daily activities and low impact sports.
PLEASE TELL DR. NOBLE IF YOU HAVE A METAL OR NICKEL ALLERGY
Total Hip Replacement
Hip replacement involves replacing the head of the thigh bone (femoral head) and the hip socket (acetabulum) with implants that resemble your existing anatomy. A femoral stem is secured inside the upper end of the thigh bone. Depending on bone quality, the metal stem (made of titanium alloy) will be inserted without cement using a rough surface that promotes bone attachment. When osteoporotic or weak bone is encountered, a cemented implant might be used. The femoral head is connected to the top of this stem and is made from Ceramic or Oxinium (a metal that has the surface characteristics of ceramic). The outer shell of the hip socket is made out titanium metal and is secured with screws. The inner lining of the socket is made of highly cross-linked polyethylene, an advanced medical grade plastic. Dr. Noble will perform the minimally invasive Direct Anterior (DA) approach for appropriate patients.
Total Knee Replacement
In total knee replacement, all 3 worn out compartments of the knee are replaced with implants that resemble the shape and contours of a normal knee. The femoral component has a curved shape that fits on end of the thigh bone is made of either Oxinium (a metal that has the surface characteristics of ceramic) or Cobalt Chrome metal. The tibial component is made of titanium metal with a medical grade polyethylene plastic that locks into the metal plate. The polyethylene serves as the "cushion" or cartilage space between the metal femoral implant and the tibial base. The underside of the kneecap is resurfaced with polyethylene that articulates with femoral implant. The components are often cemented to the bone, or in some cases, press fit without cement to allow bone growth onto the metal implant.
In Selected patients, Dr. Noble will perform robotic assisted total knee replacement with the Mako robot.
Partial Knee Replacement With Robotic Surgery
Robotic assisted partial knee replacement is performed for patients who suffer with localized pain and arthritis that affects one area of the knee joint. Only one of the three compartments of the knee is replaced with a combination of metal and plastic. Most often, the medial or inner compartment of the knee develops severe arthritis and is resurfaced with the new joint. The femoral component is made of metal and has a curved shape that matches the natural contour of the knee. The tibial component has a metal base that is secured to the bone and a polyethylene plastic insert acts as the cushion. Both femoral and tibial components are attached using cement. This surgery is performed with robotic and computer assistance through a minimally invasive incision. A CAT scan is done before surgery for planning.
Location For Surgery
Outpatient/Same day Surgery at Palm Beach Surgical Suites: Patients who are healthy, motivated and have good social support can go home the same day after having knee or hip replacement surgery. The procedure is performed under sedation with a spinal anesthetic and use of a long-acting local anesthetic. Dr. Noble offers this option to patients who do not have any major medical issues and are less than 70 years old.
Hospital: Certain patients may require a night or two in the hospital due to underlying medical issues, older age, or need to more closely monitor the patient after surgery. Typically, patients with cardiac conditions, previous stroke, kidney problems, or other multiple medical issues will need to stay in the hospital.
Dr. Noble will discuss the best location for your surgery and make the appropriate arrangements.
Before Surgery
Pre-Op Testing and Physical Exam
All patients need blood work and urinalysis performed within 1 month from the surgery date. A chest X-ray and EKG are also required. A physical exam and Medical Clearance will be done by your medical doctor within 1 month from surgery. You will also need Cardiac clearance if you have a history of heart disease, stents, or heart attacks. Dr. Noble’s staff will help coordinate all necessary labs, tests, and office visits and can make suggestions if you don’t already have a medical doctor.
Dental Care
It is important to see a dentist on a regular basis to maintain proper dental hygiene. This is especially important if you are preparing to have a knee or hip replacement since your mouth could be a source of infection. If it has been over 6 months since your last dental visit, it is highly recommended that you see a dentist prior to surgery and have a dental clearance letter sent to Dr. Noble's office. Dental procedures such as extractions and periodontal work should be completed before joint replacement to reduce the potential of infection.
Skin Ulcers and Non-healing wounds
The condition of your skin is very important to prevent post-operative infections. Bacteria can enter your blood through a skin wound and cause an infection of your artificial joint. If you have any ulcers, non-healing wounds, or boils you must see a skin specialist (dermatologist) to have complete resolution of these problems before surgery. Please tell Dr. Noble if you have any skin problems.
Smoking and Nicotine
There is a higher risk of wound complications and infections in smokers due to the constriction of blood vessels caused by the nicotine. You must stop smoking and not use any nicotine products (including nicotine gum) for at least 6 weeks prior to surgery.
Physical Therapy
Physical Therapy (PT) is an important part of your preparation for surgery. Your recovery will be faster and easier if you invest the time and energy before surgery. Dr. Noble recommends and will provide a prescription for "Pre-hab" physical therapy starting 4 to 6 weeks prior to surgery. This will give you an opportunity to work with a physical therapist to learn a strengthening program that should continue (on your own) until you have surgery. Stationary bike, swimming, walking in the pool, or any type of low impact physical activity is highly encouraged in addition to physical therapy.
Pre-Op Joint Replacement Class
Pre-op education is required by the hospitals and surgical suites to provide you and your family members information to prepare for surgery.
Jupiter Medical Center REQUIRES all patients to attend the pre-operative joint class provided on Monday and Wednesday at 10AM, available by interactive virtual class or in-person (when available). To register, please contact the Jupiter Medical Center Orthopaedic Coordinator at (561)-263-3633
For those patients having same day surgery at Palm Beach Surgical Suites, please view the pre-operative online education that can be found at www.palmbeachsurg.com
Blood Donation is NOT needed for surgery
Patients do NOT donate their own blood. Research has shown that this is not beneficial and does not reduce the need for additional blood transfusion. If necessary, the patient will receive blood from the hospital blood bank. Hospitals follow universal guidelines in screening blood and blood products to assure the patient’s safety as much as possible in this situation.
Medications
Continue taking your routine medications unless your medical doctor makes adjustments. The hospital or surgery center will tell you what medications to take (if any) on the morning of surgery.
10 days before surgery you should STOP taking Aspirin and NSAIDs (Advil, Ibuprofen, Aleve, Naproxen, Mobic, Diclofenac) since these medications will affect bleeding. In addition, stop taking Fish Oil, Supplements, Multi-vitamins and Vitamin E 10 days before surgery.
It’s OK to continue taking Tylenol/Acetaminophen since it’s not an NSAID and won’t affect bleeding.
Blood thinners should be stopped based upon these guidelines. You should discuss details with your primary care physician or cardiologist before stopping these medications.
- Aspirin: 10 days prior to surgery
- Plavix: 10 days prior to surgery
- Coumadin / Warfarin: 5 days prior to surgery
- Pradaxa / Dabigatran: 5 days prior to surgery
- Eliquis: at least 96 hours (3 DAYS) prior to surgery
- Xarelto: at least 96 hours (3 DAYS) prior to surgery
Reducing the Risk of Infection
- Nasal Antibiotic/Mupirocin: You will receive a prescription for Mupirocin antibiotic ointment before surgery. STARTING 5 days before surgery, apply a thin layer of this antibiotic into each nostril using a Q-tip TWICE per day. This antibiotic is used to help eliminate bacteria like Staph that could be colonized in your nose, which could pose a risk for surgical site infection.
- Chlorhexidine shower: Typically, you will be given a bottle of Chlorhexidine antiseptic soap from the hospital. Surgery centers patients will need to purchase this product, which is also called HIBICLENS from their pharmacy, Walgreens or CVS (OK to buy generic brand). You MUST take a shower with this soap the night before AND the morning of surgery to reduce your risk of infection. Apply the soap to your entire body from the neck down (do not put the soap on your face or in your hair).
Eating and Drinking before Surgery
We recommend that you stop drinking alcohol 10 days before surgery to reduce your risk of bleeding. To improve hydration, you should drink a 20-ounce bottle of GATORADE G at LUNCH and DINNER the day before surgery. You can eat solid foods until mid-night the day before surgery, with a light meal recommended for dinner. On the morning of surgery, you can drink 20 ounces GATORADE G 2 hours before your arrival time.
Items to Bring to the Hospital/Surgery Center
All patients should bring their personal toiletries and shaving gear, loose fitting, comfortable clothing, non-skid shoes or slippers (slip on type with closed back preferred), a list of their current medications (including dosages), and any paperwork the hospital may have requested. Please be advised that the hospital provides gowns, slipper socks, and a small toiletries supply.
If you are having surgery at the surgery center, wear loose fitting clothes. You will not need an overnight bag, since you will be going home the same day.
When to Arrive at the Hospital for Surgery/Surgery Center
Patients are generally instructed to arrive 1 to 2 hours prior to the scheduled surgery time. This allows time for paperwork, changing into hospital clothing, and meeting the anesthesiologist and nursing staff. The hospital or surgery center will contact you 1 or 2 days before surgery to provide the exact time and location to arrive.
Family Members
Due to COVID, family visitation has become limited and will be determined by the facility. Please check with the hospital or surgery center regarding current visitation policy. Your family member or significant other will be called by Dr. Noble after surgery. The nursing staff will also remain in contact as you progress through you stay.
Day Of Surgery
Type of Anesthesia
Most cases are performed under spinal anesthesia with sedation. Special circumstances or personal preference may indicate the use of general anesthesia. The anesthesiologist will explain the procedure and address your questions.
Length of Surgery
Surgery times may vary depending upon the difficulty of your case. Generally, you may spend 2 to 3 hours in surgery and about 1 to 2 hours in the recovery room.
Activity on the Day of Surgery
Almost all patients will stand and walk on the day of surgery, depending on the time and location of surgery. Surgery center patients will walk and use the bathroom prior to leaving the facility. Hospital patients will usually be seen by the physical therapist for standing and walking.
Immediately After Surgery
Pain Control
Good pain control is a big priority after surgery. Dr. Noble has developed a very effective multi-modal pain control regimen with the objective of using the least amount of narcotic pain medication. This starts before surgery with medications provided to you in the pre-operative area or taken at home (for surgery center patients). These medications include Tylenol, Celebrex (or another type of anti-inflammatory), Lyrica (nerve calming medication), and Ultram/Tramadol (a non-narcotic pain medication).
During surgery, Dr. Noble injects the joint and tissue around your incision with a combination of anti-inflammatory, numbing, and pain medication. This dramatically reduces the amount of immediate post-operative pain.
After Surgery, you will be started on a non-narcotic schedule of medications which includes Tylenol, Ultram/Tramadol, Gabapentin/Neurontin, and Celebrex. If you experience higher levels of pain, you can take an oxycodone as needed for breakthrough pain.
Blood Clot Prevention - Anti-Coagulation and SCD’s
- You will take Baby aspirin 81mg twicer per day for 1 month after surgery to prevent blood clots.
Dr. Noble prefers Aspirin (instead of Coumadin or Lovenox) for blood clot prevention due to the proven effectiveness with reduced risk of developing surgical site bleeding and hematomas. An alternative blood thinner will be utilized if you have a history of blood clots, or if you were already taking a blood thinner before surgery – this needs to be discussed with Dr. Noble.
- The Compression TED hose stockings should be worn for the first 2 weeks to reduce leg swelling. You need to periodically remove the stockings for an hour to check your skin. The TED stocking can be removed at night and put back on in the morning. You can stop wearing the stockings once the swelling has resolved in your leg.
- SCD’s – Sequential Compression Devices are inflatable wraps that are placed around the calf to mechanically assist venous blood flow and prevent blood clots. These will be worn in bed at the hospital and should be used at home after your discharge. Portable SCD’s are highly recommended for HOME use and can be purchased for $300 at PBOI. The surgery center will provide most patients the SCD’s.
Physical Therapy (PT)
Patients that have surgery in the hospital will typically be seen by physical therapy the same day as surgery to assist with standing and short distance walking. You will receive PT twice a day while in the hospital for strengthening and gait training. You will also be instructed on activities such as bathing, dressing, using the bathroom, getting into and out of a car, and stair climbing.
Patients that go home the same day from the Surgery Center will stand and walk with the assistance of the recovery room nurse. Once at home, you can walk short distances the same day. A physical therapist will come to your house the following day to start the at home PT program.
Foley Catheter
A Urine (Foley) catheter may be placed during the time of surgery. This will allow your bladder to empty without having to use the restroom. The catheter allows the nursing staff to monitor your urine output. The catheter is recommended for men who have an enlarged prostate and for women who have stress incontinence. If you are in the hospital, the catheter will be removed the morning after your surgery. Not all patients require the catheter, and you should discuss your preference with Dr. Noble prior to surgery.
CPM Machine for Total and Partial Knee Replacement
The use of CPM (Continuous Passive Motion) machines after surgery is discouraged by the Joint Commission for Hospital Accreditation. Dr. Noble has followed these recommendations, and has limited the use of CPM machines, since research has not proven a benefit for most patients. Your knee range of motion will be evaluated by the physical therapist, and if you have limited flexion after surgery, a CPM machine can be ordered.
Seeing your Doctor while in the Hospital
Dr. Noble or his Physician Assistant/Nurse Practitioner will see you daily to discuss your progress and address any questions. The case manager will also meet with you in order to assure the proper discharge plan.
Length of Hospital Stay
For total knee and hip replacement surgery, most patients stay in the hospital for 1 or 2 nights. Occasionally, some patients will stay for 3 nights based upon their progress and medical issues. If you are undergoing partial knee replacement, you may be discharged the same or next day after surgery.
Discharge to Home vs. Rehab Facility
Discharge to home is preferred. A physical therapist and nurse will come to your house for the initial 2 to 3 weeks to provide strengthening, range of motion, and walking exercises. The home care team will also change your dressing and contact Dr. Noble if there are any concerns during your recovery. You should plan to have a family member or friend stay with you for the first week after surgery. Due to the Coronavirus, we recommend that you plan to recover at home instead of a Rehab/Nursing home facility.
After Discharge & Recovery
Pain Mediation
Good pain control is required to have a good recovery and return to normal function. Please refer to Dr. Noble’s pain control regimen that will be provided during your pre-operative visit.
Blood Clot Prevention - Anti-Coagulation and SCD’s
- You MUST continue taking Baby Aspirin 81mg twice per day for 1 MONTH after discharge to prevent blood clots and pulmonary embolus. If you were already taking a blood thinner before surgery (Plavix, Xarelto, Coumadin, Eliquis, Pradaxa, etc.) you will be given instructions regarding the appropriate blood thinner and dosage.
- The Compression TED hose stockings should be worn for the first 2 weeks to reduce leg swelling. You need to periodically remove the stockings for an hour to check your skin. The TED stocking can be removed at night and put back on in the morning. You can stop wearing the stockings once the swelling has resolved in your leg.
- The home Sequential Compression Devices (SCD’s) should be applied to both calves and can be worn through-out the day. You can wear the devices for short walks in the house. It is recommended to wear the SCD’s for at least 8 hours in a 24-hour period for the first 2 to 4 weeks after surgery, based upon activity.
Physical Therapy
You will receive home Physical therapy for 2 to 3 weeks. Patients with a total hip will continue at home with a self-directed program of walking and strengthening and will usually not require outpatient PT. Knee replacement patients will transition to outpatient PT after the home therapy is completed. This will continue for 4 to 6 weeks.
Walker, Crutches and Cane
A walker (or crutches) is normally used for the first 1 to 3 weeks after surgery. You and your physical therapist will determine when you're ready to start using a cane based upon your motion, strength, and balance. Patients will use the cane for the next several weeks based upon recommendations by the physical therapist as well as your comfort.
Bandage
A silver backed waterproof dressing will be applied over the incision in the operating room. This bandage will be changed by the home nurse 7 to 10 days after surgery.
If there is bloody drainage that gets larger, the bandage should be changed daily, until the drainage stops. If the drainage continues for more than 3 to 4 days, please call Dr. Noble or Sharon. Do NOT apply any ointment to your incision for the 1st month.
Showering and Bathing
Do not get your incision wet for 10 days. It is OK to get in the shower. When you get in the shower, keep the dressing in place (remove the ACE bandage if you had knee replacement) and apply clear food wrap over your dressing to prevent any water from getting under the bandage.
After 2 weeks, your incision can be open to air and you can get the incision wet in the shower if there is no incisional drainage. DO NOT go swimming or submerge your incision for at least 5 to 6 weeks after surgery, since the skin needs to be completely healed and sealed.
Ice Management and Swelling
The use of ice or a cryo-cuff/ ice management system is extremely important for healing, pain control, and helping to reduce swelling. Elevation of the leg is also important to reduce swelling.
Patients will be provided a Cryo-cuff knee or hip wrap system in the hospital. This device belongs to the patient and should be taken to rehab or home. To prevent frostbite and skin sensitivity, an empty pillowcase can be applied over the knee, before placing the cryo pad. The system should be used during times of rest and after physical therapy for 4 to 6 weeks after surgery.
Climbing Stairs
You are allowed to climb stairs at home, and this can be done one or two times per day after discharge. Patients undergoing Total Hip Replacement need to refrain from climbing stairs too often during the first 2 months, since this activity places high torque on the implants, and could delay proper healing.
Going Outside and Making Local Trips
To reduce the chance for infection, falls, and excessive swelling, Dr. Noble recommends that you stay at home for the first 7 days after discharge from the hospital. Comfort and safety should be the primary guidelines for going outside your house. It is suggested to start with short trips as the passenger, perhaps to physical therapy or your local supermarket or church if nearby. Gradually increase the number and length of outside activities as you feel more comfortable.
Driving
The type of surgery, side of surgery and your overall condition must be considered before you decide to drive. Other important considerations are discontinuation of narcotic pain medication (oxycodone) in the daytime and your ability to walk with ease with or without a cane. Typically, patients are instructed to wait 4 weeks before driving if you had RIGHT sided surgery and 2 weeks if you had LEFT sided surgery.
Return to Work
Returning to work varies with each patient, the type of surgery, and the particular job duties. The amount of time can vary between 2 to 8 weeks and is most dependent on the level of activity expected of the patient. Dr. Noble will discuss the details about your return to work and will provide out of work and return to work notes when required.
Return to Sports
Initially patients can return to low impact, less strenuous activities such as walking, stationary cycling, and swimming after 4 to 6 weeks. As your physical therapy progresses and your strength and balance return, patients gradually return to hiking, doubles tennis, cycling, and golf at 2 to 3 months. High impact activities such as running, racquet ball, and basketball should be avoided.
First Office Visit After Surgery
Your first post-op office visit with Dr. Noble’s team will be about 2 to 3 weeks after surgery. X-rays will be taken in the office. Your incision will be checked as well as range of motion and your ability to walk. Additional visits will be made at 6 weeks and 3 to 4 months after surgery.
Taking Care Of Your Joint Replacement
Dental Visits
Good dental hygiene is important, and you should see your dentist for regular dental care even if you don’t have a dental issue. Dental procedures as well as procedures involving our gastro-intestinal tract or genito-urinary area can result in the circulation of bacteria within your bloodstream. Antibiotic prophylaxis prior to these procedures is an important part of your continued care after total joint replacement.
The Academy of Orthopaedic Surgeons (AAOS) official statement is to continue antibiotic prophylaxis for 6 months after joint replacement UNLESS the patient is immunocompromised with poorly controlled diabetes, rheumatoid arthritis, psoriatic arthritis, or taking a Chemotherapeutic drug. If you are immunocompromised, the AAOS recommends continued pre-dental antibiotics for life. All patients undergoing a deep dental procedure such as root canal or removal of infected tooth should take an antibiotic before the procedure.
The following antibiotics are recommended and can be obtained through our office or your dentist or surgeon:
- Amoxicillin 2,000mg (4 pills of 500mg) by mouth 1 hour prior to the procedure.
- If you have a true penicillin allergy: Clindamycin 600mg (2 pills of 300mg) 1 hour prior to the procedure.
Routine Orthopaedic Follow-Up
After your initial follow-up after surgery, you will have routine follow-up every 5 years to ensure that your joint replacement continues to function properly. X-rays will be taken to monitor the parts for any wear or loosing. If you experience a new onset of pain or swelling in the joint associated with fevers, please make an appointment as soon as possible with Dr. Noble.
Sports and Walking after Joint Replacement
You should avoid repetitive high impact activities such as recreational running. You can walk as much as tolerated and participate in sports like tennis, pickleball, golf, hiking, biking, skiing and working out at the gym.