The Basics

What is hip replacement?

Hip replacement involves the removal of the damaged and worn cartilage and bone and replacement of the joint with metal and plastic. Restoring proper leg lengths and removal of bone spurs (osteophytes) is also performed.

What can I do pre-op to get ready and make recovery easier?

•  Stay active and strong
• Minimize pain medicine
• Weight optimization: Maintain a healthy weight or lose excess weight
• Eat healthy food
• Manage all medical problems:
  • Blood sugar
  • Blood pressure
  • Take medications regularly and as prescribed

What should I avoid?

Stress and anxiety

What do I need to prepare for my recovery?

• Walker (front wheel adjustable walker)
• Cane (adjustable or correct height for you)
• Solid railing on stairs
• Ice pack (frozen peas, ice, gel pack)
• Consider bathroom shower chair, pull bar installation

Who will be taking care of me?

Who are resident physicians? Why should I let them be involved in my care?

Resident physician who work with our team are college and medical school graduates who have succeeded at gaining entrance into our orthopaedic surgery training program. Orthopaedics is frequently one of the most competitive medical subspecialties to get into, and thus orthopaedic surgery residents were at the top of their medical school classes. They are physicians with several years of experience. They assist with your care to your benefit and theirs, and our team is in control of all protocols, decisions and the entire surgical procedure. If you have specific questions or concerns about this, please let us know.

How do I know if I need to go to a skilled nursing rehab facility after surgery?

If you live alone and have no one available to come and care for you, then a rehab stay is recommended. Details of this all depend on your recovery and insurance benefits. Caseworkers at the hospital will be available to arrange this after surgery. Having several facilities in mind and visiting them before surgery is very helpful for this process, though availability and insurance coverage will determine the final plan.

How much help will I need when I get home?

You will need to be home with a family member, friend or caregiver who is going to be available and helpful most of the days and nights. For the first few nights home, having someone around 24 hours a day is best.

Will I be able to climb stairs?

Yes, you will be taught how in the hospital.

When will I be able to drive?

Most patients resume driving about one month from surgery. Right hips are slower than left hips to heal. Before you drive you should be:

• Walking well with cane
• Weaned off pain medication
• Have good control of the leg

Wound care

When can I remove my bandages?

Leave PICO dressing intact until battery begins to alarm or you reach post operative day seven, then remove. You can leave wound open to air or cover as you desire. You may shower immediately. Do not expose battery pack to direct water stream.

Should I put Neosporin or vitamin E on my wound?

Please do not put any ointments on your wound until given the all-clear in clinic. Ointments such as Neosporin can be irritating to healing skin if used regularly. Skin will naturally heal and touching it repeatedly exposes the wound to infection.

How painful is hip replacement?

There is significant pain involved in hip replacement. You may feel worse before you feel better. The best candidates for hip replacements are patients who have severe arthritis but who have coped well and maintained their activity levels in spite of discomfort.

Much of the early pre- and postoperative care is directed toward controlling postoperative pain. Regional anesthesia procedures such as spinal anesthesia are encouraged to minimize early pain. Oral narcotic (opioid) and non-narcotic pain medications are used. Intravenous (IV) pain medication is also available. In addition to pain medications, ice and elevation are used for comfort.

What if I hate taking pain medications?

Typically some amount of pain medication is necessary to get people moving around after hip replacement. Pain medications have several common adverse reactions, such as nausea, itching, confusion and even delirium. Also, constipation and sleep disruption can occur. Some side effects can be treated; others are more difficult to control. Several different oral and IV pain medications exist, and patients respond differently to pain medications. Please inform us if you have had a previous reaction to a pain medication. While adverse reactions to pain medications are problematic, they rarely represent true allergies.

How long will I need pain medications?

Every patient is unique. A typical patient who did not take pain medications before surgery is able to wean off of all narcotic medication in the first month after surgery.

Patients who were taking oral narcotic pain medications prior to surgery may take longer to wean off of pain medications. Patients who take narcotics for some other reason may not wean off at all. The goal is to get you back to at-or-below pain medication doses by six weeks post-operatively. At that point you will be transitioned back to the prescriber who was providing your chronic pain medication prior to surgery.

How do I wean off pain medications?

Weaning off of medications is a natural process. Pain medications are “as-needed” or “PRN” medications. They are to be taken when needed, not on a rigid schedule. If you are sleeping, you should not set an alarm to awaken you to take more pain medications. They should only be taken when you are awake and feeling discomfort. Sleeping is a sign of appropriate pain control. You will notice in the early days after surgery that if you rest, ice and elevate your hip that you will take less pain medication. If you stand or walk for long periods, you will need more. As time passes, pain from surgery naturally goes away. As this happens, you decrease the dose and frequency with which you take medications. For example, if you are taking three pain pills about every four hours when you are discharged from the hospital, you will likely be able to decrease to pain pills every five or six hours within the first week after surgery. Keep track of how many pain pills you take every day, and slowly decrease the number of pills per day over time.

We may be able to switch you to a more mild pain medication than the one you left the hospital with. We will discuss this with you at your follow up appointments.

How do I get refills on pain medications?

Please plan ahead. We provide you a reasonable estimate of the quantity of pills you will need until your first follow up appointment. If you are running low and do not have an appointment, please call our office and request a refill when you still have at least two or three days of medications left. Narcotics are controlled substances and all but the mildest narcotics require a physical paper prescription to have them filled. We cannot phone in most pain medication prescriptions or refills. You will need to arrange to have the prescription picked up or it will be mailed to you. Every pain medication refill request will be answered with weaning encouragement and instruction.

Extremely large quantities of pain medications are not safe to prescribe, and each prescriber must use his or her judgment as to an appropriate quantity of pain medication that can be prescribed at one time.

Why am I on a blood thinner?

Thinning blood, or anticoagulation, after hip or knee surgeries is routine and recommended by several national guidelines. It is done to prevent blood clots from forming. Blood clots, or deep venous thromboses, form in the legs and can cause pain and swelling. If the clot mobilizes, it travels through the heart and into the lungs. This is called a pulmonary embolism, or PE, and can be life threatening.

Blood clots are common after hip and knee replacement surgeries if we do nothing to prevent them. Our team follow national guidelines and do several things to prevent blood clots:

1. Early mobilization after surgery
2. Sequential compression devices (SCDs) on legs in the hospital
3. Anticoagulation

Xarelto, or rivaroxaban, is one of several choices of anticoagulating medicine. It has the advantage that it is a pill that does not require blood monitoring. Other anticoagulants are low molecular weight heparins (Lovenox, Fragmin), Coumadin (Warfarin), or aspirin.

In addition to the three preventive measures above, we ask if you have a personal or familial history of blood clots or clotting disorders. We may ask that you temporarily stop taking hormone replacement therapy. Blood clot prevention is one of many reasons we require patients to quit smoking before surgery, as nicotine increases the risk of blood clots.

Like many aspects of medicine and surgery, anticoagulation has benefits and risks. We carefully monitor for signs of hematoma or other bleeding while patients are on an anticoagulant.

When will I start physical therapy?

Some people start physical therapy before surgery. All patients start physical therapy the day of or morning after surgery while in the hospital.

Once you are home, you should do your exercises from the hospital and work on walking, but no formal outpatient therapy is initiated until six weeks post-op. This delay in therapy is so your hip capsule can heal and to allow bony ingrowth into your prostheses.

What are therapy goals?

Walking with a cane in two weeks and without any assistance at six weeks. It is important that you can walk with no limp. The criteria for changing from a walker or crutches to a cane, then nothing is that you do not limp.

Will my leg be longer?

Yes, very slightly. Your hip is strongest and most stable if the hip is restored to its original position. As your cartilage wears out, the hip loses height. We restore that height. Restoring your natural leg length during hip replacement helps prevent hip dislocations, a major complication. We use pre-operative digital (computerized) templates to create a road-map for your surgery and measure your leg length several ways in surgery to assure appropriate leg length. The differences we are talking about are less than a centimeter, approximately 1/4 inch.

After surgery, your spine and pelvis have to adjust to a new leg length. It is common for people to feel excessively long at first. We verify leg length with X-ray and can reassure you that it is not “inches too long.” We encourage you to walk and use your leg and over time, as most people adjust and by 12 weeks after surgery the leg length feels appropriate.

Why is my motion limited after surgery?

“Hip precautions” are recommended after all hip replacements. The specific details of your precautions depend on the surgical approach you have. Regardless of surgical approach, your hip capsule is incised to perform the hip replacement, and the restricted motion early after surgery promotes healing of the capsule and promotes hip stability.

What is a knee replacement (arthroplasty)?

Knee replacement involves the removal of your damaged and worn cartilage and bone and replacement of your joint with metal and plastic. Joint realignment and ligament balancing are also performed.

What can I do pre-op to get ready and make recovery easier?

• Stay active and strong
• Minimize pain medicine
• Eat healthy food
• Maintain a healthy weight or lose excess weight
• Manage any existing medical issues:
  • Blood sugar
  • Blood pressure
  • Take medications regularly and as prescribed

What should I avoid?

Stress and anxiety

What do I need to prepare for my recovery?

• Walker (front wheel adjustable walker)
• Cane (adjustable or correct height for you)
• Solid railing on stairs
• Ice pack (frozen peas, ice, gel pack)
• Consider a bathroom shower chair, and/or pull bar installation

How much help will I need?

You will need to be home with a family member, friend or caregiver who is going to be available and helpful most of the days and nights. For the first few nights home, having someone around 24 hours a day is best.

When will I be able to drive?

Most patients resume driving about one month after surgery, providing you are:

• Walking well with cane
• Weaned off pain medication
• In good control of your leg

Will I be able to climb stairs?

Yes, you will be taught how in the hospital. “Up with good, down with bad.” Lead with your good, non-operative leg going up the stairs, and lead with your sore operative leg going down. Work toward using both legs symmetrically.

How do I know if I need to go to a skilled nursing rehab facility after surgery?

If you live alone and have no one available to come and care for you, then a rehab stay may be recommended. Details of this all depend on your early recovery and insurance benefits. Case workers at the hospital will be available to arrange this after surgery. Having several facilities in mind and visiting them before surgery is very helpful for this process, though availability and insurance coverage will determine the final plan.

Who will be taking care of me?

Before surgery, the care team is comprised of your surgeon, physician’s associates, nurses and resident physicians. Our schedulers will assist with arranging your surgery and all pre- and post-operative visits.

After surgery, the surgeon and resident physicians will coordinate your care. Also, we are fortunate to have a dedicated and experienced orthopaedic nurse practitioner on the inpatient ward to assist with your care and discharge planning. A nurse will be assigned to you every shift, along with a nurse’s aide. A team of dedicated orthopaedic physical therapists will evaluate and work with you daily, typically twice a day. An occupational therapist may evaluate you as well. A nurse case manager will be available to assist with any discharge planning needs, such as arranging additional rehab as needed. Our team is a consistent and dedicated team on our orthopaedic specialty ward. This ward was specifically designed to optimize your comfort and recovery and is equipped with a physical therapy gym, complete with a car simulator to facilitate your transition home

Who are resident physicians? Why should I let them be involved in my care?

Resident physicians who work with our team are college and medical school graduates and are part of our orthopaedic surgery training program. Orthopaedics is frequently one of the most competitive medical subspecialties to get into, and thus orthopaedic surgery residents were at the top of their medical school classes. They are all physicians with several years of experience. They assist with your care to your benefit and theirs, and our team in control of all protocols, decisions and the entire surgical procedure. If you have specific questions or concerns about this, please let us know.

How painful is knee replacement?

There is significant pain involved in knee replacement. You may feel worse before you feel better. The best candidates for knee replacements are patients who have severe arthritis but who have coped well and maintained their activity levels in spite of discomfort.

Much of the early pre- and post- operative care is directed toward controlling post-operative pain. Regional anesthesia procedures such as femoral and sciatic nerve blocks, nerve catheters, and spinal anesthesia are encouraged to minimize early pain. Oral narcotic (opioid) and non-narcotic pain medications are used. Intravenous (IV) pain medication is also available. In addition to pain medications, ice and elevation are used for comfort.

What if I hate taking pain medications?

Typically some degree of pain medication is necessary to get people mobilized after knee replacement. Without adequate pain control and mobility, you cannot participate fully in physical therapy exercises that are crucial for successful results. Pain medications have several common adverse reactions, such as nausea, itching, confusion and even delirium. Also, constipation and sleep disruption can occur. Some side effects can be treated; others are more difficult to control. Several different oral and IV pain medications exist, and patients respond differently to pain medications. Please inform us if you have had a previous reaction to a pain medication. While adverse reactions to pain medications are problematic, they rarely represent true allergies.

How long will I need pain medications?

Every patient is unique. A typical patient who did not take pain medications before surgery is able to wean off of all narcotic medication in the first month after surgery.

Patients who were taking oral narcotic pain medications prior to surgery may take longer to wean off of pain medications. Patients who take narcotics for some other reason may not wean off at all. The goal is to get you back to at-or-below pain medication doses by six weeks post-operatively. At that point you will be transitioned back to the prescriber who was providing your chronic pain medication prior to surgery.

How do I wean off pain medications?

Weaning off of medications is a natural process. Pain medications are “as needed” or “prn” medications. They are to be taken when needed, not on a rigid schedule. If you are sleeping, you should not set an alarm to awaken you to take more pain medications. They should only be taken when you are awake and feeling discomfort. Sleeping is a sign of appropriate pain control. You will notice in the early days after surgery that if you rest, ice and elevate your knee, you will take less pain medication. If you stand or walk for long periods, you will need more. As time passes, pain from surgery naturally abates. As this happens, you decrease the dose and frequency with which you take medications. For example, if you are taking three pain pills about every four hours when you are discharged from the hospital, you will likely be able to decrease to pain pills every five to six hours within the first week after surgery. Keep track of how many pain pills you take every day, and slowly decrease the number of pills per day over time.

We may be able to switch you to a more mild pain medication than the one you left the hospital with. We will discuss this with you at your follow-up appointments.

How do I get refills on pain medications?

Please plan ahead. We provide you a reasonable estimate of the quantity of pills you will need until your first follow-up appointment. If you are running low and do not have an appointment, please call our office and request a refill when you still have at least two or three days of medications left. Narcotics are controlled substances and all but the mildest narcotics require a physical paper prescription to have them filled. We cannot phone in most pain medication prescriptions or refills. You will need to arrange to have the prescription picked up or it will be mailed to you. Every pain medication refill request will be answered with weaning encouragement and instruction.

Extremely large quantities of pain medications are not safe to prescribe, and each prescriber must use his or her judgment as to an appropriate quantity of pain medication that can be prescribed at one time.

When will I start physical therapy?

Some people start physical therapy before surgery. All patients start physical therapy the day of, or morning after surgery. A continuous passive motion machine, or CPM, is used to control swelling and initiate motion. Therapists will teach in-bed stretching and strengthening exercises. Therapists will also assist you with standing and walking. You will be taught to walk with a walker and how to maneuver stairs.

Why is therapy so important?

The success of knee replacement is dependent on correct surgical implantation (our job) and early achievement of motion and strengthening (your job). Both are absolutely necessary for a successful outcome. Pain control, swelling control and dedication to achieving early motion with daily exercises are the keys to success.

What are therapy goals?

By two weeks:

• Full active knee extension, straightening, against gravity
• Knee flexion, bending, to at least 90 degrees

By four weeks:

• Minimal swelling
• Heel-toe gait with cane only or no device
• Wean pain medication to low dose, occasional use

What are the best exercises to achieve these goals?

• Ice and elevation to control swelling and pain
• Successful pain medication regimen that enables you to move and perform therapy, but does not make you goofy, sleepy or feel over-sedated
• Keeping knee straight while in bed or in a chair by resting your heel on a rolled towel, armrest, footstool or coffee table
• Actively straightening knee in this position by tightening quadriceps muscle and pushing the back of the knee to the floor
• Sitting in a hard chair and bending knee, using non-operative leg to assist with bending
• Meeting with your therapist for active and passive stretching, strengthening and gait training exercises

How do I elevate my knee?

Helpful post-operative elevation requires that the knee is above the level of the heart. This requires that you are lying down completely and elevating your leg on multiple pillows or cushions

When can I remove my bandages?

Leave PICO dressing intact until battery begins to alarm or you reach post operative day seven, then remove. You can leave wound open to air or cover as you desire. You may shower immediately. Do not expose battery pack to direct water stream.

Why am I on a blood thinner?

Thinning blood, or anticoagulation, after hip or knee surgeries is routine and recommended by several national guidelines. It is done to prevent blood clots from forming. Blood clots, or deep venous thromboses, form in the legs and can cause pain and swelling. If the clot mobilizes, it travels through the heart and into the lungs. This is called a pulmonary embolism, or PE, and can be life-threatening.

Blood clots are common after hip and knee replacement surgeries if we do nothing to prevent them. Our team follows national guidelines and does several things to prevent blood clots:

• Early mobilization after surgery
• Anticoagulation
• Sequential compression devices (SCDs) on legs in the hospital

Xarelto, or rivaroxaban, is one of several choices of anticoagulating medicine. It has the advantage that it is a pill that does not require blood monitoring. Other anticoagulants are low molecular weight heparins (Lovenox, Fragmin), Coumadin (Warfarin) or aspirin.

In addition to the three preventive measures above, we ask if you have a personal or familial history of blood clots or clotting disorders. We may ask that you temporarily stop taking hormone replacement therapy. Blood clot prevention is one of many reasons our team requires patients to quit smoking before surgery, as nicotine increases the risk of blood clots.

Like many aspects of medicine and surgery, anticoagulation has benefits and risks. We carefully monitor for signs of hematoma or other bleeding while patients are on an anticoagulant.

View and download the patient guide

Total hip and knee arthroplasty surgery patient preparation and recovery guidelines

Pautas de preparación y recuperación para pacientes de cirugía de artroplastia total de cadera y rodilla (Spanish language version of guidelines)

View and download the patient guide

Total shoulder arthroplasty surgery patient preparation and recovery guidelines

Pautas de preparación y recuperación para pacientes de cirugía de artroplastia total de hombro (Spanish language version of guidelines)

View and download a guide on how to take care of yourself after your surgery

Click on the link for your type of surgery for important information on what to expect after surgery and how to care for yourself while you recover.

Total knee arthroplasty

Total knee arthroplasty with Prevena

Total hip arthroplasty posterior approach

Total hip arthroplasty posterior approach with Prevena

Total hip arthroplasty anterior approach

Total hip arthroplasty anterior approach with Prevena

The goal of rehabilitation is to increase your strength and endurance so you can achieve your activity goals. These are general guidelines and may not completely apply to your situation. When in doubt, please clarify any questions with your therapist and/or physician.

Timeline

Surgery

• 1-3 days in the hospital

First 2 weeks

• Home exercise program
• Walking program

At 2 weeks

• Start 2nd part of exercise program
• Continue walking program

At 6 weeks

• If you are not meeting your activity goals, outpatient physical therapy may begin

Before surgery

*Your responses will help us with working with you to prepare for your return home

In the hospital –beginning the day of surgery

To regain your strength and energy, it is important to get up to the chair for your meals and to take 1-2 walks in the hall every day you are in the hospital.

A physical therapist will work with you to gain independence with getting out of bed and chairs, walking, and climbing stairs.

An occupational therapist will work with you to gain independence in dressing, showering and toileting. They will help you determine what additional equipment you may need at home. See next page.

Initially you will need an assistive device (walker, crutches) to walk. If you have one already, bring it to the hospital to use, otherwise you will be provided one.

Primary focus after surgery

Progressive Walking Program

It is important to walk! Walking helps to increase blood flow, flexibility, muscle strength, balance and endurance. Below is a general walking program progression, which may be adapted based on your specific needs.

Initially, make sure your walking path is safe and manageable. It is important as your recover to challenge yourself, but please progress safely and with input from your outpatient physical therapist.

The goal of rehabilitation is to increase your strength and endurance so you can achieve your activity goals. These are general guidelines and may not completely apply to your situation. When in doubt, please clarify any questions with your therapist and/or physician.

Timeline

• Surgery
  • 2-3 days in the hospital
• — First 7-10 days after hospital stay
  • Home exercise program
  • Walking program
  • Initiate outpatient physical therapy
• After 7-10 days – 12 weeks
  • Continue outpatient physical therapy
  • New home exercise program from outpatient physical therapist—see attached protocol

Before surgery

Think about:

• The family/friends who will be available to help you once you leave the hospital
• How far you need to walk to get to your house and around your house
• How many stairs you need to climb
• Any obstacles you are worried about navigating at home

*Your responses will help us with working with you to prepare for your return home

In the hospital – beginning the day of surgery

To regain your strength and energy, it is important to get up to the chair for your meals and to take 1-2 walks in the hall every day you are in the hospital.

A physical therapist will work with you to gain independence with getting out of bed and chairs, walking, and climbing stairs.

An occupational therapist will work with you to gain independence in dressing, showering and toileting. They will help you determine what additional equipment you may need at home. See next page.

Initially you will need an assistive device (walker, crutches) to walk. If you have one already, bring it to the hospital to use, otherwise you will be provided one.

Primary focus after surgery

• Get the knee straight—the most important within the 1st 2 weeks
  • No pillow under knee in bed
  • Heel prop—see home exercise program
• Control swelling
  • Ice
  • Important for reducing swelling and can also assist with pain management
  • 15-20 minutes, 3-5 times a day
• Elevation
  • Ankle above knee and knee above hip, make sure the knee is straight
• Bend the knee
• Quad muscle activation

Progressive Walking Program

It is important to walk! Walking helps to increase blood flow, flexibility, muscle strength, balance and endurance. Below is a general walking program progression, which may be adapted based on your specific needs.

Initially, make sure your walking path is safe and manageable. It is important as your recover to challenge yourself, but please progress safely and with input from your outpatient physical therapist.

How does PatientIQ work?

PatientIQ will contact you through email and/or text message to:

• Ask you questions about your health
• Ask you questions about how your visit went
• Send you educational videos or care instructions

While the emails or text messages come from PatientIQ, the questions being asked are from your healthcare team at OHSU. It is very important to answer the questions so we can provide you with the best care possible.

How long will it take to answer questions?

Just a few minutes. We know you are busy, so we will ask only the most important questions.

How often will I be contacted?

Because your health can change, it’s important to stay connected and make sure everything is going well. Your Total Joint health team will have PatientIQ reach out to you at key times during your recovery. You will only be contacted when it’s necessary.

Will my answers be kept private?

Your responses are kept completely secure and will only be seen by your doctor and health care team.