THE
OPERATION
The surgical procedure is
scheduled the day before surgery by the operating room staff in consultation
with the surgeon and the anesthesiologist. There will usually be from four to
six operations performed in each room each day. This happens in each of the many
operating rooms in the hospital. Patients are scheduled in every room based on
the age and general health of each patient, the type and complexity of the
operation and the equipment needed for the procedure. The first operation begins
at 7:30 A.M. and subsequent operations follow as soon as possible. Dr. Bertin
can usually estimate how long each operation will take and when each operation
will start, but this is just an educated guess. It is important for each patient
to know that all the time necessary will be devoted to his operation. Sometimes
situations arise which take more time than anticipated. If you find yourself
waiting, please understand and be patient.
Orthopedic surgical procedures are similar to other operations in some respects and different in others. Like all major surgeries, an anesthesiologist will start an IV (intravenous for fluid administration) and monitor your vital signs. Usually either a general or spinal anesthetic will be administered. Both are acceptable to Dr. Bertin, and the choice as to which is used depends on you, the patient, and the anesthesiologist.
Your anesthesiologist will
discuss the options of general or spinal anesthesia after becoming familiar with
your specific medical history. This information sheet will hopefully help you
decide which way is best for you. With a general anesthetic, the parts of the
brain that perceive pain are temporarily shut down.
The patient is unconscious. Sodium
Pentothal, injected through an intravenous tube, is often used to start the
process and induce sleep. Additional
medications are then given to maintain the induced state of sleep, provide pain
relief and cause muscle relaxation. A
breathing tube is usually inserted into the windpipe to protect the airway and
maintain breathing. Nausea and
vomiting are a common side effect and usually don’t last very long.
Recently, we have been doing
most of the hip and knee replacements under spinal anesthesia.
There are potential advantages with “spinals” which have recently
increased their popularity. Studies show that regional anesthesia (spinal) for
total hip replacement results in less blood loss and a lower incidence of deep
venous thrombosis and pulmonary embolism (blood clots in the legs and lungs).
A spinal is administered by numbing the skin on your back and injecting a
small amount of local anesthetic into the fluid surrounding the nerves in the
spinal canal. This results in you being numb from the waist down. You will not
feel the surgical procedure at all. Most
patients like to sleep through the operation and it is standard for the
anesthesiologist to administer some sedation medication to facilitate this
sleep. Thus you will not hear anything nor will you remember what happens in the
operating room. Spinals, as they
are done today, are much safer than in the past.
While any anesthetic or surgical procedure has its risks, a spinal is as
safe as a general anesthetic. Spinals
do rarely cause headaches due to leakage of spinal fluid from the injection
site, but this can be treated effectively.
Of our patients who have
previously had both a general and a spinal,
virtually all have said they preferred the spinal.
They like being more alert after the operation and appreciate the more
gradual onset of pain as the spinal slowly wears off. Spinal anesthesia is a very attractive option that you should
consider when the anesthesiologist discusses your specific case with you.
Indeed, we will tentatively be planning on this for your surgery.
You can reduce your risk for
anesthetic complications by taking some steps now. Avoid non-prescription drugs
and alcohol. Stop smoking for as
long as possible before your surgery and after.
This would be a great time to stop smoking for the rest of your
life.
Three procedures are unique in
total joint replacement to help prevent infection. First
is the use of "prophylactic antibiotics." These antibiotics are
given immediately before and for three to six doses after surgery to prevent
infection. This has proven very effective and cuts the infection rate almost in
half. The second thing which is
different in joint replacement surgery is a very special ventilation system in
the operating room. This is called "laminar air flow." Certain
orthopedic operating rooms are constructed with this expensive air-filtering
device. It removes all particles from
the air, notably bacteria, and then through a sieve‑like wall delivery
system, blows this sterile air across the surgical field. The air is picked up
by air return ducts and taken back to the filter. This system of air delivery
has additionally reduced the infection rate by half in patients who have a total
joint replaced. Third,
special
sterile drapes isolate the surgical site, and special sterile gowns are worn
during the operation. These are made of impermeable plastic and paper which
limit any contamination which might cause an infection. Special head covers
are also worn to enclose all hair in addition to the traditional hats and masks.
At
the completion of your operation, a sterile dressing is applied to the incision.
Special drains are placed in the incision and taped to the dressing. These
drains fill an important function. They allow for any small amount of bleeding
which may occur at the end of the operation to drain out of the joint area. This
decreases swelling which might occur after surgery and accelerates recovery from
the operation. Allowing this drainage to occur also decreases any hematoma
(blood clot) formation, which helps minimize the chance for infection. The blood
which is removed from the incision can often be given back to the patient
through a special filter system. This decreases the need for a transfusion, the
drainage is measured regularly by the nurses, and then the drains are removed on
the first or second day after surgery.
The surgical dressing is removed on the third or fourth day following surgery. The wound is usually sealed by this time although it is not unusual to have a small amount of drainage for a few days. If this occurs, the nurses will keep a dry dressing over the incision. The incision is closed with a synthetic absorbable suture which dissolves. Therefore, sutures do not need to be removed. The small strips of tape which cover the incision serve as a protective dressing. They are called Steri-Strips and help keep the skin edges together to minimize the scar. They also keep the incision from being irritated. They will start to loosen after a week or two and can be removed as soon as they are loose enough not to pull extensively on the incision.
DISCHARGE FROM THE HOSPITAL
Financial Concerns
In most situations, the hospital will simply bill you and/or your insurance company for your treatment in the hospital. They usually do not require any substantial payment before you can be discharged if your deductible has been paid. The discharge instructions can be picked up from the ward clerk on the day you leave. They are very brief and only take a few minutes to complete. If you have any questions about your hospital bill or anything concerning your stay in the hospital, please call and talk to Dr. Bertin or one of his office staff.
The surgical fee for your operation will be handled in much the same way. Dr. Bertin will mail these bills to the insurance companies and to you. If you have any questions, please call the office. If you have difficulty paying the bill or feel it is too high, please talk this over personally with Dr. Bertin. He has no intention of placing undue financial pressures on anyone. That is one reason why he is a participating physician with Medicare.
Medications
You will be given the following medications on discharge from the hospital. You can get them at the hospital pharmacy or any pharmacy of your choice.
1. Pain pills. These are to be taken only as needed. After a few days you will probably need them only prior to exercise periods or before sleeping. Within a few more days, you will find that Tylenol will be adequate for your discomfort.
2. Coumadin. This is the blood thinner you have been taking in the hospital. It is important for you to continue taking this medication only if it is specifically prescribed. The correct dose is written on the bottle, and these instructions should be followed to the letter. When the bottle is empty, you do not need to continue taking the medication. We will check your blood test weekly to determine how thin your blood is and adjust the medication as needed.
3. Iron. Due to the blood loss associated with your operation, your blood count (hematocrit) is probably a little low. To help your body rapidly replenish this blood, you should take either ferrous sulfate or ferrous gluconate, 300 mg., two or three times a day for the next three to four weeks. This can be purchased without a prescription.
4. Vitamins. It is recommended that you take a good multiple vitamin daily for the next month for the same reason that iron is being taken. It provides an extra supply of needed nutrients to speed recovery. No prescription is given for this since most people have some or can easily purchase a bottle.
5. Other medications. On returning home, you should resume all the medications you took before coming to the hospital. The only exceptions would be any which Dr. Bertin recommended you stop taking, and arthritis medication which should not be taken for at least six weeks. If no other recommendation was made, you should resume all previous medications.
Transportation
Arrange to have the ride home as comfortable as possible. A large car with a roomy seat would be fine. Some very high or very small cars are difficult to enter and exit. Avoid them. A nurse will help you get into the car and load your belongings. It would be advisable to have two people available when you arrive home to help you get out of the car and get into the house.
Skilled Nursing Facilities
After having a major joint replaced, it is impossible for some people to immediately return home, especially if they have to care for themselves. Rehabilitation centers, extended care facilities, transitional care centers, and nursing homes help fill this intermediate need extremely well. They provide a place for continued recuperation after discharge from the hospital. The stay is not as expensive as the hospital, and Medicare or other health insurance may help pay for it. This provides continued daily physical therapy and nursing care. As patients get stronger and become more independent, their rehabilitation is progressed. When an individual is ready and able to go home, he can then be discharged.
