Preparing for Surgery & Procedure

Congratulations!

If you are on this page, you have already made one of the most important decisions in your life- picking your surgeon! I say decision in your “life” because I consider getting a hip replacement or knee replacement surgery a partnership for life. You can divorce your husband or wife, you cannot divorce the artificial implant in you! Picking a surgeon for the procedure is the most important and yet the most difficult decision a patient makes.

How about my referral source? My primary care physician?

The decision to pick your surgeon should be independent of who referred you to your surgeon. You may be referred by your primary care provider who belongs to a certain healthcare institution who has no option but to refer you inside the same “health system” irrespective of the competencies of the surgeon (who is another employed physician in the system). The referring physician maybe part of an IPA (Independent Physician Association) and there are monitory incentives to refer in the same “network”. These monitory incentives are legal and is called “profit sharing’.

How about I look at the hospital ratings?

Hospital ratings are based on numerous factors like receipts of grants for research, papers produced by surgeons in the hospital etc – items that are not necessarily related to patient care. I personally know bad surgeons that exist at top rated hospitals. Does your surgeon have enough assistance in the operating room? I know hospitals that are understaffed and surgeons are told they got to work with as much assistance as they get. Surgeons cannot demand the assistance that they want. The hospital ratings are based on paperwork that’s submitted to ranking companies and hospitals get ranked on how the papers are submitted. There are trainees operating on the patients.  Physician assistants or physician extenders are used for postoperative visits.  Hospital ratings not help much in surgeon selection.

Well, my insurance company will help me find the right surgeon.

Yes! Right! The ONLY item your insurance company will look at is the cost of care. Who is a cheap surgeon? Which hospital is cheap? They will try to direct you strictly to surgeons and hospitals “in network”. They care about their expense for that fiscal year. The “partnership for life” concept just does not exist.

Why can I not look up surgeon ratings websites?

Surgeon ratings websites rank some physicians higher than others based on how physicians pay them. Even government websites are not reliable because the metrics are not uniform for comparing “apples to apples” because not all patients are the same.  Eg- If you compare a surgeon who treats primarily younger patients with minimal comorbidities, this surgeons length of stay will be shorter than someone treating older patients with significant comorbidities. It’s just not a level field!

How about I look up online reviews?

If you are looking to have lunch, there is not much to loose! Choosing a hip replacement and knee replacement surgeon requires more than this! You cannot be cavalier about choosing someone operating on you! Competitors of physicians have placed negative reviews about their colleagues. Additionally, one unhappy person has been known to place several negative reviews on a physician.

How about asking personnel working in the operating room?

That’s a good choice! Staff working in the operating room can comment on the surgical skills of the surgeon.  However, operating room personnel don’t have access to the entire spectrum of armamentarium needed for successful outcome. They do not know if the surgeon is forced by the hospital to use a particular implant which may not be the best choice for the patient. Staff does not know if the hospital directs patients to a certain physical therapist who may or may not be good. The post-operative care is equally important in ensuring optimal outcome!

Again -Congratulations! If you are preparing for surgery, you hopefully you are beyond the stage of picking your surgeon.

Preparing for Replacement Surgery

During the office visit, I discuss the risks, benefits ad alternatives with my patient. On this webpage, I will let you in on a little secret – I am picking my patients too. I ask – is this person someone whom I want a lifelong relation with? Once the decision is made to have surgery, my surgical scheduler guides the patient regarding the subsequent steps for the procedure. I tell my patients that “the world should revolve around you” when they have surgery.

Hip replacement and knee replacement surgery is elective surgery. The patient should pick a good time in their life and then decide what time they want to undergo the surgery. Winter, spring, summer, fall are all good! No season is associated with better or poor outcomes.

A personalized treatment plan is made for every patient. Remember that the rehabilitation is different for hip replacement and knee replacement surgery. While patients recover faster from hip replacement surgery than knee replacement surgery, there are certain predictors of outcome like body mass index, medical comorbidities etc.

What should you expect the day of surgery? What do you expect the day after? Do you do home or to rehabilitation? How do you prepare yourself mentally and physically for surgery? Patient should not undergo surgery if there are any answered questions or concerns.

Working with me and my team

Once surgery is scheduled, my surgical scheduler works with the patient at every step. The action really starts four weeks before the surgery. Why 4 weeks? – Its beause we need fresh investigations. While surgery maybe scheduled months before our medical conditions may change.

I don’t look at the cardiovascular status- someone else does. This someone maybe your primary care provider or maybe the hospital medicine doctor – depending on the hospital. All I need is Xrays of the body part, a CT scan if I am doing a custom knee or a robotic hip and some routine blood work to look at the hemoglobin status and bleeding profile.

I advise discontinuation of certain medications before surgery. Blood thinners should be discontinued after discussion with your primary care provider. Hormone replacement therapy should be stopped to decrease the risk of post-operative blood clots.

There are options for replacing your own blood with your own blood (autologous blood donation). However, I do not do this anymore because this is not covered by insurance, if we don’t use it. its thrown away and more importantly today its rarely needed. We have excellent ways to minimize blood loss during surgery.

  • Weight loss before surgery will help in decreasing risk of complications. Remember – after surgery, I recommend excellent nutrition for healing.
  • I advise no pain medications before surgery. Anti-inflammatory medications including aspirin, ibuprofen should be stopped one week before surgery.
  • Stop smoking before surgery. I know – surgery is a stressful situation but smoking increases risks associated with surgery.
  • Get dental clearance. Infection in the teeth may travel to your joints and cause havoc!
  • I also advise getting urine tests to ensure there is no infection.
  • Your diet should be well balanced. If your hemoglobin is low, take iron pills.

Remember – “the world should revolve around you” when you have surgery. Arrange for help with shopping, laundry and other assistance required at home.

Make a list of items you use the most. Keep these items within easy reach.

No falling after surgery! Tape down electric cords. No loose curled up carpet edges. Use walker till you are comfortable walking with a cane. Use cane till you are comfortable walking without assistance. Use a firm seat with to strong arms.

After Your Surgery

I like my patients to walk the same day as surgery. I want patients to place as much weight as possible on the operated extremity.

Do NOT stand up and try to walk on your own! Get assistance. There is plenty available in the hospital. It does not have to be the physical therapist only. Nurses and nursing aides will help you.

You will need help driving to your home. Be careful of “hip dislocation precautions’ when entering and leaving your vehicle.

Take pain meds before leaving the hospital. If you are going to a rehabilitation facility, you may not get your medications for a while. Yes – most rehabilitation facilities are slow! Stay ahead of your pain.

Use ice fomentation as needed on your extremity. It wil hlp with the pain. We want to keep the pain 2 to 3 on a scale of 1 to 10.

Don’t eat or drink too much fluids right before you get into your vehicle to go home. Anesthetic agents may make you nauseous.

After your surgery don’t drive straight to the Chinese buffet! Begin with sips of water and then go to a light meal. Progress after you are able to keep food in.

I have a protocol for my post-operative hip and knee replacement patients that includes-

We call patients consistently after surgery to check on them.

There is a direct line of communication with the surgical scheduler, so patients don’t have to call the main number after the surgery.

We expedite any authorizations that maybe needed by your insurance company (for devices, physical therapy, splints etc.)

In one of the post-operative phone calls, my office will give you post-operative appointment and will mail you a script for x-rays that will be required for the appointment.

We don’t use any physician assistance for postoperative visits.  The surgeon is available for all postoperative visits.

Post-operative hip and knee replacement surgery patients have access to cell phone. Patients can text us. They have direct land phone access (without involving extension etc). Patients have e-mail access.

As part of quality improvement, I tell my staff that I feel it’s a failure of my system if the patient has to call my office for anything. If a patient does call our office, we attempt to get back to them as soon as possible- it maybe for a medication refill or to answer to any question/concern.

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