Joint Preservation, Resurfacing and Reconstruction ...

Joint Preservation, Resurfacing and ReconstructionOrthopaedicSurgery


CommunicationOur goal is to provide easy access to the team in order improve patient care.

Clinic: (972) 669-7179 Clinic Fax: (972) 669-7017 Physical Therapy: (972) 669-7189 PT Gym: (972) 669-7167

https://utswmed.org/doctors/joel-wells


Our MissionBuilding our legacy of excellence in orthopaedic surgery, finding cures and enhancing lives through patient care, research, innovation and education.


What Drives Us

Improve your quality of lifeHelp your joint painMinimize your post operative painMinimize post operative complicationsPrevent blood clotsProvide you with an exceptional health care experienceMaximize your recovery


The Team

Dr. Joel Wells

Nurses: (Jennifer) Lauren Yager

Dawn Kleckner

Athletic Trainers: Angie FradyAmber Bell

Dominique BrownMorgan Barnhart

X-ray Technologist: Ron Pipes

Surgery Scheduler: Alexis Coffman

Authorization Specialist: Tiphany Taylor

Physical Therapists: Lauren Bryan PT, DPT

Emily Middleton, PT, DPTJordan Hawkins, PT, DPT

Lauren Gass, PT, DPTJulie (JC) Chrisman, PT, DPT


Overview of Total Knee ReplacementThe knee joint is the hinge joint of the leg. It allows the leg to bend and straighten. It is made up of four bones: femur, tibia, patella, and the fibula.

During a total knee replacement surgery, the damaged part of your knee is removed and replaced.

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Overview of Total Hip ReplacementThe hip allows us to walk upright, keep our balance, and provides range of motion necessary for all tasks.

The goal of a hip-replacement is to restore quality of life, improve pain, and function.

Advances in technology have driven development of hip prostheses. Allowing longevity, better outcomes, and better satisfaction.

During a total hip replacement, the damaged part of the hip is removed and replaced, with components that are sized and chosen for you.

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ComplicationsSwelling/Bruising Swelling is common. You may or may not have bruising possibly from your groin to your toes. Pain not relieved by surgery Dislocation This is the number one complication with hip replacement surgery. Wound infection/joint infection You are given pre, intra, and post-operative antibiotics for prevention of infection. If warranted,

you may be sent home on oral antibiotics. Deep vein thrombosis (Blood Clot) The SCD’s combined with your prophylactic medication will significantly help to reduce this

risk. Failure of osseointegration – loosening of your hip replacementFracture Using your walker for the first 6 weeks after surgery will help to reduce this risk. Component wear Highly Crosslinked polyethylene currently- great profile with very good long-term results

Important to continue proper surveillance, follow up at 1 year, 2 years, 5 years, 10 years, 15 years, 20 years!


Scheduled visits before surgeryTwo visits with Dr. Wells prior to surgery – 1) initial visit and 2) pre-surgery consult We want you to know our team and know that we care and want to provide you the best outcome.

Pre-surgery Physical Therapy: One-time session where you will get a list of individualized exercises, go through your precautions, as well as learn proper gait mechanics from one of our licensed Physical Therapists. Do the best you can to get strong and keep moving for a better outcome. Try to be vigilant in the month before your surgery.

Pre-anesthesia phone call: You will get a phone call from pre-surgery testing. Medications will be reviewed as well as pre-surgery instructions. Please make sure your medication list is accurate, including the dosages. If your health is more complex, they may ask you to come to Zale, 2nd floor for an in person

appointment.

MUST SEE: Primary Care Physician (PCP) for surgical clearance (if no PCP must obtain one prior to surgery)

MUST SEE: Dentist for surgical clearance (if no Dentist must obtain one prior to surgery – we can refer you to one at UT Southwestern): poor dental hygiene is a modifiable risk factor for infection.

Case-by-case basis: may also need clearance from Cardiology/Rheumatology/Neurology/Infectious Disease/Geriatrics, etc. Our team will let you know if you need one of these.


Preparing for SurgeryPOSH: Perioperative Optimization of Senior Health

Provides comprehensive evaluation of older adults who are planning to undergo surgery. Designed to ensure surgery for our older patients is safe and that their recovery is smooth.Board certified physician-led; performs preoperative assessment to anticipate risks related to surgery, and then develops individualized plan to optimize health status during surgical period; ensures best possible outcomes.All patients 75 and olderPatients 70 and over with one or more of the following: Polypharmacy (greater than 5 medications) Suspected or known cognitive impairment At least 3 comorbid medical conditions Unintended weight loss of > 10 pounds in the past year


Preparing for Surgery

Hip or knee questionnaire research packet: This is to be filled out at your first visit and/or preoperative visit. This information is used to track your progress and for quality assurance.Durable Medical Equipment (DME): You will require a walker and sequential compression device (SCD’s) – VenaGo’s). You will be contacted by representative within a week prior to surgery. Please contact: Tyler and Hunter from Matrix Orthopedics: (214) 449-4480 if you

have not been called about the walker and VenaGo’s The DME company will deliver equipment to the hospital, on the day of your surgery. If

you have your own walker or VenaGo’s, bring them to the hospital You will need your own walker for PT. You will wear the VenaGo’s home from hospital, so do not send home early with

family.


Preparing for Surgery

Modifiable Risk Factors:Smoking and Tobacco Use Smoking and tobacco use has been shown to significantly increase the risk of post operative complications, especially that of

wound healing and infection.

We want to provide you with the best outcome; therefore all patients must stop smoking at least 8 weeks prior to surgery and 6 weeks postoperatively.

Nicotine screen – this will occur at least 2-3 weeks prior to surgery when you get your pre-operative labs drawn

Diabetes Control Hemoglobin A1C < 7.5, if greater than 7.5 we will postpone surgery and refer to Endocrinology

Healthy Weight (BMI = Body Mass Index) BMI < 35, If BMI > 40 will refer to Nutrition/PCP/Bariatrics. Significant Increased risk of infection and complications with BMI > 35.

Nutrition referral/Utopia Food and Fitness

MRSA Screen (all patients will be treated with nasal ointment regardless of results) All patients must be off any hormone replacement therapy 1 month prior to surgery and 1 month after surgery (Includes Birth

Control/Progesterone/Testosterone/Estrogen).

Proper Nutrition Hypoalbuminemia (Albumin < 3.5): Malnutrition, postpone surgery and referral to Nutrition

Optimize Nutrition Pre Operatively – Increase protein intake at least 30 days prior to surgery

Our goal is to minimize risk for complications to optimize your outcome!!!


Preoperative Checklist

You have preoperative check lists in the Journey Guide including Home Readiness, 6 weeks, 3 weeks, 1 week, 2 days, night before and day of surgery.

You will also be given a list of things you can do in preparation to your surgery. Prepare your home, pack your bags, store throw rugs, prepare

meals/frozen dinners, make pet food and supplies accessible Discontinue appropriate medications, 1 month, 1 week, 1day, and

day of surgery Call clinic if you have any questions


COVID-19 Testing Approximately one week prior to your surgery date, you will receive a call from the hospital to schedule your COVID-19 drive-up test at UT Southwestern.

All patients must have their COVID-19 PCR (nasal swab) testing completed no more than 3 days prior to their surgery date. Surgery on Monday, COVID testing on previous Friday Surgery on Thursday, COVID testing on Monday Surgery on Friday, COVID testing on Tuesday

You can stay up-to-date on the latest COVID-19 information here:

https://www.utsouthwestern.edu/covid-19/At this time, the hospital is permitting two visitors per patient in the room and they can come and go. We are no longer tracking which two individuals are in the room – just the total number in the room.

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https://www.utsouthwestern.edu/covid-19/


Day Before Surgery Use Hibiclens Wash the night before and the morning of surgery. Do not use any lotions,

perfumes, or powders. Use Mupiricin (Bactroban) ointment, applied with Q tip, twice per day for 2 days before

and morning of surgery. You will continue this for 2 days after surgery. Stay well hydrated. Eat well-balanced meals which include protein. Nothing to eat after midnight. Please keep the meal light before midnight. You may drink

water up until 2 hours prior to surgery. (20 ounces total) Have bowel regimen ready at home

Metamucil + Colace + Miralax Expect a call from team to verify time of surgery. The hospital will call between 2 pm and

5 pm the day before your surgery. This is to accommodate a very fluid OR schedule. If you have them, bring your walker and sequential compression devices (SCD’s) with

you to the hospital.


Day of SurgeryArrive 2 hours before scheduled surgery at Zale Lipshy Pavilion*, (Valet parking available for $5.00). 5151 Harry Hines Blvd; Dallas, TX 75390

Check in on first floor with hospital registration. Once complete, you will be escorted to the pre-surgery area on the second floor.

You will see the team with Game Ready for instructions, if you have rented this unit.

In the pre-operative unit, we will review your history and medications, start an IV in your arm, and the anesthesiologist will discuss your plan for pain management.

A urinary catheter that is placed before surgery will be removed the morning following surgery, if you require a catheter. Due to the shorter length of some surgeries, no catheter will be used, which reduces your risk of infection.

Dr. Wells will review surgical plan and mark hip or knee. Medications will be given for comfort, to include antibiotics.


Post Operative Expectations After surgery, a Game Ready ice machine will be placed on your surgical limb in the operating room. Hips with

posterolateral approach will have a special pillow placed between your legs.

Dr. Wells will visit with your family and/or friends to update your progress after surgery.

You will wake up in the recovery room, where you will be carefully monitored by nurses and an anesthesiologist.

Dr. Wells and team will visit you after surgery to check progress, discuss your surgery, and answer questions.

Your vital signs, IV fluids, and healing progress will be monitored frequently, as well as pain level and meds.

Dressing: Your incision will be covered with an ABD that can be removed the next day. If the incision is covered with Prineo mesh dressing, it will remain in place for 21 days. You may have a Mepilex post-op Ag that will remain for 5 days. You may have a Prevena vac attached to a canister that will remain in place for one week or more.

Specific instructions, both verbal and written, will be provided for the dressing.

Ice pack or ice machine and elevation will help keep swelling under control and help reduce pain.

The Occupational and Physical therapists will help you to get out of bed the same day as surgery. We expect you can, at least, stand at the bedside. For your safety, if you want to get up, please call the nurse or tech for help.


Hospital Stay and DischargeExpect a Physical Therapy to come and get you out of bed 2 times per day. You may also get out of bed with nurse or tech assistance when you would like. Please call for assistance. Do not get up without help. Your help cannot be a family member due to fall risk.

You will be given a folder describing the protocol including dressing, SCD’s, implant information, and x-rays of your new hip or knee.

To prevent a clot: Wear your ted hose for 5 days after surgery Wear your SCD’s for 21 days after surgery

Wear at night when you sleep and during the day when you are resting Charge your SCD’s while in hospital because you will wear them on your way home

Take your oral DVT prophylaxis ( aspirin, Xarelto, Coumadin) as prescribed for 6 weeks after surgery.

Incision Care: Keep a close watch on your incision. Watch for drainage, rash, redness, or increased warmth. Contact the Surgeon or clinic with any concerns about your incision.

Please call surgeon’s office with any concerns/problems at 972-669-7179, 24/7.


At Home InstructionsYou will be given discharge instructions verbally and in writing. These will be specific to your surgery, and you will be able to refer to these at home, so keep them available.

Your prescription medications will be e-scribed to your pharmacy. Please take medications as prescribed. As your pain lessens, take less medication.

Please do not take narcotic medication to get ahead of the pain. This causes nausea, constipation, fall risk, delirium and addiction.

Use your non-narcotic medication to reduce that amount of narcotic medication that is necessary for pain relief.

Pain management techniques: Ice - for pain control and to reduce swelling – use machine or ice packs

Elevation - Toes WAY above nose, at least 60 degrees, ramp the straight leg to reduce swelling.

Activity - movement and activity helps to lessen pain. Get up every 2 hours.

Distraction - focus on something other than your pain.


Narcotics Prescriptions

Narcotic prescribing law as of September 1, 2019:

The new narcotics prescription law limits the amount of narcotics that can be prescribed for post operative or acute pain. • Narcotic medication may be prescribed for 7 days. • All refills require the patient to come to the clinic, in person, to receive a refill for 7

more days. (COVID-19 allows escribing for refill at this time.)• We can only prescribe narcotic medication for 4 weeks. • After 4 weeks, the patient must get narcotic medication from a primary care physician

(PCP) or a pain management doctor.

We understand that this makes things a bit harder, and we apologize for the inconvenience.


At Home Instructions

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Home Health and Physical therapy will be set up for you at the hospital through the social worker/care coordinator. They will come to your room and give you a list of Home Health companies to make a choice. If you live outside of the DFW or have a preference for HH or PT, please bring the

name, address, and phone number of the facility with you to the hospital.

The Physical Therapist will come to your home 3 times per week for 6 weeks. They will teach you about exercise and hip precautions, evaluate your progress, watch incision for changes, and update the rest of the team on your progress.

During this time you will use your walker for 6 weeks with all walking. This is required for balance, healing, and gait mechanics. You will be weight-bearing as tolerated unless otherwise instructed.You may be 20 pound flat-foot weight-bearing or 50% partial weight-bearingWe ask you to stay on the walker, rather than switch to a cane, to give yourself time

to get back to proper mechanics with walking.


At Home Instructions

Constipation Narcotic pain medication, decreased mobility, and iron supplements can cause the slow down of

normal bowel movements. This is common, so please use all three products in the bowel regimen.

Stay hydrated- Water is best. Coffee, tea, and soda can increase dehydration, so please limit the consumption.

You can lose your appetite, so try smaller nutrient-packed meals more often. Try for 40 g of protein per day to promote healing.

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Rehabilitation Expectations

GOALS Reduce Pain Promote Healing Maximize Outcomes

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Pre-Surgery

Acute Care

(Hospital)Home Health Outpatient


Rehabilitation Expectations

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Pre-Operative PT

• Maximize Post-Operative Outcomes• The stronger you are going in, the better function you should have coming out• Motion is Lotion

Home PT

• Promote Tissue Healing• Incision• Muscular and Tendinous Tissue

Outpatient PT

• Maximize Functional Goals• Activities of Daily Living • Job Related Activities• Recreational Activities


Physical TherapyPre-Op PT Visit is part of our protocol to optimize your outcome – the stronger and more mobile you are prior to surgery, the chance for good outcomes is improved.

In this visit you will receive: A comprehensive evaluation, including functional outcomes testing A tailored home exercise program to perform prior to surgery (clarify timing, duration

and frequency) Gait and assistive device training, home training including gait belt and transfers as

needed Review of precautions specific to your planned surgery type Education regarding expectations for after surgery


Home Physical TherapyA therapist will be coming to your home for approximately 4-6 weeks

Stay on the walker for 6 weeks – you will be weight bearing as tolerated (unless told otherwise) until the follow up visit with the surgeon Safety Healing Balance Proper gait

Keep progress in the middle of the road Too much = sore Too little = stiff

Doing well means you are on target – don’t progress too far too fast

Use pain as your guide - NOT no pain, no gain


ConsiderationsAssistive Device

Weight bearing Weight-bearing as tolerated WITH Walker/Assistive Device until 6 week check up After 6 weeks weight-bearing as tolerated (WBAT) WITHOUT assistive device with guidance

of PT

Walker (given at hospital)

Crutches(given at hospital) Cane


Hospital Hip Kit

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Reacher

Sock Aid

Long Handled Sponge

Long Handled Shoe Horn

Leg Lifter


Additional Considerations

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(Don Joy for purchase)

Elevated toilet seat

Other Medical Equipment – not covered by insurance

Shower bench Tub bench

Ice Machine(per patient request) (Game Ready for rental)

Ice


Total Knee Expectations

Minimize Swelling DVT prevention Improved range of motion (ROM)

Range of Motion Expectations End of Week 1 – 90° 0-120⁰ as soon as possible! Expected: at least as much motion as pre-operatively Full Extension is critical for normal walking

Recovery happens quickly! 3 month outcome is good indicator of how you will do, recovery will slow from 3-6 month

Gait Work with home therapist for weaning from assistive devices – quality is important

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Leg PositioningResting with your leg straight helps you reach your recovery goals. Elevation- helps reduce swelling Heel prop- helps regain knee extension ROM

Do not rest with your knee bent It may feel more comfortable, but it will make reaching your ROM goals more challenging and painful.

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Hip Precautions


Global Hip Precautions

First 12 Weeks:NO straight leg raises Do NOT extend operative hip past neutral, including end range bridging and

terminal stance in gaitDo NOT flex the operative hip > 90° (do not sit on low surfaces, be cautious

when bending forward to put on shoes and socks)Do NOT internally rotate the hip (let the toes roll in – especially when your

trunk is leaning forward)Do NOT adduct the hip (cross the leg past the center of your body)Do NOT push range of motion


Weight Bearing and Driving PrecautionsTypically, you will be weight-bearing as tolerated, heel first contact WITH rolling walker at all times

Patients 25 years and younger, and select older patients with revisions or abductor repairs, will be in a hip abduction brace while 20 pounds flat foot or 50% partial weight-bearing with assistive device

Driving: NO driving until:(1) full weight bearing(2) OFF narcotic pain medication(3) cleared by Physical Therapist


Outpatient Physical Therapy

Home Therapy must be complete and you must be discharged prior to your first outpatient appointment. This is because of how insurance pays for services

Attendance in outpatient PT typically occurs between 4-6 weeks post op.

What you will receive: Evaluation of current functional status Update to home program Plan for continued therapy


Outpatient Physical Therapy at Richardson/Plano Location

If you plan to complete your outpatient PT with us at the Richardson Plano location, please let us know prior to surgery. This will allow you to secure your spot at your preferred

time.

Please call the clinic to schedule at (972) 669-7189 Schedule starting at 6 weeks post-op Schedule 2x/week for 6 weeks

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ExercisesWalking is the best therapy! Must be of good quality – NO limp Minimal, ideally NO pain

Tailored exercise by the physical therapist to target Gluteus Muscles (buttocks) Quads & Hamstrings (thighs) Balance Encourage good function in everyday and recreational activities

Return to Activity


Commonly Asked QuestionsWhy should I exercise before surgery? The better condition your muscles are in prior to surgery, the easier it is to improve after surgery. Learning

some of the exercises prior to surgery helps you to become comfortable with them.

Will I need a walker, crutches, or cane? Yes, we want to allow time for the limb to heal, as well as ensure good safety, balance and strength. You will be

on some device until your post-operative visit with surgeon.

Will I need any other equipment at home? You may need a shower seat or raised toilet seat that will need to be obtained before you come to surgery. You

will be given information on where to purchase these. A reacher and other equipment for activities of daily living will be provided a the the hospital.

Will I need PT at home? Yes, PT at home is a key factor in recovery. The number of sessions is based on your progress, typically home

health is 4-6 weeks and outpatient PT an additional 4-8 weeks.

Are there any activities that I should avoid initially? It is important to keep the hip moving, but you should return to your previous activities gradually. Typically, if

there is a specific activity you were doing prior to surgery, you should be able to return to that activity by 12 weeks, with the help and guidance of your physical therapist.


How long will my new hip/knee last and will I need to have my hip/knee replaced again in the future? Current research shows that prosthetics can last 20-30 years. This depends on how you care for your hip/knee

replacement. It is very important to ensure you make all your follow up appointments (6 weeks, 4 months, 1 year, 2 years, 5 years, 10 years, etc.)

How much time will the surgery take? Approximately 1 ½ to 2 hours for an uncomplicated procedure.

Who will be performing the surgery? Dr. Wells will be performing the surgery.

Will I be awake during the surgery? If you have general anesthesia, you will be intubated and asleep. With spinal anesthesia, you will be given

medication through your IV to put you to sleep.

Will I be in a lot of pain after surgery? If you have spinal anesthesia or a block, your legs will be numb up to 6 hours after surgery. Your pain will be

controlled with IV and oral pain medications.


Will I notice anything different about my hip/knee?

The pain in the hip/knee will have a different character. The groin and arthritis pain will be gone, and you will have surgical site pain that is much less than your arthritis pain.

Will I need a blood transfusion after surgery?

This will depend on your blood loss during surgery, your state of health, and any other conditions you have. We will monitor and discuss with you if transfusion is necessary.

How long will I be in the hospital?

The team plans carefully that you may be able to go home the day after surgery. This will depend on certain factors, and you will stay until it is safe for you to go home.

Can I go directly home, or do I have to go to a rehabilitation facility?

Most people go home after surgery. Certain criteria that must be met for insurance to authorize an inpatient rehab facility.

After leaving the hospital, when do I see my surgeon again?

You will hear from Dr. Wells and one of the nurses after surgery. You will follow up with Dr. Wells in clinic at 6 weeks for evaluation and x-ray.


When can I return to work? The best situation is to return to work after 6 weeks of recovery. If you need any paperwork for work ,for yourself

or your partner/spouse, please bring it by the office or fax it to us.

When can I go up stairs? You may use the stairs from the beginning. Go “up with the good (non-surgical)– down with the bad (surgical)”

leg. Be sure to use a railing for balance and assistance.

When can I drive? Right Surgical Leg: 5-6 weeks, when you are no longer taking medication for pain, you can walk comfortably

without support, and you are clear with your currently-treating physical therapist. Left Surgical Leg: 4-5 weeks, with the same criteria listed above.

Will I always have one leg longer/shorter than the other? There is a chance there will be a subtle difference, but often this initial discrepancy is due to the soft tissues.

The muscles must adjust to your new joint. This is a long process, and not a complication to worry about in the first several months. Often there are changes in body mechanics and function.


Questions Regarding Presentation InformationIf you have any questions regarding information provided in this presentation, please feel free to contact us.

MyChart is the preferred contact method.

If you need to reach any of our medical staff, please send the message to Dr. Wells, and the message will be directed to the appropriate staff member.

If your question is related to physical therapy, please contact Lauren Bryan, PT, DPT.

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