ANESTHESIA,   OPERATION    AND  RECOVERY

CONTENTS

• Length of stay
• anesthesia for total hip and knee surgery
• pain relief after surgery
• what to expect after leaving the operation room:           
• General preventive measures after the total hip / knee surgery
• Abduction brace / pillow of the hip
• CPM - continuous passive motion of the total knee
• General rehabilitation program in a patient with total knee arthroplasty
• General rehabilitation program in a patient with total hip arthroplasty

11

Length of stay   at the hospital

Nowadays, you will usually arrive at the hospital only hours before your total joint operation, and you will probably leave the hospital some four or five days after the operation.

The reasons for this short patient stay at the hospital are both economical and bacteriological.

All hospitals are contaminated with the hospital’s own bacteria that are resistant to antibiotics. The longer you stay at the hospital, the greater the risk that you will be contaminated with these bacteria too and  eventually develop nosocomial infection  = infection caused by bacteria present in a hospital (Osmon, 2001)

The precise routines for your admittance, the personnel who will meet you, etc. vary from clinic to clinic.

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Anesthesia

"Q:  How to guarantee that I will be sleeping during the whole surgery without any predisposition for waking or hearing anything...."

"A:  If you are scared about waking up during surgery, your anesthesiologist can make sure that doesn't happen. Go with the anesthesia your surgeon and anesthesiologist are comfortable with and make them explain your options...."

Important information to tell the anesthesiologist:

• Your previous experience with any form of anesthesia: did you have an adverse reaction to anesthesia, to the drugs used at it? ( Even adverse reactions to local anesthesia your dentist uses, such as palpitation, blood pressure fall, etc. ).

• Your reaction to drugs: have you ever experienced adverse reaction from any drug?, what kind of adverse effect? What medications, vitamins, alternative medicines (herbal etc.) are you currently using?

• Your current health condition: Do you smoke, use "recreational drugs" or alcohol? Are you being treated for any other disease ?

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The choice of anesthesia for your total joint operation depends on several factors, such as your health condition, the risks involved, and on the preference of the surgeon and the  anesthesiologist.

For your total hip /knee replacement there are two categories of anesthesia:

General anesthesia:

General anesthesia acts on the brain and affects the whole body. The patient is in a deep sleep. In general anesthesia, the anesthesiologist places a breathing tube (endotracheal tube) to keep free breathing ways, and administers oxygen directly in the lungs through this tube. There are several drugs used for general anesthesia and your anesthesiologist will discuss the characteristics, risks, and benefits of them with you.

During general anesthesia the heart function, breathing, blood pressure, pulse rates, and temperature are constantly monitored. This is so because general anesthesia slows your pulse and breathing rates. During general anesthesia the blood vessels dilate (open widely), which increases bleeding during surgery.

The anesthesiologist may lower the blood pressure during   the operation to diminish the bleeding from the slack, open blood vessels  (controlled hypotension).

Disadvantages of general anesthesia:

The endotracheal tube usually gives a sore throat and hoarse voice for a few days. Patients are often drowsy and nauseous after general anesthesia, older patients may be confused for a few days.

General anesthesia is thus used for extended total hip / knee replacement operation that are expected to take several hours.

Regional anesthesia

(spinal block and epidural anesthesia)

is the common form of anesthesia used for total hip /knee replacement operations. The numbing liquid is injected around the nerves in your lower back (in your spinal canal).

Your body below the injection site will be insensitive to pain and the muscles will be limp.

Your brain and your spinal cord will not be affected.

Because you will be conscious, the anesthesiologist will usually give you sedative drugs or will put you in a light sleep. Discuss the alternatives with your anesthesiologist.

The two types of regional anesthesia used in total hip / knee surgery are

• spinal block and
• epidural block. (Picture)

Spinal and epidural  block.

(Click on the icon for a full size image).

The spinal canal is a space inside your spine, which contains dural sac.  Dural sac is formed of  though connective tissue that protects the spinal cord and the spinal nerves.

The space inside the dural sac is called the subdural space.

The dural sac is placed in an envelope of loose connective tissue that fills the rest of the spinal canal. The space in the spinal canal outside the dural sac, which  is filled with loose connective and fat tissue, is called epidural space. 

All spinal anesthesia is done in the lower lumbar spine (lower back).

The spinal cord ends at the first lumbar vertebra, lower downwards continue only nerve roots.  Dural sack  in the lower back area  thus contains only loose nerve roots, floating freely in spinal fluid.

Thus, the spinal cord is not in danger with this kind of anesthesia.

The nerve roots  are neither of danger to be stuck because they float freely so that they will go away from the contact with the spinal needle.

In spinal block

the  anesthesiologist injects a small quantity of anaesthetic (numbing) liquid inside the dural sac  into the subdural space. The needle for this purpose is long and thin and flexible.

You will be asked to bend your lower back spine forcibly. By this maneuver the  distance between the vertebral arches (the back parts of the vertebrae) will increase. The needle will thus be easier to insert in the spinal canal.

The numbing liquid  injected into the subdural space is heavier than spinal fluid, it sinks into the lowest  part of the subdural space and numbs the nerve roots there.  

The spinal fluid may, however, seep through the opening in the dural sac caused by the injection needle; this may cause severe headache after the operation.

To prevent possible ascent of the numbing liquid upwards, the patient must   repose supine with elevated upper part of the body until the numbing liquid is resorbed.

In epidural block,

the anesthesiologist places a thin tube -  catheter - (through the spinal anesthesia   injection needle) outside the dural sac in the epidural space. Through this catheter the anesthesiologist then instills numbing liquids around the nerve roots in the epidural space. The dural sac is not stuck and there is no risk of escape of spinal fluid. Thus, the epidural catheter may be left in place after the operation for hours and even longer.

The anesthesiologist may also inject a small dose of morphine directly into the subdural or epidural space after the operation for relief of postoperative pain.

Pain relief after surgery

" My biggest concern is that I do not want to wake up after my knee surgery in pain. Was anyone able to manage the pain well throughout the healing and rehabilitation? How long does the pain after surgery last?"

You are supposed to start the training of your new total hip / knee already the next day after your surgery. Can it be done without pain in the operation area?

Yes! There are several ways how to achieve almost pain-free movement in your operated joint already the next day after the surgery. Take time to discuss these options with your surgeon and ask questions about things you don’t understand.

Most patients are actually surprised how little pain they have suffered after their total joint replacement operation. Some options for pain management after the operation.

• If you have had epidural anesthesia, the epidural catheter can be left in place for one or two days and the anesthesiologist may inject small quantities of numbing liquid through the catheter. The effect of this continuing anesthesia is usually sufficient to make your exercise pain-free. At some centers the patient may use a computerized device for self-administering small quantities of numbing liquid.

• Patient Controlled Anesthesia (CPA) is another mode of management of postoperative pain. A computerized device containing narcotic solution is attached to the intravenous line. By pressing a button at the end of an electric cable, the patient can self-administer small doses of narcotics. The device is pre-programmed so that the patient cannot give himself /herself a narcotic dose that is not safe.

The advantages of CPA: First, the patient does not need to call a nurse to administer pain injection. Second, because the patient administers only small doses at a time, the patient is not drowsy with this treatment. This device is usually ended after 2 days.

• For total knee patients, there is still another effective method for relief of the  postoperative pain in the operated knee. Before the end of the operation, the surgeon instills solution of pain relieving medicines (morphine, local anesthetics) into the knee joint space. These medicines stay long time in the knee and alleviate the postoperative pain.

• It is important to know, that in spite of these pain management options, you may still experience pain. It is important that you ask for pain pills, pain injections, and sleeping pills. Do not restrict yourself from asking for pain relieving medicines. It is better to forebode pain than treat it when it has become severe.

Let your doctor know immediately if you have

calf pain and swelling

shortness of breath, and /or

chest pain.

These may be the signs of blood clots or lung emboli that must be treated immediately.

How quickly will the pain after total hip / knee operation disappear?               

• Most patients recognize within 1 - 2 days after surgery that their pain in the hip / knee joint area is markedly different from the pain they suffered before the operation. They note that the old "arthritic" pain has gone almost immediately after the operation.

• The pain from the operation wound, from the divided muscles and sawed off bones improves quickly during the first  seven postoperative days, but then gets better more slowly. Most patients still have some pain in the hip / knee area two months after the operation.

• Persistent pain, especially after walking and exercising, can persist several months or years. The patients with cementless total hip prostheses have more often this kind of pain.

• The relief of pain is usually much slower after the total knee operation than after the total hip operation.

• The preoperative anxiety and the negative mood usually disappear within days after the successful surgery. Be prepared, however, that the general satisfaction with your new life might improve more slowly.

• In some patients appears even a late period of postoperative depression. These patients feel despair when the mobility in their new hip / knee is still not "normal" six or eight weeks after the operation.

• Be patient! Remember that the operation takes only about two hours, the rehabilitation, however, may take one year!

What to expect after leaving the operation room:

• Drainage and other tubes

After the operation, you will discover that you have

several tubes attached to your body:

intravenous line to your arm for secure, easy, and quick administration of medicines -

suction tubes to your operated hip / knee wound - to remove all blood that collected there after the operation (in some centers this blood will be processed and the blood red corpuscles infused back to you -

catheter to your urinary bladder inserted in anesthesia - to avoid difficulty passing urine

possibly an epidural catheter to your low back

 

Most of these lines and tubes will be removed one or two days after the operation, otherwise there is a risk that bacteria can wander through them upstream and cause nosocomial infection. - the time of removal is, however, dependent on several circumstances. The removal  does not cause pain.

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Machines / braces attached to the operated leg:

Prevention of deep vein thrombosis

In some centers special pneumatic hoses will be applied to your legs. These are inflatable tubes that will rhythmically compress your calves and propel the blood in the calf veins. This rhythmical massage will prevent formation of blood clots in your veins.

Usually, the patients are also applied special elastic stockings directly after the operation. Also  this measure is  done to prohibit formation of blood clots in your leg veins.

1

Total hip patients : Abduction brace /pillow

Patients with total hip replacement will  have a special pillow / brace placed between their legs  to keep their legs apart. In this position the femoral ball reposes securely in the cup component. The abduction brace / pillow would thus prevent the dislocation of the new total hip joint.

The length of the use of the abduction brace / pillow varies between 2 and 6 weeks.

2

Total knee patients: Continuous passive motion (CPM)

Some clinics use a Continuous Passive Motion device to improve the range of motion after total knee replacement.  CPM device is a movable knee brace, driven by a small motor.   The brace moves continuously from full knee stretching to about 70 degrees knee flexion.

The surgeon selects the range of passive motion and the pace of the extension - flexion movement. The operated knee reposes on the movable brace and is moved passively.

There are several possibilities how to keep the newly operated knee without pain during this movement:

prolonged epidural block

placing numbing substances with long lasting effect into the knee at the end of operation (solution of morphine, local anesthetics (numbing substances)

block of the nerves around the knee joint

The CPM is used during the first 4-5 days postoperatively about 3 times a day

The use of CPM remains controversial. Some reports claim that the use of CPM increases the range of motion in the operation more quickly, decreases the need for manipulation of the total knee in narcosis, and prevents development of deeps vein thrombosis.

Other studies maintain that CPM causes more postoperative pain and increased wound bleeding, whereas the final range of motion in the total knee is not influenced by the use of CPM. (Lachiewicz 2000)

 

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• Operation wound

will be  covered by a dressing which will  be changed repeatedly as necessary, first time usually after the removal of suction drainage tubes.

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• Temperature

Practically all patients run a temperature up to 38 degrees Celsius ( 100 degrees F) in the first  five days after the total hip / knee replacement. This is considered "normal" temperature. Postoperative fever after total joint arthroplasty is a "normal" inflammatory response of the body on the operation trauma.

A study of patients with flawless healing after total hip operation demonstrated, that mean patient temperature on the  first postoperative day was 38,0 degrees C.  At the fifth postoperative day less than 5 % of all. patients still have had 38,0 degrees Celsius maximum day temperature. (Summersell 2003)

The maximum  daily temperature   occurs in most patients on postoperative Day 1 and gradually levels off toward normal by postoperative Day 5. If the febrile response is decreasing progressively there is no reason for concern..

  Only if the temperature continues to be high after the fifth day or rises over 38 C (101 F) successively the surgeon should suspect postoperative complications and take appropriate measures. The  postoperative complications causing fever are: postoperative wound infection, infection in the urinary tract, deep venous thrombosis, postoperative lung inflammation, haematoma (blood collecting in the operative  wound), and incipient ossification in the muscles.   (Shaw, 1999)

3

Preventive measures against:

• infection - antibiotics are the single most effective preventive measure against postoperative infection. They should, however, be applied only very shortly, before, during and after the operation. Usually they are continued for only one day after the operation moment. The practice of this prophylaxis varies from hospital to hospital.

• pressure sores - develop when constant pressure is acting on your skin, e.g. when lying motionless. You should change position as often as possibly. This may not be easy after anesthesia and you may need help. Ask for it. Ask also for special soft bedding or inflatable mattress.

• deep vein thrombosis (DVT) - blood clots form when the blood stagnates. Moving your legs is the best prevention. Passive muscle massage with inflatable hoses and elastic stocking is another.

In most hospitals you will be given also chemical prophylaxis with either coumadine medicines or heparin-like medicines. The practice of this prophylaxis varies from hospital to hospital.

• nerve injury - continuous pressure on peripheral nerve may damage it. Peroneal nerve, which crosses the outer side of the knee, is a nerve that may be damaged in this way. This may happen if your leg rests motionless and rotated outward on a hard surface - e.g. on a badly bolstered brace.
• lung inflammation - your lungs need motion too to prevent lung inflammation. Your physical therapist will teach you some tricks, such as breathing in the bottle etc.
• heterotopic ossifications (HO) - drug prophylaxis with NSAID medicines (indomethacines) - usually applien in patients at risk (muscular male patients). In some hospitals the prophylaxis is by irradiation already before the surgery

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4

General rehabilitation program in a patient with total knee arthroplasty

The rehabilitation program  after total knee arthroplasty varies in dependence on the type of prosthesis, diagnosis of the knee disease, and the surgeon's preference. In general, your  rehabilitation program will probably be like this

Day of surgery

     deep breathing exercises

     operated knee placed on an elevated brace

      active motion in the ankle

Postoperative day 1

learn to put on and wear a knee brace on your operated knee

you will wear this brace until you will get enough strength to actively extend (stretch) the operated knee joint and have a good leg control during walking. This will take some days or even weeks.

continuous passive motion of the operated knee three times a day for about four days

isometric training of muscles around your hip and   knee

weight bearing after the total knee replacement may be partial or full, and it will be decided by your surgeon;  it may be started already at  the first postoperative day.

Postoperative day 2 - 3

standing at the bedside with knee immobilized and partial weight-bearing exercises

active and assisted range of motion training of the muscles around your knee

Postoperative day 4 and later

progressive exercises to strengthen your hip and knee joint muscles

concentrate on to attain full active knee stretching

active and passive exercises to increase flexion in the operated knee

learning stair climbing

pool therapy when the wound has healed

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5

General rehabilitation program in a patient with total hip arthroplasty

The rehabilitation program  after total hip arthroplasty varies in dependence on the type of prosthesis, diagnosis of the hip disease, surgical approach, and the surgeon's preference.

 In patients operated on with MIS -minimally invasive surgery approach, the whole rehabilitation program is taught before the surgery.

In general, your  rehabilitation program will probably be like this

Day of surgery

pillow / brace to keep legs apart for 2 to 6 weeks

deep breathing exercises

active motion in the ankle

Postoperative day 1

isometric exercises of quadriceps (contractions in the knee extensor muscle without moving the extremity)

isometric exercise of the buttock musculature , depending on the surgical approach

knee bending exercises as tolerated

Postoperative day 2 - 6

begin walking training with walker, crutches, rail support

cemented total hips: weight bearing as tolerated

cementless total hips: toe touch weight-bearing as tolerated (not all surgeons subscribe to this)

patients with trochanteric osteotomy:  weight- bearing decides by your surgeon. Either weight-bearing as tolerated or partial.

teach hip precautions

active and assisted exercise of the hip and knee musculature

Postoperative day 7 and later

progressive strengthening of the musculature of the trunk, hip and knee joint

improving gait pattern

successively learn to walk without assistive devices (walker, crutches)

learn stair climbing

pool therapy when the wound has healed

References:

Osmon, D R, JB -Am, 2001, 83-A, 1891-1899)

Aarons H, et al.   J Bone Joint Surg- Br, 1996, 78-B, 555 - 558

Shaw JA, Chung R. Clin Orthop, 1999, 367, 181-9

Lachiewicz PF   Clin Orthop 2000; 380: 144-50

Summersell PC et al.  J Arthroplasty  2003; 18: 426 - 9

(Contamination = presence of living bacteria, e.g. on the surface of the skin, clothes, on the objects in a room, in the air, etc. Don’t confuse contamination with infection. If the body's defense is strong, it will kill most of the contaminating bacteria so that they cannot multiply and cause infection.)

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