325 East Sonterra Blvd.
Clinic: Suite 120
Administrative Office: Suite 220
San Antonio, TX 78258
Phone: (210) 614-5100 / Fax (210) 614-5103
Adam I. Harris, M.D.
Frequently asked questions:
How long will I be in the hospital?
This is the most commonly asked question. Unlike some of my colleagues both in town and across the country, I don’t treat people like ingredients in a recipe. The length of the hospital depends upon both the patient’s capacity and their needs. You can imagine that the younger patient who lives in a single story house and has a large family available to help would in general go home before the older patient who lives alone and has 30 steps to their front door! Few of my patients under 80 years of age require a stay in a rehabilitation hospital. On average, patients who have a tissue sparing total hip will stay one night, rarely two. The vast majority of patients who have a tissue sparing total knee will stay two nights. A few are able to leave after one, some will need to stay three nights. Patients who have a revision or re-do of a previous arthroplasty will stay one night longer and are slightly more likely to need a stay in a rehabilitation hospital before going home.
The exact length of the stay is, in a sense, a "game" where many of the rules are made by the government and the insurance companies. The only portion that is true to “medicine” is that you should stay in the hospital until you are medically stable. Further, you should not go home until you are safe to go home to your home environment. In general, if “medically stable” and “physically safe” are separated by about a day, then you can stay an extra day in the hospital, then go home. If they are expected to be separated by several days, then you will have to be transferred to a rehabilitation facility. Experience with these procedures is that for those under eighty years of age, a rehab stay has been needed about two per cent of the time. About forty percent of those over eighty do require a rehabilitation stay.
How soon after my surgery can I drive?
There is not a good scientific answer to this question. There are many people driving right now that have no business being on the road and who did not have recent surgery. What little data is available is primitive, and looks only at reaction times. There is a great deal more to driving than just reaction times. I’m admittedly conservative on this issue. The real question is not whether you can operate the vehicle. That you’d be able to do in a few hours after the surgery. The real question is, “When can you respond appropriately to an emergency?” If you are going to think twice about your hip or your knee before responding to the emergency that is in front of you, don’t get behind the wheel in the first place. When my kids were younger, I’d tell my patients that if they were going to drive early, call me at home so that I could keep them inside.
The limited data that does exist tells us that reaction times are not as good as they were before the surgery until six weeks after the surgery. Therefore, if you want my “blessing” to drive, then I’ll have you wait six weeks. If on the other hand, you feel that you can respond the the emergent issue in an appropriate manner, then you are (or at least should be) a responsible adult. It becomes your decision. If you spend a fraction of a second extra thinking about your new joint, somebody is likely to get hurt. The attorney on the other side is sure to ask, “Didn’t you just have major surgery?” I hope that you get my point.
Can I get a handicapped license plate or placard?
For this one, the state makes the rules; the doctors just have to follow the rules. There are strict rules regarding prescribing handicapped license plates and placards. Failure to follow these rules can result in the physician’s license to practice being “pulled”. Unfortunately, the state is unwilling to help in defining what constitutes “appropriate prescriptions”. I know. I’ve asked. On the other hand, they are more than willing to revoke a license to practice if the rules are violated. Go figure.
The rules include criteria such as: “unable to walk without assistive devices”, and “unable to walk 200 feet”. (Emphasis added.) The bottom line on this is that most patients will not qualify for the placard after a few days, maybe a few weeks, while the shortest term temporary placard is either three or six months.
Can I have both knees (or hips) replaced at the same time?
I don’t recommend replacing both sides at the same time. There are several good reasons for this. First, for knee replacements, doing both at the same time (with standard approaches) is associated with many times more than double the rate of strokes, heart attacks, and lung problems when compared with doing one at a time. In the past, when I did traditional approaches, I successfully avoided these problems. However, my experience with replacing both knees at the same time is that the long term results are not as good. The ultimate range of motion is less, so the functionality is not as good as if the knees are replaced one at a time.
Secondly, when one has both knees replaced under one anæsthetic, there is some overlap. The second side is started while the bone cement is hardening, saving some time. Two surgeons close the wounds, again saving some time. With hip replacements, this sort of overlap is not possible. One would need to finish one, shift the position of the patient on the table, and start with a fresh surgical scrub on the second side. The total time under anæsthesia then becomes an unnecessary additional risk.
When should I arrive at the Hospital?
In general, the hospitals will want you to arrive about two hours before your surgery. If your surgery is scheduled for early in the morning, please double-check this with the hospital. Occasionally, less time is required if your surgery is the first of the day.
May I go to the hospital the night before?
Federal regulations and subsequent insurance company rules have made "prior night admission" a thing of the past. Very few circumstances qualify for prior night admission. If your surgery is scheduled for early in the morning and you live a long distance from the hospital, either plan on staying in a nearby hotel the night before, or ask not to be the first case of the day. My office will be able to help you find hotels nearby.
Should I have blood tests or other tests done before surgery?
Several tests including basic blood work, EKG, Chest X-Ray, and urinalysis are part of the preoperative preparation for the surgery. In the two to three weeks before your surgery, your primary care physician and/or your insurance company may prefer that you have your preoperative laboratories done at your primary care physician's office or a designated lab. We will help to coordinate this, but please also check with your primary care physician or insurance company. If you have blood or other tests done before the surgery, please be sure that the results are forwarded to our office. Blood tests and urine tests must be done within 30 days of the surgery. EKG can sometimes be within the last 3 months, and chest X-Ray can sometimes be within 6 months. We can provide a list of requisite studies. Your primary care physician should also have our fax number. (210) 614-5103.
Please do go to the hospital to have the hospital’s own lab draw a “type and screen”. Depending on the hospital, this can be done up to 30 days before your surgery. This eliminates one of the most common delays in getting the surgery started. The type and screen cannot be done at outside laboratories. It must be done in the hospital.
What about eating/meals and surgery?
Do not eat anything after midnight the night before your surgery. After midnight, you may drink water up until four hours before the scheduled time of your surgery. It is better for you to show up well hydrated than dry and shriveled like a prune. Please do read this correctly. You have permission to drink water. You do not have permission to drink any other liquid. Coffee is not water. Orange juice is not water. Tea is not water. “Vitamin water” does not qualify as water. Only water (tap or purified) is water.
Again, you may drink water, as much water as you want, up to 4 hours before your surgery time. This is true regardless of who else might call to tell you to put nothing whatsoever in your mouth. Some hospital employees have even told other patients that Dr. Harris wants you to have no water. This is just not true. You may have water.
People with diabetes, please also read the section on medicines below carefully.
What can I do to minimize my risk of infection?
First, the record of known infectious complications in this office is better than published reports. Unfortunately, the so-called “super bugs” have become very common in the community in some studies representing 30% or more of organisms cultured off otherwise healthy skin. Therefore, a shower or bath with a Chlorhexidine based soap (Hibiclens and others) may reduce your risk. Please be careful though! Some people are allergic to this soap. I recommend washing for several days before the surgery in the region of the incision with Chlorhexidine. Please try the soap on the opposite side a week or more before to be sure that you tolerate the soap. Rashes or blisters near the incision area will force postponement of the surgery. Chlorhexidine soaps are available at most drug stores, and many groceries without a prescription.
Next, while losing weight is a good thing for most of us, if you’re overweight, don’t scrimp on protein in the few weeks before the surgery. Adequate protein levels are important with regard to wound healing. Short term increases in cholesterol or fat intake will not be significant in the long run. If you have concerns about “eating meat” please bring them up to your primary care physician. It is outside the realm of this office to make more specific nutritional recommendations.
Tell me about any remote (away from the surgical area) infections. Boils, open wounds, and decaying teeth are a few examples. Check with your primary care physician about urinary tract and sinus or respiratory infections. Check with your dentist to be sure that you have no active infections in your mouth.
Lastly, avoid cuts and scratches in the region of the planned incision. A common reason that women have their knee surgery postponed is that they shave and nick the skin near the knee. Men tend to try to get one last garden project done before the surgery and end up with ant bites or deep cuts/scratches. (Women have been postponed for ant bites and men for nicks from shaving.) If you shave in the area of the surgery on a regular basis, please don’t do so for five to seven days before the surgery. Remember, that the hip surgery incision is usually placed near the groin area.
What about my medicines?
Medicines for Diabetes:
If you have diabetes and take either insulin or an oral hypoglycemic medication to control your blood sugar, in general, these medications should NOT be taken on the morning of your surgery. Please check with the physician who manages your diabetes. Sometimes, the doses of medicine given the night before should also be altered. Some patients should use some of the medicine in the morning. The doctor who knows your diabetes best is the best one to make these recommendations.
Non-steroidal Anti-inflammatory Drugs:
During the ten to fourteen days before your surgery, you should avoid non-steroidal anti-inflammatory drugs. These specifically include aspirin, Motrin, Advil, and most of the over-the-counter pain remedies. Mobic or Celebrex should be stopped three to five days before the surgery. Acetaminophen (Tylenol) is okay to take up to the night before the surgery. NOTE: Almost all over the counter pain relief medications have non-steroidal anti-inflammatory compounds which are also blood thinners. Only acetaminophen (Tylenol) is a pain reliever that is not an NSAID.
Blood Thinners, NSAIDs (non steroidal anti-inflammatory drugs) and Aspirin:
If you are on a blood thinner (i.e., Coumadin, aspirin, Plavix, Pradaxa, Xaralto, and others), please check with your primary care physician. In the vast majority of cases, this medication can be stopped safely a few days (Coumadin – 5 days, aspirin or Plavix – 10 to 14 days) before the surgery and then resumed shortly after the surgery. Again, please check with your primary care physician if you have any questions about this type of medication.
Fish Oil, Omega-3, Mega-Red etc.
These compounds seem to be increasingly popular over the last few years, though the first reports that Omega-3 fatty acids were beneficial to you heart were published in the 1980’s. There is not any good evidence about how long the blood thinning effect of Omega-3 fatty acid takes to “wash out” of the system. The standard dose of Omega-3 has been 1000 mg per day (less for Mega-Red). Recently, patients are reporting 5,000 mg per day or more. Please stop using any of these medicines at least two weeks before surgery, preferably more.
Mega-Vitamins, Nutraceuticals, and other potential blood thinners
There is no problem with the use of ordinary multivitamins. Brands such as “one a day” or “Centrum” even “Centrum Silver” will cause no problems with bleeding, and are generally good for you, whether you’re having surgery or not. The so called “mega-vitamins” or “nutraceuticals” can increase your risk of excessive bleeding at and around the time of the surgery. Particular offenders include Fish oil (Omega-3), Vitamin E, Ginko, Ginger, and Garlic. Less well established, but also probable trouble makers include Glucosamine, Chondroitin Sulfate, turmeric, and cinnamon.. All of these medicines should be stopped at least 10 days before the surgery. Vitamin C supplements are not a problem. Neither are Vitamin B complex supplements. If you take an iron supplement, please also do take a B vitamin complex supplement. Iron supplements are a different issue. Constipation is a frequent problem after any surgery. Stopping supplemental iron at least 3 days in advance may minimize this issue.
Bottom line here is that you should let me know about any and all supplements that you use.
Heart and Blood Pressure Medications:
Blood pressure medicine, with regard to surgery, are broken into two different types. Some are diuretics, or water pills. Please do not take any medications that are purely diuretics on the morning of surgery. On the other hand, there are many blood pressure pills that are not water pills, or are combinations of diuretics with other types of medicines. If you are taking any of these medications for high blood pressure do not interrupt your usual schedule for these medicines. If they are “morning drugs” then take them with a sip of water per your usual schedule. If they are “evening drugs” then do not take an extra dose.
Medicines for Rheumatoid Arthritis:
Many anti-rheumatic medications are also antimetabolites. Methotrexate is an example. These drugs should be stopped prior to the procedure. Please check with your rheumatologist regarding optimal timing.
Medicines for Asthma or other breathing problems:
Breathing is a good thing! You should take any medicines that help you breathe. This includes any antihistamines, even if you take them only as needed. If you need them the morning of the surgery, take these medicines. Bronchodilators or inhalers should be used according to your usual schedule.
Steroid medications such as prednisone must be continued. They need not be taken the day of the surgery, as you should receive supplemental steroid medication in the hospital. If you have been on steroids by mouth for more than a week within the last year, or a full year at any time, please review this with me and the anesthesiologist and the nurses before your surgery.
Pills for Neuropathy, Chronic Pain, Peptic Ulcers, or Psychological issues:
For the most part, these medicines should not be interrupted. Please, if you are on any of these medicines, discuss them with me.
Medications for Erectile Dysfunction:
Viagra, Cialis, Levitra, and herbal remedies are a potential problem, and a potentially very serious problem. If the effects of the drug are still in your system, and you need certain medicines for your heart either during your surgery or thereafter, a dangerous drop in blood pressure may occur. I recommend stopping at least three days before the surgery.
When should I schedule my follow-up appointment?
The first follow-up appointment is about two weeks after the surgery. Your staples (if any) will be removed at this appointment. Usually, this visit is scheduled at the same time that the surgery is scheduled, and the pre-operative visit is scheduled.
How do I care for the wound(s)?
The first question is really, “When should the operative dressing be removed?” The answer to this question depends on the type of dressing, and the type of the incision. Most patients will receive a “long term” dressing. These can be identified by the thicker brownish color of the dressing, and that gauze cannot be clearly/easily seen through the dressing. These should stay on in general, until the first post operative visit. They may curl up at the edges. This is OK. So long as there is not a communication between the “outside world” and the central portion of the dressing, leave it on. Should such a communication develop, then take off the long term dressing and start the wound care as described below. Attempting to remove this dressing early is hard on the skin along the edges.
Standard surgical dressings can be identified by the clear plastic overlying gauze. These surgical dressings should be removed two to three days after the surgery. Then, a clean, dry dressing should be placed once a day, or more often as needed. Only the surgical dressing is held on with plastic. Subsequent dressing should allow the wound to “breathe”. It is not unusual for there to be a few drops and up to a quarter-sized spot on dressings of blood or clear yellow fluid from the incision. (Drainage that has been sitting on the gauze may be different.) You should clean the wound with sterile normal saline or dilute hydrogen peroxide (one part hydrogen peroxide to three or four parts water or saline). Please do not use full strength hydrogen peroxide or alcohol to clean the wound. Full strength peroxide will do more harm than good, particularly if used repeatedly. A thin film of antibiotic ointment is not harmful, but also not needed. If there is drainage from the wound (not what you see on the gauze) and it is green or cloudy, increasing in volume, more than a quarter’s worth a day, or the wound appears an angry red, then call the office immediately.
The initial surgical dressing is waterproof. You may shower with this dressing in place. (No soaking as in a bath tub or pool). If the dressing fails, and the wound gets wet, remove the dressing, and start local care as above.
After the wound has been clean and dry for 48 hours, then you may shower without protection. The running water is good for the wound. Soaking is not good for a fresh operative wound, so don’t sit in tubs, pools, or lakes, etc. A lightweight dry dressing may help keep clothing from rubbing on the wound.
Before the wound is "bone dry," you may also shower with some preparation. To do this, get OpSite, Tegaderm or any other waterproof over the counter dressing, and cover the wound. They look a little like Saran Wrap™ with one sticky side. After the shower, remove the waterproof dressing and replace the regular gauze. Stay out of tubs and pools until the wound is at least three weeks old. It is not necessary to cover a long term dressing.
Lastly, a pink color to the wound is very normal. Red, in particular if there is also hardness is not. If you have a concern, then please call me. Do not just start antibiotics. Inappropriate use of antibiotics can make matters worse.
Suggestions for the few days before the surgery:
1) Help yourself prevent constipation. All good pain medicines cause some constipation. If your bowels are less full, then you should have less trouble with constipation after the surgery. You might consider using an enema the night before the surgery, and/or sometime in the morning of the day before the surgery (not the day of the surgery). Alternately, or in addition, you could take one or two tablets of Ducolax, a medication that is available over the counter a full day before the surgery.
2) Do you shave your legs or pubic hair? If so, please don’t do so for a week or so before the surgery. More than a few surgeries have been cancelled for razor induced rashes or nicks at or near the planned incision. Waxing also should be avoided. It has caused local problems.
3) Do you enjoy gardening or do a lot of work outside? Please protect your legs from cuts, scratches and insect bites. Again, open wounds on the leg can force postponement of your surgery.
Important points in closing for all Arthroplasty patients
Without some protection, after joint replacement, there is a risk that you’ll develop an abnormal blood clot in your leg. These clots can break off and cause all sorts of trouble, particularly in the lungs. Many web sites, sponsored by the makers of the blood thinners advertise that without (their drug as) prophylaxis for these clots, 1% of elective patients died from this complication. There is however, NO good evidence for this claim. With any form of prophylaxis, the rate is around 0.02%. Therefore, after your joint replacement, you will receive treatment to prevent abnormal blood clots. Since 2007, I have followed the recommendation of the American Academy of Orthopædic Surgeons. This has proved to be both safe and effective. In 2014, the government finally caught up, and admits that the recommendations of the American Academy of Orthopædic Surgery are “acceptable”.
Many physicians and other health related professionals though still believe that the recommendations of the American College of Chest Physician’s 8th edition of guidelines (and earlier versions) are the gold standard. The Center for Medicare and Medicaid Services had for many years adopted the ACCP 8th edition guidelines. Further, the government, with their great wisdom, have asked the drug companies that make expensive and in my opinion dangerous drugs to sponsor required educational modules for primary care physicians. By contrast, I have substantial evidence that the 8th edition guidelines are dishonest. The ACCP 9th edition guidelines, published February 2012, are very much in line with the AAOS guidelines. So, if another physician, therapist, nurse, or insurance agent tells you that you need something stronger to make your blood thinner, please tell them to catch up. You will receive state of the art treatment.
Most patients will receive a combination of aspirin, early mobilization, and sequential compression devices. A few patients will be better served by alternate drugs. The duration of therapy may range from 10 days to 6 weeks. You should refrain from using other types of blood thinning drugs while you’re on the prophylactic medicine. For example, anti-inflammatory medications, like aspirin, are platelet inhibitors. If you are using aspirin for prophylaxis, you may use non steroidal anti-inflammatory medications (NSAIDs), but not Vitamin E, Glucosamine, Garlic, etc. If you’re on a heparin like drug, you should not use NSAIDs, or Coumadin. This can be confusing. If you have any questions, please ask before adding a drug or nutritional supplement that could make your blood too thin. In particular, many antibiotics increase the effect of Coumadin, so please let me know if another physician prescribes an antibiotic.
Dental Hygiene and similar procedures:
Many things that we do during ordinary activities will cause some bacteria to float around in our blood system. Simple acts, like brushing your teeth or moving your bowels will cause a detectable rise in the number of bacteria in the blood. For these ordinary activities, some very very sensitive tests are needed to detect the levels. For some activities, such as dental hygiene at the dentist’s office are thought to spill a larger number of bacteria into the bloodstream.These bugs can take up residence on the metal of your prosthesis, and cause all sorts of problems.
For decades, orthopaedic surgeons have recommended that you a single dose of antibiotics 30 to 60 minutes before such procedures. In early 2013, the American Academy of Orthopaedic Surgeons changed the recommendation. It is now very “Charlie Brown-ish”. Recent reviews of the literature suggest that there really is not adequate evidence for this traditional recommendation. The conclusion of the review is that the doctor may not want to routinely recommend prophylactic antibiotics. I take two things from this review. First, it is probably more important to maintain good dental hygiene day to day than to worry about the dose before seeing the dentist. Secondly, when one of the authors of the AAOS review was asked what he did for his patients, he responded that he gives them antibiotics. Therefore, until there is “more evidence”, I recommend using antibiotics before dental hygeine every time, indefinitely.
If you choose to take the antibiotic, then you can get the prescription from your dentist, your primary care doctor, or from me.
Larger procedures, such as “standard” surgery should be accompanied by preoperative antibiotics anyway, and no special additional medications are needed to protect your prosthesis. In the past, prophylaxis for other procedures that stir up bugs such as colonoscopy was recommended. This is no longer the case.
It is a pleasure to participate in your health care. If you have other questions, please call.