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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.

San Antonio Orthopaedic Specialists

Adam I. Harris, M.D.


Congratulations!

You have elected to receive a total hip arthroplasty via Tissue Sparing techniques. These groundbreaking techniques allow for much more rapid relief of pain and return to function than previous, more standard techniques. Dr. Harris is the first in South Texas and in South Louisiana to offer these procedures, and has taught these techniques across the country.


The "rules" for your rehabilitation may be very different from hip replacements done by other techniques. Not all therapists understand this in advance, and may not believe the rehabilitation orders. Please read this information carefully and share it with your family and your therapist. Please call the office with any questions.


Your Hospital Stay

You will be admitted to the hospital on the day of your surgery. The hospital stay is usually one but occasionally two nights. The length of your stay depends on many things. The better general condition that you are in before the surgery, the shorter your hospital stay is likely to be. Those with single-level houses and supportive families will also have shorter stays. Those living by themselves or with "obstacles" at home (such as a large number of stairs) tend to stay longer.


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 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.


The length of the hospital stay is not a recipe where the patient is merely an ingredient. People respond to the surgery differently. Most get up quickly, but some go a little more slowly. It is NOT possible to predict who will “bounce” and who will need some more time. The length of the stay cannot be absolutely predicted before the surgery. The length of the stay is determined after the surgery. Dr. Harris will do what best fits each individual patient.





What can I do before 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. Dr. Harris recommends 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 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 Dr. Harris 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 may be placed near the groin area.




Discharge Plans:

Like the stay itself, the plans for care after the hospital stay vary from patient to patient. In most cases, the ideal situation is for the patient to go home and from there go to outpatient physical therapy. It is simply not practical to do this for each and every patient. That which may work for one patient won’t work for the next. A key determinant here is the function that is gained during the hospital stay. Discharge plans are made as you progress with the therapy in the hospital after the surgery. Dr. Harris will do what best fits each individual patient.





Your Weight bearing Status

The vast majority of patients are "weight bearing as tolerated." The emphasis here is on the "as tolerated." Don't be a hero or a couch potato. Please wean from assistive devices as rapidly as it is safe to do so. Some patients have not needed supportive devices from the first step. Most use them for a few days. Unless you have heard specifically from Dr. Harris otherwise, you can be weight bearing as tolerated. If anybody suggests otherwise, please call the office yourself to confirm.


Use supportive devices as you need to, to keep yourself from falling over. Use these devices only as long as you need them, not one day longer. On the flip side, no patient has Dr. Harris's permission to fall and break anything. He does not give out airline miles for your returning to the hospital with something broken


Please use the walker or two crutches until you are ready to discard all supportive devices. A cane can become a self fulfilling prophesy. While using the cane, one does not build muscles properly. Then, one becomes dependent upon the cane. Dr. Harris would much prefer that you go from a walker to nothing, even if it means a day or so longer on the walker.


If you are one of the less than 2% who require some protection, your rehabilitation will start as "touch-down weight bearing." This means that you may rest your leg on the ground, but not add the weight of the body to this. The object is not whether you place your foot flat on the ground, or only your toe. The issue is that you should not put more than the weight of the leg on the ground. This is slightly different from "toe-touch weight bearing" that is frequently taught by therapists. If you think about it, walking on one's tiptoes is both "toe-touch" and "full weight bearing."





Hip Restrictions:

Patients undergoing primary, or first time, total hip arthroplasty will not require hip restrictions! Many therapists won’t believe this one. If the therapist starts teaching you about where you can or can’t put your foot or leg, show them this note!





Hip Restrictions (revision or “re-do” cases):

Most, but not all patients undergoing revision arthroplasty will have hip restrictions. (These are position restrictions – where your leg is in space They are not motion restrictions – how you move your leg.) These restrictions last for only 8 weeks.


You may not cross your legs. The concern here is moving the knee across the midline of the body to the other side.

You may not flex your hip more than 90°. The position of 90° is sitting straight up in a standard chair. The position of the knee is not important.

You may not pivot on your hip. Pivoting maneuvers include turning corners, particularly at landings between flights of stairs, a full swing in golf, and many dancing maneuvers.





Wound Care:

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 for ten to fourteen days after the surgery. Basically, when they start to come loose at the edges, help them off. If they lift up enough that there is a path from the central dressing to the edge, then remove the dressing and start wound care as 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. 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 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.These are waterproof dressings that are available over the counter. 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.If the long term dressing is intact, you may shower without additional preparation.





Blood Thinners:

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.


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 has recently adopted the ACCP 8th edition guidelines. Further, the government, with their great wisdom, have asked the drug companies that make expensive and (in Dr. Harris’s opinion) dangerous drugs to sponsor required educational modules for primary care physicians. By contrast, Dr. Harris has proof 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 for this potential issue.


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.





Dental Work and other procedures after Hip Replacement

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.





Other Frequently Asked Questions and Occasional Problems


1) When can I drive?

There is not a scientific answer to this question. There are many people driving right now that have no business being on the road 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. Dr. Harris is 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 Dr. Harris’ kids were younger, he’d tell the patients that if they were going to drive early, call him at home so that he could keep them inside.


The limited data that does exist tells us that reaction times are not as good as before the surgery for six weeks. Therefore, if you want Dr. Harris’ “blessing” to drive, then you will have to 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.





2) When should the stitches be removed?

In many cases, there are no stitches above the skin. The wound is closed under the skin. When the tapes across the wound look as if they are no longer helping after about ten to fourteen days, then help them off. If you have staples, they should be removed in the office about two weeks after the procedure.





3) Do I have to limit my motion?

MOST PEOPLE DON’T! The whole concept of hip restrictions is a holdover from traditional techniques and earlier designs of implants. Patients who have their first hip surgery with the direct anterior tissue sparing approach do not have hip restrictions.


That being said, most people who have second time surgeries will still require hip restrictions. In this setting, the restrictions last eight weeks. When given freedom to increase your range, Dr. Harris does not suggest that you test it in detail immediately. You should gradually increase your activity and range.





4) How much pain medication should I take?

You should have a prescription for a narcotic pain medicine. Use these as you need them. Some patients need nothing but plain Tylenol after a few days, others will need three to six pills a day for a few weeks. In general, if you feel that you need more than six pain pills per day, then Dr. Harris needs to know about that.


If you have pain, take the medicine. It is legitimate to use pain medicine before physical therapy or exercise sessions. Otherwise, don't take pain medicine "in case you might have pain." Narcotic pain medicines are often not that effective against "soreness." If you primarily have only soreness, try plain Tylenol, or, if you’re using aspirin for prevention of blood clots, an over the counter anti-inflammatory instead of narcotics. (See also below.)


The common prescriptions after surgery all also contain Tylenol. (APAP is an abbreviation for acetaminophen, which in turn is generic for Tylenol.) Total acetaminophen in a 24 hours should be limited to 3 grams (3000 mg).


Please also be careful about the "non-aspirin pain relievers" during the first six weeks. Most of these contain anti-inflammatory medications. (See also below) These are also blood thinners and can interact with the blood thinner that your receive. If you are using aspirin as a blood thinner, they are OK. If you are another blood thinner, they probably are not.


If there is sudden onset of dramatically increased pain, call Dr. Harris immediately. Truly emergent problems that require a late night trip to the emergency room are rare.




5) What about anti-inflammatory drugs (NSAIDs)?

Dr. Harris prescribes an anti-inflammatory drug on the day of the surgery and for a while after that. Thereafter, the use of NSAIDs will depend upon the type of blood thinner that is used. NSAIDs themselves are blood thinners. They belong to the category of thinners known as platelet inhibitors. If you are on aspirin after surgery, it is also a platelet inhibitor. You may mix platelet inhibitors, and use NSAIDs in addition to aspirin. However, if you’re on a different blood thinner, you shouldn’t mix two different types of blood thinners. In that setting, NSAIDs should be avoided.




6) How long do I take Blood Thinners?

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.


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 has recently adopted the ACCP 8th edition guidelines. Further, the government, with their great wisdom, have asked the drug companies that make expensive and (in Dr. Harris’s opinion) dangerous drugs to sponsor required educational modules for primary care physicians. By contrast, Dr. Harris has proof 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 for this potential issue.


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.





7) When may I roll onto the surgical side in bed?

The issue here is potentially twofold. Many people are uncomfortable doing so for a few weeks. For most patients, and for all first time hip surgery patients, comfort is the only issue.


For the few patients who have hip restrictions, the key is the hip position restriction. Dr. Harris really doesn't care if you sleep on your head – so long as you don't violate the hip restrictions. Particularly in a soft bed or waterbed, rolling onto the surgical side will violate the hip restriction of crossing your legs. If you have a hard mattress and can follow the hip restrictions, make yourself comfortable on your side. Enjoy.





8) What about sex?

There are a few potential issues here. The first and most important potential limit is comfort. It may only be a few days, or it may be several weeks until you are comfortable enough to engage in this activity. For most patients, and for all first time hip surgery patients, comfort is the most important issue. The second issue is hip position. Though most patients don’t have hip restrictions, it is probably not a great idea to have an enthusiastic partner put or push your legs into extreme positions during the first three months. Any position that you, the patient feel comfortable placing your leg is fine.


For those patients with weight bearing or position restrictions, a bit more planning is needed. Some people forget that touchdown weight bearing makes it very difficult, for example, to get onto both knees. It is common for a woman in particular, to flex a hip more than 90° during sex. The man may hyperextend the hip (by arching the back with the legs extended), which may be equivalent to "pivoting" on the leg. Spend some time thinking about positions and restrictions and talking about them with your partner ahead of time.





9) What should I do about drainage?

A small amount of drainage is not unusual. In general, the wound should be bone dry within seven to at very most ten days from the time of the surgery. For those with long term dressings, the odds are that the wound would be clean by the time that the dressing is removed. Normal drainage is clear, clear-yellow, slightly pink, or clear and blood stained. If the drainage is cloudy, green, or malodorous, call the office. Drainage that has been sitting on the dressing for a while may change colors on the dressing or become malodorous. The concern is the color of the active drainage, if any.





10) The wound is red or hard. What should I do?

It is common for the wounds to be a little pink after the surgery. If the wound is red, hard, painful, or tender, then you need to be evaluated in the office. Call now!





11) I have a fever of 100°. What should I do?

A low-grade temperature is common after any open orthopedic surgical procedure. This is a result of some blood getting in between the muscles and the body trying to absorb the blood. Temperatures in the 99 to low 100's are not considered fevers. Temperatures over 101° may represent a problem, particularly if you feel "ill" at the same time. A measured oral temperature over 102° should prompt an immediate call to the office.





12) When should I call the office?

If there is something that you don't understand, or if you have a concern not covered in these pages, please call. Dr. Harris is a firm believer that there are exactly two types of "stupid questions." There are those that you don't ask, and there are those that you ask five times. Everything else is legitimate. These frequently asked questions are updated periodically. If there is a topic that you think should be covered and is not, please let us know.























Adam I. Harris, M.D.

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Your Hospital Stay

Discharge Plans

What can I do before to minimize my risk of infection?

Important Information

and

Frequently Asked Questions:

Total Hip Replacement

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Hip Restrictions (revision or “re-do” cases):

Wound Care:

Your Weight bearing Status

Blood Thinners:

"Hip Restrictions":

Dental Work and other procedures after Hip Replacement

4) How much pain medication should I take?

3) Do I have to limit my motion?

1) When can I drive?

2) When should the stitches be removed?

5) What about anti-inflammatory drugs (NSAIDs)?

6) How long do I take Blood Thinners?

7) When may I roll onto the surgical side in bed?

8) What about sex?

9) What should I do about drainage?

10) The wound is red or hard. What should I do?

Important Information

Other Frequently asked Questions

11) I have a fever of 100°. What should I do?

12) When should I call the office?