Joint Replacement Institute

Planning for Your Surgery (Pre-Op)

The following topics will assist you in planning for the day of your total knee replacement surgery:

Arbitration Agreement

Informed Consent

Health Insurance and Prior Authorization for Surgery

Blood

Medications

Weight Reduction and Home Exercises (Knee)

Home Preparation

Medical Evaluation

Pre-operative Orthopaedic Examination

What to Bring to the Hospital

After Your Knee Surgery (Post-Op)

Arbitration Agreement

If you did not sign an arbitration agreement at the time of your initial consultation, one will be presented to you for signature prior to surgery. The physicians will not perform surgery without a signed arbitration agreement on file. These agreements are required by the physicians’ liability insurance carriers.

Informed Consent

It is essential that you fully understand the risks, potential complications and treatment alternatives related to joint replacement surgery. The physician will discuss these issues with you prior to surgery, usually at the time of your initial consultation. Separate "consent" forms will be presented to you by the physician’s office and the hospital’s admitting department for your signature. The physician will not perform surgery without a signed informed consent on file. Please discuss any concerns which you may have with the physician prior to surgery to ensure that you are making an informed decision regarding your health care.

Health Insurance Coverage and Prior Authorization for Surgery

Physicians and hospitals are required to verify your health insurance benefits and obtain prior authorization or "pre-certification" for surgery. In the case of Medi-Cal or other state Medicaid programs, a "Treatment Authorization Request" must be submitted by the physician and hospital and approved prior to surgery. This process may take several weeks. A similar approval process is required for Medicare beneficiaries and other patients who are enrolled in Health Maintenance Organizations (HMO’s). An approved "Referral Authorization" is required from the HMO and/or Primary Care Provider (PCP) before surgery or other treatment can be rendered. Medicare patients who are not enrolled in an HMO do not require prior authorization for surgery. Other insurance plans including Preferred Provider Organizations (PPO’s), Exclusive Provider Organizations (EPO’s) and "fee-for-service" or indemnity type plans usually require prior authorization and may require second opinion consultations. Although our office will verify benefits, request authorizations for surgery and provide supporting documentation if necessary, it is ultimately the patient’s responsibility to ensure that surgery and hospitalization are covered benefits and authorized in advance.

Blood

You'll be asked to donate one or two units of your own blood before surgery. As with many surgeries, bleeding can occur during knee surgery and you may require a blood transfusion. There are several options available to replace the blood you lose during surgery and these include: 1) autologous blood; 2) directed donor blood; 3) banked blood; and 4) cell saver blood.

Autologous blood is your own blood that is set aside before surgery so that it is available during or after surgery if the need for a transfusion arises. Since the blood is your own, it has the advantages over blood from other individuals in that it is incapable of causing stimulation of antibodies to its contents (transfusion reaction). It also carries no risk of transmission of infectious diseases such as hepatitis or AIDS.

Depending on the number of units estimated to be needed for your surgery, you will be advised to begin donating blood in advance of the surgery. Your blood can be kept fresh for 42 days. The interval between blood donations should be no shorter than one week, and the last unit should be drawn no later than 5 days prior to surgery. Patients who weigh less than 110 lbs. are eligible to give smaller amounts (e.g., only 1/2 unit at each donation) and therefore may need to start donating earlier.

The procedure of drawing blood takes about one hour each time, although the first time will take about 15 minutes longer to complete the paperwork. You will be asked to rest for 15 minutes before leaving the donor center. You can drive an automobile if you feel perfectly well but should inform the nurse if you have any doubt. One week prior to when you begin your blood donations and during the donation period until surgery, it is advisable that you take iron (ferrous sulfate FeSO4) 325 mg and Vitamin C (ascorbic acid) 500 mg - 1 of each, three times a day with meals.

Blood can be collected at the hospital or if you do not live nearby, your blood can be donated at another blood bank and transferred to the hospital prior to your surgery. Do not cut the donation schedule too close because your donation schedule can be delayed if you become ill or your blood count becomes too low. This will not allow you to give the necessary number of units.

A special fee must be paid at the time the blood is drawn. These charges pertain even if the blood is not transfused. If you donate your blood at the hospital where the surgery will be performed, then you are usually not required to pay the fees at the time of donation as the charges are included as part of the hospitalization. Autologous blood donation has been highly successful, and in most instances has avoided the need for the use of homologous (another donor's) blood.

Designated Donor blood is donated from someone that you designate in advance, such as family members, relatives, or close friends. These can be arranged if you are unable to donate the appropriate number of autologous units before your surgery. However, the designated donors must have a blood type that is compatible and meet the strict donation criteria of the blood bank. These include no history of previous blood transfusions, hepatitis, or jaundice, no surgeries during the past 6 months, no anti-malaria medication in the last 3 years, no previous donations for 56 days, and age between 17 and 66 years (over 66 requires blood bank doctor's approval). A perfect match may be difficult to find, so your own blood is still the best and highly recommended. Further, designated donor blood has not been documented to be any safer than banked blood.

Banked blood (homologous blood) is donated by volunteers to local blood banks. The donors are thoroughly questioned and tested for potential transmissible diseases and the blood is carefully screened. There is a minimal risk of transfusion reactions. The risk of transmitting HIV is estimated to be 1 in 150,000 units of blood and the risk for hepatitis is estimated at 1 in 30,000 to 1 in 50,000.

Cell saver blood is your own blood that is collected during surgery and reprocessed by a special machine. This blood can then be given back to you during surgery. There are some limitations to this system and the blood cannot always be used. Therefore, other types of blood should also be available. Erythropoietin is a naturally occuring hormone that regulates the production of red blood cells in the human body. Recent advances in technology have provided the basis for the development and production of recombinant human erythropoietin, which is now available worldwide. It is a safe and effective method of increasing the blood volume prior to joint replacement arthroplasty for a selected population which cannot donate blood or accept transfusions because of religious beliefs (e.g., Jehovah’s Witness).

Medication

If you are taking birth control pills, or anti-inflammatory medications such as aspirin, Indocin, Motrin, Feldene, Naprosyn, Voltaren, Lodine, etc., please discontinue their use at least one week prior to surgery. These medicines can cause increased bleeding. If you need pain relief, you can take Tylenol or your doctor can prescribe narcotic pain medication.

Weight Reduction and Home Exercises for the Knee

Keeping your weight down is not only good for your knee, it is good for your general health. You should make an effort to get "in shape" for surgery and, therefore, it is recommended that you begin a preoperative program of exercise (only if it is comfortable to do so). Easy isometrics (muscle tensing exercises) will help maintain the strength of your leg muscles in preparation for postoperative walking. The following exercises can be done in bed. Exercise each leg remembering to breathe normally throughout the exercise. Perform 2-3 times per day.

Gluteal Setting Exercise: Squeeze your buttocks together tightly, hold for ten counts. Relax. Repeat ten times.
Quadriceps Setting Exercise: Tighten the muscle on the top of your thigh by pushing the back of your knee down on the bed. Hold for ten counts. Relax. Repeat ten times.
Hamstring Setting Exercises: Keep the knee bent slightly. Push your heel down into the bed and then pull toward buttocks. Hold for ten counts. Relax. Repeat ten times.
Ankle Circles: With lower leg resting on a towel roll, move the ankle in a circle first in one direction, then in the other. Repeat ten times.
Ankle Pumps: Move the ankle up and down slowly. Repeat 10 times.

You will be using your arms often during the postoperative period while moving in bed and with the walker or crutches. Therefore, strengthening your upper body is also important. Exercises should include:

Pull-ups: While sitting in a chair, hold onto a bar that is overhead and raise your buttocks off the chair. Repeat ten times.
Reverse Push-ups: While sitting in a chair, place your arms at your side and hold onto the chair next to your buttocks. By straightening your elbows, lift your buttocks off the chair. Repeat ten times.
You can also do general strengthening exercises with small weights.

You may wish to consult with the hospital physical therapist before surgery to discuss these and other beneficial exercises.