Prior to your hospital arrival, the anesthesia staff has prepared a preoperative record for you based on information that you, your medical doctor, and I have sent them. On the day of surgery, the anesthesiologist will perform a final review of this record. You will be taken to the preoperative holding area for final preparations. You will change into a hospital gown. The staff will confirm data, take vital signs, and clarify any remaining items. They will insert an intravenous line, draw blood and perform an initial preparation of the area of operation.
You will be asked to sign a hospital consent form for the operation. We have already discussed your operation in the office in detail and answered all of your questions in advance. You have already signed a very detailed consent form in my office. The anesthesiologist will discuss your anesthesia options and answer your questions about these. We will draw a small vial of blood from your IV that will be processed into platelet concentrate and later sprayed into your surgical wound to enhance the healing process. We will ask you to confirm the side of your surgery and mark this with an indelible marker while you are awake to prevent wrong site surgery.
You will be given a number of medications prior to the operation. We utilize a multimodal pain management protocol to minimize your postoperative pain. The first step is to load your system with anti-inflamatory medicine, IV Tylenol, long-acting narcotics, and three anti-nausea medicines before we start the operation. We will also administer an IV antibiotic just prior to starting the operation.
Your partner can stay with you in the preoperative holding area until you are taken to the operating room. At that point, your partner will be directed to the waiting room where I will look for them immediately after the operation to inform them of the result.
You will be taken to the operating room on a stretcher. At that point, anesthesia will be administered. During the entire time in the operating room, a specialized nurse anesthetist (who works directly under the supervision of the anesthesiologist) will carefully monitor you throughout the operation. Once you are under anesthesia, a catheter will be inserted into your bladder, when you are not aware of it. This will usually remain in place overnight to drain you bladder to protect it and to monitor your fluid balance.
If we remove it too soon before the spinal anesthesia has completely worn off, your bladder will not function properly and we will need to reinsert the catheter. Therefore, we usually leave it in overnight the first night and remove it first thing in the morning. Inserting a catheter under anesthesia is painless; removing a catheter the next morning is virtually painless, inserting a catheter on the nursing floor is quite uncomfortable. Next, you will be positioned on the operating table, braced into place and the operative site will be prepared.
My preference is spinal anesthesia with sedation because the recovery is smoothest and least painful with this technique. Safety of spinal and general anesthesia is similar. There may be certain situations where the anesthesiologist feels that one type is better, and you should follow their advice. Usually both types will work, and it is your choice. In a spinal anesthesia, a very thin needle is inserted into the fluid around your spinal cord in the lower back and local anesthetic medicine is injected. The exact type of medicine that the anesthesiologist chooses, determines the duration of the effect. Your legs will become completely numb and you will not be able to move them. The anesthesiologist will give you a sedative prior to the procedure so that you won’t be uncomfortable.
Once the spinal anesthesia has taken effect, the anesthetist will administer additional sedatives through your IV so you sleep through the operation. They will monitor you and administer medication as needed. If the spinal does not work properly, the anesthesiologist will then convert to a general anesthesia technique. This is required in less than 1% of patients. The surgery can be performed under spinal with you fully awake because your legs are numb, but I don’t recommend this. You can tell the anesthesiologist how deeply you prefer to sleep. Most people choose heavy sedation; they wake up in the recovery room only vaguely remembering that they bent over to get a spinal.
After you are under anesthesia and positioned and prepped and draped, I enter and perform the operation. Before starting, we always confirm the operative site by the marks we placed on your skin earlier, and we review the written paperwork. Lee Webb, my nurse practitioner, is usually my first assistant in the operation. I always perform the operation personally. No residents, fellows or other surgeons will ever perform the operation. Usually, two surgical technicians are scrubbed in to assist. A circulating nurse is in the operating room to assist as well. The nurse anesthetist continues to monitor you and consults with the anesthesiologist as needed.
Details of your specific operation were discussed with you prior to surgery. Whenever possible, I perform minimally invasive procedures. Patients who are large, have previous scars or complex deformities, or need revision surgery typically require larger incisions. My standard hip incision is 3-5 inches long, while knee incisions are 4-6 inches long. Because I use minimally invasive techniques and a tissue sealer device, blood loss is low, and less than 1:1000 need a transfusion. The national rate of transfusion for joint replacement is 30%. In selected cases, we use a cell saver that can process and allow us to re-infuse blood lost in surgery. Usually, we do not lose enough blood to make this practical.
At the end of the operation we spray your tissues with platelet concentrate processed from your own blood to speed up the healing process. We also inject local anesthetic to reduce postoperative pain. In addition to the IV antibiotics that you receive, we irrigate your wound copiously with a dilute betadine solution with a jet lavage and place concentrated antibiotic powder directly into your wound. We operate in an ultraclean operating room with over 25 complete filtered air changes every hour. All personnel that are scrubbed wear a personal body exhaust system that prevents them from shedding bacteria into your wound. Your tissues are closed with multiple layers of absorbable sutures. They usually dissolve in about 3-4 months.
All sutures are under the skin; none require removal. We then place a silver impregnated antibacterial dressing over your incision that will stay on for one week. This further protects you from infection. It also makes it convenient to shower immediately after the operation. With the comprehensive infection prevention program that we have developed, my deep infection rate is 0.2%. The national average for joint replacement is tenfold higher.
Over many years of perfecting our techniques we have developed a program that allows us to perform a joint replacement with minimal pain, low blood loss, rare infection and a rapid recovery.
Multimodal Pain Management Protocol
RESULTS – Minimal pain, 1-2 day hospital stay, no rehab center; Outpatient joint replacement in selected patients
NATIONAL BENCHMARKS – 3-5 day hospital stay plus rehab center
Comprehensive Blood Management Protocol
RESULTS – Less than 1:1000 transfusion rate; Most revision surgery without transfusion
NATIONAL BENCHMARKS – 30% transfusion rate higher in revisions
Infection Prevention Protocol
RESULTS – 0.2% deep infection rate
NATIONAL BENCHMARKS – 1-2% deep infection rate