The weeks before knee or hip replacement

What the research says: a modest head start, with weak evidence.

AAOS OrthoInfo: “Ask your doctor about exercises you can do before surgery.” It adds that a stronger upper body makes crutches or a walker easier, and that learning the after-surgery exercises now means you are ready for them.

In plain words: getting stronger before surgery usually helps a little before the operation and in the first weeks after it. It is not a promise of a faster recovery, and for hips there is not enough research to say.

The home routine

The 2 to 4 week routine lives on one page, Get stronger before surgery, so its doses never differ from this one. It is taken from the AAOS Knee Conditioning Program and Hip Conditioning Program: a daily walk, then half squats holding a chair, straight-leg raises, side leg lifts and calf raises, three days a week, building from 1 set to 3. It has its own one-page print sheet with a tick box for each day.

The AAOS programs say you should not feel pain during an exercise; if you do, talk to your doctor or physical therapist.

Set it up before you go, and try it out.

MedlinePlus: plan this “well in advance of your surgery so you can test the preparations you have made.” Tick what is done.

• Someone to drive you to and from the hospital, and to stay with you or check in every day. MedlinePlus: if no one can help for the first 1 or 2 weeks, ask your surgeon about a trained caregiver coming to your home. AAOS · MedlinePlus 000167
• A bed, a bathroom (or a portable commode) and the things you use, all on the floor where you will spend most of the day. Limit stairs to once a day. MedlinePlus 000167
• A bed low enough that your feet touch the floor when you sit on its edge. MedlinePlus 000167
• Throw rugs taken up; electrical cords fastened to the edges of the room. AAOS
• Things you use often (phone, medicines, glasses, remote, water) at arm level, so you do not reach up or bend down. AAOS
• A chair with a firm back in each room you will use, so you can sit for daily tasks. MedlinePlus 000167
• If you can, borrow a walker, cane or crutches before surgery and practise moving through your home with it; move furniture if you need to. AAOS
• In the bathroom, if possible: a shower chair, grab bars (never a towel rack) and a raised toilet seat. AAOS · MedlinePlus 000167
• Meals ready: cook double batches and freeze half for 1 or 2 weeks, or stock up on ready-made food. AAOS
• A bag or basket on the walker, or a fanny pack, to carry your phone and a notepad. MedlinePlus 000167
• If you or your driver needs one, apply for a temporary disabled parking permit several weeks before. AAOS

Ask your surgeon, health care provider or physical therapist about getting your home ready (MedlinePlus). The interactive version, which turns what is not ready yet into a to-do list, is the Know before you go worksheet. After surgery, how to lie, sit and move around at home: the first weeks at home.

One list you can hand to every person who asks.

AAOS: many people will ask the same questions, and the repetition is part of keeping you safe. Write it down once.

• The family member or friend who will come to appointments, drive you on the day, and help you remember instructions.
• Every doctor you see: name, phone number and why you see them.
• Your health conditions (for example diabetes, asthma, anemia, high blood pressure) and past operations.
• Every medicine, vitamin and supplement, with how much and how often. Your doctor may ask you to stop some a week or two before surgery.
• Allergies or bad reactions to drugs or anesthesia, and what happened.
• Food restrictions and food allergies.
• Your insurance card, and copies of any care-wishes papers you have signed, such as a living will.

From AAOS OrthoInfo, Preparing for Joint Replacement Surgery.

Bring these, and write the answers down.

AAOS: “Don't be afraid to ask questions, especially if you don't understand something.” Picked from its list of questions patients should ask:

1. If I do not have surgery, what are the short-term and long-term risks?
2. What are the results and complication rates for the operation you recommend?
3. How many of these do you, and this hospital or surgery center, do each year?
4. How long will I stay? Can I go home the same day?
5. Will I need a walker, crutches or a cane, and for about how long?
6. Is physical therapy necessary after surgery? If so, where will it happen, and who books the first visit?
7. Will I go straight home, or to a rehabilitation facility first? If a facility, can I tour it and meet the staff before surgery?
8. Which exercises will you prescribe after surgery, so I can learn them now?
9. How much pain should I expect, and how will it be managed at home?
10. When can I shower, and when do stitches or staples come out?
11. What will I be able to do, and not do, after surgery?
12. Am I at greater risk for any complication, and what can I do to lower it?
13. Which signs after surgery mean something is wrong, and who do I contact, and how?
14. Will I need antibiotics before dental work afterwards?

The last two questions come from AAOS, Preparing for Joint Replacement Surgery: if going straight home is not possible, the doctor and the social work team help choose a rehabilitation facility, and you can tour it before surgery; learning the exercises now means you are ready to do them afterwards.

The full list: AAOS OrthoInfo, Questions Patients Should Ask Their Surgeon.

Some pain is expected. Plan for it before the day.

• After surgery you will feel some pain. AAOS calls it “a natural part of the healing process”, and says reducing it can help you recover faster. AAOS Total Knee Replacement
• Your doctor may combine several kinds of pain medicine (for example acetaminophen, an anti-inflammatory, a local anesthetic and, for a short time, an opioid) to give better relief with less opioid. For a knee, a regional nerve block may also be used; AAOS says to discuss that with your surgeon and the anesthesiologist. AAOS Total Knee · Total Hip Replacement
• Get the pain prescription filled on the way home, so you have it when you need it. MedlinePlus 000170 · 000169
• Take the pain medicine when pain starts; waiting lets it get worse than it should. In the early weeks, taking it about 30 minutes before exercises or more activity can help. Never double up if you miss a dose. MedlinePlus 000170 · 000169
• After a knee replacement: ice the knee for 30 minutes before and 30 minutes after activity or exercises, to bring the swelling down. MedlinePlus 000170
• Opioids can be addictive. Use them only as directed and stop as soon as the pain begins to improve. If the pain has not begun to improve within a few days of surgery, talk to your doctor. AAOS Total Knee Replacement
• Pain that does not go away after you take your pain medicine is a reason to call your surgeon. MedlinePlus 000170 · 000169

What it can and cannot do

AAOS: most people who have a total knee or hip replacement get a large drop in pain and can do everyday activities much more easily. It does not let you do more than you could before the arthritis. Most surgeons advise against high-impact activity such as running and jumping afterwards; walking, swimming, golf, driving, hiking and biking are on AAOS’s list of realistic activities. These describe most people in general, not a promise for you; ask your surgeon what to expect for your own joint. The published numbers before consent are on Surgery or nonsurgical care first.

Walk through the first day home before surgery.

MedlinePlus: by the time you go home you should be able to walk with a walker or crutches without much help, get in and out of bed or a chair by yourself, dress with a little help and use the toilet without much help. Try each step below at home, as if it were that day, and tick it when it works. Something that does not work yet is your to-do list.

• From the front door to the bed, the bathroom and your chair: the path is clear of rugs and cords and has good light. With a walker if you can borrow one. AAOS · MedlinePlus 000170
• Sit on the edge of the bed: your feet touch the floor. After a hip replacement, your hips are also higher than your knees. MedlinePlus 000170 · 000169
• The chair you will use has a firm back. After a hip replacement, it is not a low chair or a soft sofa. MedlinePlus 000170 · 000169
• The toilet and shower: a hand rail by the toilet and in the shower, a slip-proof mat, and a raised seat or shower chair if your team suggests one. MedlinePlus 000170 · AAOS
• Phone, medicines, glasses and water are at arm level on the floor where you will spend the day, so you do not reach up or bend down. AAOS · MedlinePlus 000167
• A bag or basket on the walker, or a small backpack, for your phone and a notepad: your hands are for balance. MedlinePlus 000170 · 000169
• Shoes that fit well with non-skid soles are by the bed; no slippers or high heels. MedlinePlus 000170
• The person who will be with you for the first 1 to 2 weeks knows the plan. If no one can, you have asked your surgeon about a trained caregiver. MedlinePlus 000170 · 000169
• Who picks up the pain prescription on the way home is decided. MedlinePlus 000170 · 000169
• The surgeon’s office number and its after-hours number are written by the phone, with the signs that mean call 911 (the list; to check a sign later, Is this normal, or call now?). MedlinePlus 000170 · 000132

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Tell the office about anything new.

• A fever, cold or any other illness in the week before surgery: call your doctor. AAOS
• Any cut, scratch, rash or bug bite on the leg being operated on: tell your doctor. A break in the skin raises the risk of infection, and an infection means the surgery is cancelled. AAOS
• Dental work such as an extraction: schedule it well before surgery, and no dental work, cleanings included, for several weeks after. AAOS
• Alcohol: none for at least 48 hours before surgery. If you smoke, cut down or quit; it slows healing. AAOS
• Eating and drinking before surgery: AAOS says nothing after midnight the night before, but your team’s own instructions come first; follow theirs exactly. AAOS
• The night before: shower or bath. If your surgeon’s team gives you an antibacterial soap or other medical wash, use it the way they tell you; AAOS says this helps lower the risk of infection. Do not shave where the operation will be; if shaving is needed, it is done at the hospital. AAOS
• The night before: check your skin all over in a mirror, including the groin, under the breasts, behind the knees and under the arms. Tell your doctor about any break in the skin. AAOS