Slide 1-
Welcome to the UVA joint replacement patient education video. My name is Shelly, and I'm one of your joint replacement coordinators here at UVA Orthopedics. This video will discuss ways for you to prepare for your upcoming joint replacement surgery. This will include preparing your home and self for the upcoming surgery as well as what to expect after you have surgery. We have created an enhanced recovery program to get you back to a healthier and more active lifestyle, and we will discuss this more in detail in the upcoming sections. So set back, relax, and enjoy this presentation. 

Slide 2-
We are very proud to be certified for Advanced Total Hip and Knee Replacement by The Joint Commission. With this distinction, you can expect outstanding care from the UVA joint replacement team. 

Slide 4-
You will soon be having your hip or knee joint replaced, and this graphic shows what is involved in joint replacement surgery. The total knee replacement procedure involves the surgeon removing damaged cartilage and bone from the surface of your knee joint and replacing it with artificial components made of metal and plastic.  Like the knee replacement procedure, the total hip replacement procedure involves removing damaged bone and cartilage and replacing it with artificial components made of metal and plastic. The most common reason for patients to need a total knee or total hip replacement is osteoarthritis.

Slide 5-
Enhanced Recovery After Surgery, or ERAS for short, is a program developed to help you return to normal as quickly as possible. It involves preparing for surgery, such as watching this video and reviewing your binder, development of a pain management plan that works for you, eating and drinking soon after surgery, and getting up and moving soon after surgery. 

Slide 6-
Enrolling in MyChart is an important part of your surgical plan. MyChart is an easy way for you to communicate with your surgeon and their team, and will be the primary communication tool used by your surgeon and the team to monitor your recovery. After your surgery, you will begin to receive a questionnaire through your MyChart account. It will ask you questions about your recovery and your responses will be monitored by the surgical team. The recovery questionnaire will be sent to you every 3-4 days after your surgery, starting the day after you go home. You will continue to receive the questionnaire for six weeks. If you do not have MyChart, any team member can help you enroll. 

Slide 7-
In this section, will cover how to best prepare for surgery

Slide 8-
The best way you can prepare your body for surgery is to get it in the best physical shape before you have surgery. This includes maintaining a healthy weight, smoking cessation (if applicable), keeping the surgical site clean and healthy, maintaining a regular bowel routine, and staying active through low impact exercises such as walking. 
If your surgeon has asked you to lose weight, even a small amount of weight lose can have a big impact on the amount of pressure that is going into your new joint. 
If your surgeon has asked you to stop smoking and you are having difficulties, please reach out to your primary care provider or your RN joint care coordinator for advice. Nicotine can affect the ability of the incision to heal and can contribute to other post-op complications.
It is very important to keep yourself and your skin healthy. Practice good hand hygiene and avoid sick contacts in the weeks leading up to your surgery. The skin at the surgical site needs to be clean and free of cuts, abrasions, bruising, sunburn, or rashes. If there is an opening in the skin where the surgeon will operate, they may need to postpone your surgery because of the risk of infection. If you are feeling unwell or have any of the skin conditions mentioned, please reach out to the clinic as soon as possible for guidance. 
The better you can make your current health, the better your recovery will be.

Slide 9-
Before your surgery, there a few very important appointments that you will need to keep. Once the surgeon has decided that having a total hip or a total knee replacement surgery is your best option for helping manage your pain and discomfort, you will be asked to make an appointment with your primary care provider and potentially, any specialty provider that you see regularly. This is to make sure that everything is medically okay and you are okay to proceed with surgery.  This is a very important appointment, and you must have it to prevent your surgery from being cancelled. It must be completed prior to your orthopedic work up appointment. Your visit with your primary care provider will include a pre-operative evaluation, a physical, bloodwork, an EKG to look at the rhythm of your heart, and a chest XRAY if appropriate. After this appointment, you will have a consult with one of the joint replacement nurse care coordinators to confirm your discharge plans, review any needed education or screenings. 
Your orthopedic work up appointment is approximately 2-4 weeks before your surgery. At this appointment you will complete any necessary paperwork and have an opportunity to ask any questions that you may have about your surgery. 
You may also be seen or called by the pre-anesthesia evaluation and testing center, or PETC. You will be contacted by the PETC team if a visit or phone call is necessary. PETC reviews all posted surgery patients and determines if you will need a visit or a phone call based on your medical history.  

Slide 10-
An important part of preparing for your surgery, is making sure you stop taking certain medications at specified times. 14 days before your surgery, we ask you to stop taking any multivitamins or over the counter herbal or joint supplements.  days before surgery, we ask you to stop taking any aspirin and any products that may contain aspirin. Aspirin can be found in places that you may not expect such as Pepto-Bismol so please make sure that you are reading the labels of any medications that you take to ensure it does not contain aspirin. We also ask that you stop taking any over the counter non-steroidal anti-inflammatories such as Ibuprofen (brand names: Advil or Motrin) or Naproxen (brand name: Aleve). You will also stop taking any prescription non-steroidal anti-inflammatories such as Voltaren, Diclofenac, Mobic, or Celebrex. 
If you are taking a blood thinner like aspirin for cardiac stents, a history of a stroke, or as prescribed by your provider, we will need your provider to tell us when it is safe for you to hold this medication. Continue taking this medication until instructed to stop.
If you are taking any other prescribed medication, you should continue to take it until you are instructed to stop.
  
Slide 11-
An important part of your recovery is having a discharge plan. A joint replacement nurse care coordinator will review your discharge plan with you and your care partner. The discharge plan includes:
* Identification of a care partner to help you in the first few days after surgery
* A post-operative physical therapy plan for you to use when you discharge home. You will follow a self-directed physical plan for the first two weeks after surgery. At the start of the third week you will begin outpatient physical therapy.
* Preparing your home and having your equipment, like a walker and cane, before surgery
We will talk more about these things as we go through this seminar. As you are thinking about your discharge plan and have any needs associated with getting the equipment, transportation, food, or lodging, please contact the clinic and ask to speak with the orthopedic social worker. They are here to help connect you with community resources. 

Slide 13-
We spoke about having a care partner to help you in your recovery, but there are some specific things that we will ask of your care partner. As a reminder, anyone can by your care partner as long as they can be available to you for the first few days. This may be your spouse, partner, friend, neighbor, child, or family member. You may also have more than one care partner. 
We will ask your care partner to help get you meals, take care of any errands, provide care for pets and children, and help you with your exercises. This will allow you to focus on your recovery. They may need to assist you with personal care needs, so make sure you choose someone that you feel comfortable with.
The care partner will need to be able to provide transportation to the surgical site on the day of surgery and to take you home after discharge. They will also need to be available to take you to any appointments until you are ready to drive again. Your care partner will need to be present at the time of discharge so that they are able to listen to your discharge plans and physical therapy instructions. Finally, we ask your care partner will be your biggest cheerleader through your recovery. 

Slide 14-
Preparing for surgery includes infection prevention, and we will discuss a few things that will need to be started before your surgery. During your clinic work up appointment, you will be provided with a small bottle of antibacterial body wash. This body wash is to be 3 days prior to surgery, including the night before surgery and the morning of surgery. The body wash should only be used from the neck down, avoiding the hair, face, and genital area. You may use your normal shampoo and soap for the hair, face, and genital area. The antibacterial body wash is pink in color and could stain your washcloth, so you may want to use a dark colored washcloth. Once you have fully soaped up with the antibacterial body wash, rinse thoroughly and dry off with a clean towel. Please do not use regular soap after using the antibacterial body wash. Do not use any creams, lotions, perfumes, powder, or deodorant after using the body wash. A
You will also be provided a prescription for mupirocin antibacterial ointment at the work up appointment. This is to be applied to the inner rim of each nostril for the 3 days prior to surgery. You will place the ointment around the inner nostril rim 2 times on each of the 3 days. 
We also ask that you begin taking Miralax 3 days prior to your surgery. Maintaining a regular bowel routine is important as constipation following surgery is very common due to the medications that you will be taking. You will be moving around less than you normally do. Please do not take Miralax on the morning of surgery. You can resume taking Miralax the day after your surgery and should continue to take it while you are taking narcotic pain medication. 
Finally, make sure you have clean bed linens and pajamas the night before surgery. We ask that the night before surgery, you shower with the antibacterial body wash, dress in clean pajamas, and sleep in clean bed sheets. 

Slide 16-
In this section, we will discuss what to expect right before your surgery date

Slide 17-
You will receive a call instructing you on when to arrive at the surgical site depending on where you will be having your surgery. If you are having your surgery at the Orthopedic Center at Ivy Road, a nurse will call you 3 business days before your surgery. For patients having surgery at the main hospital, a nurse will call you 1 business day before your surgery. During this call, the nurse will review what time you need to stop eating solid foods, what time to stop drinking any fluids, and go over any medications that you take. It is very important to follow the directions given to you by the nurse very carefully. Eating or drinking after the time stop time, can potentially delay or cancel your surgery. 
If you do not receive a call by 6 pm on the night before surgery, please call the number that is listed in your binder for further instructions. 

Slide 18-
The day before surgery is the day to do a final check that you have everything you need. We ask that you purchase a 20oz Gatorade or 20 oz of water if diabetic, to drink before the instructed time. For example, if the pre-op nurse tells you to stop drinking liquids at 5 am on the morning of your surgery, you should completely finish your 20 oz of Gatorade or water before this time. This is to make sure you are well hydrated before you have surgery. 
You should confirm your care partner and take a look around your home to make sure it is arranged in a way that will make it easy to get around. Remove any tripping hazards such as electrical cords, throw rugs, and any uneven surfaces so that you donŐt risk falling after your surgery. Installing night lights and making sure you have secure hand rails will also help you move around safely after surgery. It is much easier to move furniture and household items and get your home prepared before you have surgery. 
Make sure you have your needed equipment, such as a front wheeled walker, your overnight bag, your joint replacement binder, or your cpap or bipap machine if applicable. It may help to lay out any items the night before surgery, so you donŐt forget anything. You do not have to bring your walker into the surgical site, but you should keep it in the car to assist you when you get home.  
Finally, make sure that you are feeling well and the skin around your surgical site is healthy. If you have any concerns with your skin or your health, please call us at the orthopedic clinic. 

Slide 19-
LetŐs discuss what you can expect on the day of surgery

Slide 20-
Before you leave your home and head to the surgical center, make sure you have finished your Gatorade or water before the instructed time. Remember, do not drink anything after this. 
You will also need to shower using the antibacterial body wash, avoiding the hair, face, and genital area. Once you have completed your shower, dry yourself with a clean towel and dress in clean, loose, comfortable clothing. Do not use any lotions, creams, deodorant, perfumes, or powder. You will also need to remove any nail polish, jewelry, and piercings. 
Remember to bring any paperwork given to you by the surgeon and their team, a copy of your advanced directive if you have one, any toiletries you may need, your capap or bipap machine, your joint replacement binder, and a list of your current medications. 

Slide 21-
Once you arrive at the surgery center, you will be checked at the instructed location and taken to the surgical admissions suite, or SAS for short. In SAS you will be prepared for surgery by the care team. They will verify your name, date of birth, and what surgery you are having. An IV will be placed and medications administered. You will meet the anesthesia team who will discuss the type of anesthesia you will be having including discussing placing a nerve block if you are having a knee replacement. A nerve block can help with the pain during and after surgery. You will also meet your surgeon and their team prior to going back to the operating room. During your time in SAS, your care partner will be able to stay with you. Once you are taken to the operating room, your care partner will be asked to wait in a waiting room.

Slide 22-
When you are taking to the operating room, you will be asked to verify your name and date of birth. We do this may times to confirm you are you. You will be hooked up to monitors and a compression boot will be placed on the foot that is on the non-operative leg. You will also receive the anesthesia that was agreed upon by you and the anesthesiology team, for most this is a spinal block. You will also receive medications through your IV to make you comfortable throughout the surgery. 
Right before the surgery begins, the team will do a time out. This includes confirming your identity and the location of your surgery. 
For most joint replacement surgeries, you can expect to be in the operating room for 1.5 to 2 hours. 

Slide 23-
When your surgery is complete, you will be taken to the post anesthesia care unit, or PACU, to begin your recovery. In the PACU, your vital signs and response to anesthesia will be monitored and you will receive pain medication. When you are awake, you can begin to drink clear fluids. You care partner(s) will be updated on your recovery and when you are awake, your vital signs are stable, and your pain is well controlled, you will be transferred to the recovery unit. The amount of time that you can expect to stay in the PACU will vary from person to person.

Slide 24-
In the recovery unit, you will have your vital signs taken and be allowed to eat and drink. The nurse will stop your IV fluids and encourage you to take deep breaths. You will be evaluated by the physical therapist who will work with you on getting out of bed, getting up and down from the chair and commode, going up and down stairs, and walking with your walker. The physical therapist will work closely with your nurse to make sure your pain is well controlled before you get up the first time. Before you go home, the therapist will also help you get dressed and practice getting in and out of the car. At this point you are almost ready to go home!

Slide 25-
You are ready to go home when you care team determines that your pain is well controlled, you are up and moving around, you are eating and drinking, and you have used the bathroom. Prior to going home, the team will review who will be taking you home, your pain medications, your blood clot prevention medications, your physical therapy plan, how to care for your incision, any activity limitations and guidelines, and when to come back to see your surgeon.  It is important that your care partner be present to listen to these instructions too. The instructions will also be printed and sent home with you. 

Slide 26-
Now letŐs cover your road to recovery at home. 

Slide 27-
Managing your pain is our top priority as you begin your recovery. We will help you set a realistic pain management goal so that your pain is well controlled after surgery, and you will receive and be sent home with oral pain medications.  Pain, swelling, and bruising are a normal part of the recovery process following joint replacement surgery. You may experience increased pain, swelling, and bruising during the first few days after surgery, but this should improve as your new joint heals. 
To help control pain, a combination of therapies is recommended and include oral pain medications, a regional nerve block that is placed on the day of surgery, cold therapy, and physical therapy. 
Cold therapy helps control pain and swelling, and you will be sent home from the surgical site with reusable gel packs and a wrap. Combining cold therapy with elevation is also recommended to help with swelling. 
You may need narcotic pain medications to help control pain in the days following surgery. You should begin to taper or decreased the amount of narcotic pain medicine used as your body heals and your pain improves. Taking too much narcotic pain medication can have serious side effects and more detail on weaning these medications can be found in your joint replacement binder. 

Slide 28-
Earlier, we talked about the importance of having a regular bowel routine prior to surgery, and now we are going to go over how to maintain a regular bowel routine after surgery. Constipation is very common after joint replacement surgery due to the use of narcotic pain medications, decreased activity, and often, decreased fluid intake. 
It is very important to avoid constipation, and you can do this by taking a daily stool softener such as Colace and a laxative medication like Miralax every day while you are on narcotic pain medication. You can also help prevent constipation by drinking 6-8 glasses of water, eating a high fiber diet, and getting up and moving every hour. 
The goal is for you to have a bowel movement at least once every three days. If you do not have a bowel movement despite modifying your diet or taking the recommended over the counter medications such as Miralax or Colace, we recommend adding an over the counter suppository such as Ducolax.  

Slide 29-
In addition to constipation prevention, we also will prescribe treatments to prevent blood clot formation. While you are recovering in the post anesthesia care unit, you will have mechanical foot pumps on your feet. These will inflate and deflate while you are resting in the bed and help pump fluid form your feed back to the heart. Once you are up and moving around, your team may determine that you do not need these any longer.
You will also be instructed on how to perform ankle pumps while you are resting in bed and will continue to do the ankle pump exercises after you get home. You can find instruction on ankle pumps in the section 3 of your joint replacement binder. Moving your body is the most important way to prevent blood clots and that is why we want you to get out of the bed with the help on physical therapy soon after surgery. 
You will also be provide with a blood thinner medication which will be started in the hospital. Common blood thinner medications include aspirin or Eliquis. Your surgeon will prescribe one of these medications based on your health history. You will continue to take this medication after you go home, following the instructions given to you on your discharge paperwork. 

Slide 30-
When your surgeon is finished with your surgery, a dressing will be applied to your closed incision in the operating room. This dressing will stay on for 7 days. During this week, the dressing cannot get wet so you will need to refrain from showering for the first 7 days after surgery. After 7 days, you will be instructed to change the dressing with the supplies that you purchased prior to surgery. Items to have at home are listed in your binder and include gauze and paper tape. At this point you can also take a shower which is a day most people look forward to. 
Before you leave the surgical center, you will receive instructions on how to care for your incision after the surgical dressing is removed. Most people will have their incision closed with absorbable sutures, glue, and steri-strips; however, your surgeon may had decided to use non-absorbable sutures. You will be told if your sutures are non-absorbable and when to return to clinic to have them removed. If you have non-absorbable sutures, you cannot shower until they have been removed which is typically 10-14 days after your surgery. 
Remember, no creams or lotions should be applied to your incision until it is fully healed. You should also not take any tub baths, get in the hot tub, or use a swimming pool for at least 6 weeks or until you are instructed it is safe. 
Please try your best to not allow pets in the bed with your while you incision is healing. We realize that this is often easier said than done, and you may have to have your care partner assist with this. 

Slide 31-
The surgery team requests that you refrain from routine dental cleanings and procedures the week prior to your surgery and for 6 months after your surgery. Please try to get your routine cleanings done before your surgery. If you have a dental emergency and require an urgent dental procedure during this time, please seek dental care and notify your surgeonŐs office. Your surgery team will most likely prescribe antibiotics to prevent any potential infection. 

Slide 32-
A very common side effect of having joint replacement surgery is difficulty sleeping at night. This can be due to pain, medications, anxiety, or a change in your preferred sleeping position. The good news is that this will get better; however it can last for a few weeks to a few months. There are some techniques to assist with sleeping better and those include maintaining a bedtime routine and going to bed around the same time each night. Avoiding daytime naps and limiting distractions like electronic devices at bedtime can also help. Additionally, taking your pain medications as prescribed and using your ice therapy before can help manage the pain and allow you to rest better. 

Slide 33-
When can I drive after surgery is a question that you may have. This is a very common question, and we often ask you to be the judge of when you will be able to safely operate a vehicles. You should not drive if you are taking narcotic pain medications, do not have full control of your legs, are using a walker, or have any special precautions, such as weight bearing restrictions. For most people, it is at least 4 weeks before they determine that they can drive. 
You will be able to ride in the care after surgery using the techniques and precautions that will be reviewed by the physical therapist before your leave the surgery site. 


Slide 34-
We will want to follow you closely for the first year after your operation.  You will have a 6 week appointment to come back and see your surgeon. At this visit, x-rays of your new joint will be taken and your surgeon will evaluate your progress and determine future follow-up visits. It is very important that you keep this appointment with your surgeon.

Slide 35-
The total joint zone tool is provided in your book as a quick visual reference to understand your recovery. This outlines symptoms you may be experiencing and how to respond to them. If you are in the green zone, it means your symptoms are under control. It is important to note that it is common to have a low-grade temperature elevation in the first few days after surgery. You should also expect bruising. Sometimes the bruising can occur from your toes up to your groin, and this is expected. Swelling is also expected and can be relieved by elevating the extremity and using your cold therapy. Your swelling should be decreasing as you recovery from your surgery. It is important to that you continue to increase your activity and be able to tolerate your physical therapy. 
If you are in the yellow zone, we want to know about that. If you are experiencing a temperature over 101.5, notice drainage, redness, or odor from your incision, or if your swelling is not improving or get worse, we want you to contact us at the clinic. If you experience any of the symptoms in the yellow zone, please call the orthopedic center to speak with a nurse. They will help determine if you should be seen at the clinic or monitor the symptoms. 
Any symptoms that are in the red zone are considered a medical emergency and you should go to the emergency department or Call 911. For example, if you have unrelieved shortness of breath, chest pain, or a lot of bleeding from your incision, you should seek care at your nearest emergency department or call 911. 
Please review this in your book so that you can monitor your symptoms as you recover. 

NEED PT INSIGHT SLIDE WITHOUT PT PICTURES Slide 36-
Physical therapy is an important part of your recovery after surgery. We will take some time going over some helpful physical therapy tips.

Slide 39 & 40-
Before your surgery, you will need to get a front wheeled walker and a single point cane. You will be using your walker for the first 2 weeks after surgery. Transition from the walker to the cane should be guided by your outpatient physical therapy team which you will begin visiting on week 3 after your surgery. 
Ensuring that your walker and cane is the correct height is important and will make getting around after surgery easier. The handle of the walker and cane should be at the level of where your wrist bends. If you borrowed a walker or cane from a neighbor or friend who is not the same height as you, you may need to adjust it. If you need help with adjusting it or want to make sure it is the correct height, bring it with you to the surgical site and the physical therapist will make sure it is at the correct height for you. 
We do not recommend a walker with 4 wheels, commonly known as a rollator, because it will often move faster than you do after surgery. In this case, more wheels is not better!
A walker and a cane will definitely be required after surgery, but there are a few different pieces of equipment that are optional to use. Some people may find that a raised toilet seat with arm rests is helpful to get on and off the toilet. Other pieces of equipment that you may want to consider is something to sit on when you can take a shower, a leg lifter, or a reacher/grabber. Again these are optional and you may want to wait to see how you are feeling after surgery before purchasing or borrowing these. 

Slide 41-
When you come home after surgery, you will want to make sure that you have a place to sit that is comfortable and safe for you and your new joint. Choose a chair that is sturdy and has good armrests so that you can get up and down from the chair easier. Keep in mind that higher, firmer surfaces with arm rests are easier to use than lower, softer surfaces. We also do not recommend chairs that rock, roll, or slides because you need a stable sitting surface. 
You will need to have a chair that reclines or have an ottoman or stool available to prop elevate your leg on. This will help with swelling. We do not want you to have your legs bent over the edge of the chair for long periods of time as this too can make your lower leg swell more and create stiffness, especially for knee replacement patients. 

Slide 42-
Movement after surgery is very important. You will be doing a self-directed home exercise program for first 2 weeks after surgery and begin your outpatient physical therapy on week 3. You will receive an outpatient physical therapy prescription at your work up appointment, so you will want to get an appointment before your surgery date.  
Before you leave the surgical site, you can expect your physical therapist to review the exercises that we will be asking you to do when you get home. The exercise instructions can also be found in section three of your joint replacement binder.  
The physical therapist will also make sure you can get up and down from the bed, chair, and toilet. They will instruct you on how to safely get your clothes on and off, how to walk and use stairs safely, how to get in and out of the car, and teach you how to position your leg. They will also make recommendations on how to better manage your pain. 


Slide 43/44-
We use the term active rest to describe what you should be doing at home for the two weeks after surgery. We use this term because we want you to be active, but not over do-it. Your body is healing, and we want you to rest. 
But we want you to move every 1-2 waking hours to keep your joint limber. This is the walking program that you will be following for the first 2 weeks.  If you stay in one position for longer than 2 hours while you are awake, you will be more still and sore the next time you move. 
The exercises that are in your binder and will be reviewed by the physical therapist before you go home should be completed 3 times per day.  You may want to think of them as breakfast, lunch, and dinner exercises. The only thing to remember is to not do your dinner exercises too close to your bed time as it could contribute to difficulty sleeping. So, make sure you are doing your exercises a least a couple of hours before bed. 
For the total knee replacement patients it is especially important to perform your bending and straightening exercises as instructed to avoid contractures and scar tissue build up. 

Slide 45-
Your activity after your joint replacement will be guided by your physical therapist and your surgeon. They will be able to guide you on what long term activities will be good for you and your new joint. 
Some activities that your surgeon may recommend include walking, swimming, golfing, cycling, or light tennis. We recommend avoiding activities that cause a lot of heavy pounding on your joints such as jogging, running, or high impact activities or contact sports. 
It will take some time for your muscles to strengthen and your joint to regain full mobility. We expect it to take up to a full year for you to get the full benefit from having a joint replacement surgery. 

Slide 46-
We thank you for choosing UVA Health for your joint replacement surgery. We hope this presentation has helped prepare you for your joint replacement journey. We are excited to help you return to a healthier and more active lifestyle. 
Please reach out to your nurse care coordinator for any questions you may have. They are available to help you and look forward to working with you. Your joint replacement team wishes you the very best!




Joint Replacement Online Video Script