Christopher D. Casscells, M.D.
Blood Clots: All lower extremity surgeries carry an inherent risk of blood clots in the legs which can be a life-threatening complication. The most important concept is to keep the blood from pooling in the lower legs. Blood that sits still is more likely to clot. Making the blood circulate by returning the venous blood to the heart can be best achieved by either elevating the legs or utilizing the muscles in the leg to pump the blood back to the heart. We recommend that you either get up and walk and use your muscles or elevate your legs above the level of your heart so that the blood drains by using the force of gravity. More than 20 minutes of letting your leg hang down in a seated position will cause noticeable swelling.
Do not sit for any reason with your legs hanging down for more than 20 minutes at a time without getting up and moving around or elevating your legs above your heart.
Most patients while in the hospital will receive shots to thin their blood. Most patients on discharge from the hospital will be asked to take one 81mg baby aspirin daily to thin their blood to help avoid blood clots, heart attacks, and strokes. In general low dose aspirin thins the blood more than higher dose aspirin. Some patients will be returned to their previous Coumadin dose. They should not take aspirin unless instructed. Some patients cannot tolerate any anticoagulation at all and will be so instructed. Some patients have significant risks and may be asked to take shots for about 10 days postoperatively while at home.
Total hip patients are at the highest risk, with a lesser risk for total knee patients and a relatively minimal risk for partial knee replacements (unicompartmental).
Managing Your Wound: Patients may bathe the wound if it is dry, usually after three or four days. We ask that you pat the wound dry after bathing and do not scrub or rub the wound. After drying by patting the wound or using a hair dryer, the wound should be dressed with a thin layer of triple antibiotic ointment (Neosporin or bacitracin). After a couple weeks of antibiotic ointment you may switch to treating the wound with cocoa butter, aloe, or vitamin E. If the wound is still moist it should be covered with a dry sterile dressing to avoid soiling your clothes. You do not have staples or stitches that need to be removed.
Stitches: Your stitches are buried beneath the skin and do not need to be removed. On occasion, your body may have some difficulty dissolving the stitches, in which case you may “spit a stitch.” This is nothing more than your body trying to extrude a stitch and its knot. This usually occurs after a few weeks and is accompanied by a small red pimple in the area of the stitch. If you are comfortable, you can grab a knot, cut and remove the stitch, and apply an over-the-counter triple antibiotic ointment to the area. The irritation will resolve immediately. If you are not comfortable with this, then come to the office and we can remove the stitch.
Fevers: It is not unusual for bleeding inside a joint to cause a fever of 101°F or even 101.5°F. This will usually be accompanied by a warm sensation which will feel hot to the touch. This is fairly normal and usually does not represent an infection. However, if you have repeated fevers to 101.5°F or higher you should contact our office immediately. Other signs of infection would be redness around the wound or purulent material draining from the wounds. We rarely see infection within the first 48 hours following surgery. Abnormal swelling or red appearance of the wounds accompanied by a fever after the first 48 hours is worrisome and you should call the doctor and potentially start some antibiotics.
Cryotherapy and Ice Packs: Using a cold circulating machine can sometimes relieve pain more effectively than pills. Ice packs are also very effective but they must be removed after 20 minutes of direct contact otherwise damage will be done to the fat cells in the skin. The cold circulating machines (cryotherapy) are not as cold and can be left on indefinitely. Cryotherapy should be used at the patient’s discretion and if it becomes uncomfortable please cease use of the cold therapy.
Pain Medication: If you have pain, take your medicine. Some people require very little pain medicine and some require a great deal more. This is highly variable. Some people “do not like pills” and tend to remain excessively inactive in order to avoid pain. Pain medicine can help you mobilize during the recovery. You may take as much as two pain pills every three hours provided you are in a great deal of pain. After a few days you should require very little, if any, pain medication. If you take a lot of pain medication in anticipation of pain but do not, in fact, have any pain, the medication will be overly sedating and unsafe. If you require more than two pain pills every three hours and you have attempted rest, ice, compression, and elevation, then you should call the doctor on call since this represents an abnormal amount of pain and might require different measures. Please do not take any other home remedies or illegal drugs or alcohol in attempts to relieve the pain. This could be fatal.
Nausea: Some narcotic pain medication may cause nausea and most will cause constipation. In general, if you take pain medication in the absence of pain you will be more likely to feel nausea. The side effect of nausea can be alleviated by taking a smaller dose of the medication, breaking the pills in half, switching to a different preparation of medication, or substituting a medication known to be tolerated like Tylenol or Advil. Nausea may also be relieved by taking 25 mg of Benadryl every four hours, but be prepared to be a little sleepy from this medication. Benadryl, Tylenol and Advil can be obtained without a prescription. By taking your narcotic medication with a little bit of peanut butter you may also alleviate the nausea reaction.
Anesthesia: You will have had general anesthesia. You may not remember any of the operation and even forget some things from shortly before the operation and have spotty memories of some of the time after the operation. It is important to have a companion or family member with you to help remember instructions given to you postoperatively. Otherwise refer to this document, rather than other instructions you may have been given by hospital employees.
Returning to Work: If you are not confident about your ability to do your job or return to work safely, call the office and we will discuss whatever documentation you feel necessary to validate your absence from work.
Driving: It is likely that you will not be able to drive a car until after your initial post-op visit. If you are still taking any pain meds do not operate any motorized vehicles. If you have any questions about this it should be discussed with the doctor at the time of your postoperative visit.
Running out of Medicine: Some medications such as OxyContin or oxycodone (which is the active narcotic ingredient in Percocet, Endocet and Roxicet) are Schedule II narcotics and cannot be telephoned into a pharmacy. They cannot be renewed or given refills. They can only be prescribed individually by paper prescription. However, there are several adequately strong pain medications which can be telephoned into your pharmacy if you run out of medication. We only renew narcotic prescriptions during working hours 8 a.m. to 5 p.m. Monday through Friday. We do not authorize the on-call physician to renew narcotic medications at night or on weekends. As such, you must keep track of your pills to make sure you do not run out during off hours or weekends. You may leave a message to renew your medication with our clinical staff by dialing Glasgow at 302-832-6220 or Concord Plaza at 302-477-0900 and following the prompts for the clinical staff. The clinical staff will review your chart and, if appropriate, renew your prescription after consultation with the physician.
When in Doubt: If you have an emergency after hours, call the doctor on-call at 302-477-0900 and follow the prompts for emergencies. Please leave a message and your callback number. This is for emergencies only, so please be considerate of the on-call physician who may be preoccupied with surgery or another emergency. This is not to be used for routine daily business or non-emergent questions. Please leave your message and telephone number and when you can be reached and we will return the call.
Follow-up Appointments: In most cases, you should come in to see your doctor to have the wound examined and get x-rays within three weeks of surgery. If you feel it is necessary, certainly call and see the doctor earlier. In the meantime, if you require assistance at home, we may be able to arrange to have a visiting nurse provide you with nursing care and even physical therapy at home if you are having trouble getting around. This can be arranged by simply calling one of the clinical staff at our office.
In general, it is extremely important that everyday you walk a little farther and do a little bit more than the day before. It does not matter how much more just more than the day before. We do not have specific benchmark goals but it is important to concentrate on slow steady improvement everyday.