Orthopaedic Surgery and Care with Dr. Harwin
Introduction
Your surgery will take place at Beth Israel Medical Center, located on 1st Avenue at 16th Street in Manhattan. The main hospital telephone number is (212) 420-2000. Surgical procedures fall into two general categories: Ambulatory surgery, in which you come in to the hospital the day of surgery and go home immediately following your procedure; and Same Day Admission surgery, in which you arrive at the hospital the day of surgery and then are admitted to the hospital for an overnight stay or longer. All routine arthroscopic procedures are performed on an ambulatory basis. Complex joint reconstruction including total hip and total knee replacement require a 2 day stay in the hospital.Preparation for Surgery and Medical Clearance
Because we have a waiting list for surgery, you must confirm your intent to go ahead with surgery 4 weeks before the planned date. If we do not hear from you, we will attempt to contact you, and leave a message if possible. If you do not respond within 3 business days, we will have to cancel your procedure. Re-scheduling will then be arranged as soon as a place becomes available.
Hospital rules require that all patients undergoing surgery must have a medical evaluation and 'clearance' prior to the surgery, as well as pre-admission testing. Preadmission testing can be done at the hospital or at your primary care doctor's office. If you do not have a doctor, we can refer you to one. Preadmission testing includes a complete history and physical examination, and often includes blood tests, urine tests, chest X-ray and electrocardiogram. These results must be at the hospital 2 business days before the surgery or the procedure is automatically cancelled (by the hospital). The cancellation policy is rigid and there are no exceptions to this.
Therefore, all the results should be in our office preferably at least 3 business days before the surgery to allow us time to make sure it is complete and pass it on to the hospital on time. It may take more than one visit at your doctor's office to complete the necessary tests. If you need to have more testing, such as a cardiac stress test or pulmonary function test, you must allow extra time for these results to be sent to us.
Remember that this is not just our office policy, but rather a hospital rule. Failure to comply unfortunately will result in postponement of the planned procedure. If the operation is cancelled, please be aware that it can take several weeks to re-schedule since our surgical schedule is fully booked for 2-3 months in advance.
Patients scheduled for total joint replacement are encouraged to attend our preoperative class at the hospital. It will provide you with the opportunity to meet some of your nurses and therapists who will take care of you in the hospital and prepare you for what to expect during your 2 day stay in the hospital. At the class you may inquire about private rooms, private duty nurses and our luxury suites with individualized attention, gourmet food, large screen HD TV and wireless internet access. A bed it provided for a friend or family member if they wish to stay with you. The suite is available at extra cost.
Return to TopAbout Stopping Certain Medications
- Stop all ANTI-INFLAMMATORY medication at least 10 days before your operation including Naproxen (Naprosyn, Aleve), Ibuprofen (Motrin, Advil), Diclofenac (Voltaren, Arthrotec) and others. Celecoxib (Celebrex) and Nabumetone (Relafen) do not affect bleeding and may be taken.
- Stop ASPIRIN, VITAMIN E, and all HERBAL SUPPLEMENTS that affect blood clotting (garlic, ginkgo, ginseng, kava, St. John's Wort, valerian, echinacea and ephedra, etc.), at least 10 days before your surgery
- Stop ANTI-COAGULANTS (blood thinners) such as Coumadin, Plavix, Persantine, Ticlid, Aggrenox, etc., from 5-10 days before your surgery. Check with your primary care doctor to make sure it is safe for you to stop. If you cannot stop it, let us know right away.
- In some cases a drug must be stopped 2 weeks or more before your surgery. Ask your primary care doctor, rheumatologist or oncologist and let us know if there is a problem.
- You may take certain medications on the day of surgery (like medication for blood pressure, your heart and our recommended dose of Celebrex)… see below.
- If you are a smoker, quit or cut down before your surgery to help wound healing.
Blood Issues: Donation Procedure and "Bloodless Surgery"
As Director of the Total Joint Replacement Bloodless Surgery Program at Beth Israel, it is my philosophy to try to avoid blood transfusions if possible. Patients undergoing arthroscopic procedures including ACL and rotator cuff repair will not require any blood for the surgery. Patients undergoing joint replacement procedures rarely require blood transfusion during the operation but in some cases (less than 10%) may need blood afterwards. Therefore, certain patients, who are at risk for transfusion and healthy enough to donate their own blood, may want to do so. My general recommendation is not to do so, since after donating blood, you become anemic, often making it necessary to give blood. Your blood is for you only and is either given back to you in the hospital or discarded. Pre-operative administration of Epoetin (Pro-Crit) to increase your blood count may also be recommended. Conservation measures such as a cell saver device and recovery drains are used when needed.
If you are one of Jehovah's Witnesses, and religious conviction will not allow you to receive blood transfusions or any blood products, please let us know. If necessary, joint replacements and revision surgery may be performed in a "bloodless" fashion. Patients interested in this option must follow our recommended protocol. This will be discussed on an individual basis.
How to Donate Your Own Blood Prior to Surgery
Information About Blood Conservation, Donation and Transfusion
The Days Before, The Night Before and the Day of Surgery
In preparation for your operation, to minimize any potential complications of anesthesia, you must not have anything to eat or drink after midnight before your surgery. The exception to this rule is that you should take essential medications (such as for blood pressure, your heart, etc.) in the morning with the smallest amount of water. Because you are not eating, diabetics who take insulin or oral medications should not take their usual diabetes medication the morning of surgery.
It has been shown that taking the anti-inflammatory drug Celebrex for a few days before your surgery will help to reduce the amount of pain of surgery. Therefore we recommend that you take one capsule (200mg) two days before, one capsule the day before and one capsule on the day of surgery, in the early morning with a very small amount of water, along with your other essential medications. Taking this very short course of Celebrex is unlikely to cause any significant side effects. If you have any reservations about this, speak with Dr. Harwin or your family doctor.
In the days before the surgery, if you notice any evidence of infection on your body, such as boils, skin or mouth sores, rash, toothache or other such problems, you must call us. Surgery cannot be done if infection is present. For two weeks before surgery, begin to shower daily using Hibiclens soap (chlorhexidine) available without prescription at your pharmacy. It will remove bacteria on the skin that can cause infection.
You will be asked to arrive at the hospital at least 2 hours before the start of the planned procedure. Please understand that while the procedures are scheduled for a certain time, the time is an estimate. The first operation starts at 7:30 AM on Tuesdays and Fridays and 8:30 AM on Thursdays. The hospital will call you the day before your surgery between 2 PM and 4 PM to advise you of the time to arrive. Therefore, you must provide us with the number where you can be reached the day before the procedure. If you do not hear from the hospital by 4 PM, you must call the Admitting Department at (212) 420-4557 and ask what time to arrive.
If your surgery is ambulatory, you will go home the same day and you must arrange for someone to escort you home. This is for your own safety and is a hospital rule. An escort is mandatory. If this is not arranged, the surgery must be cancelled.
Family members or friends may wait in the Surgical Waiting Room during your procedure. If you would like me to call someone after your procedure, please give their cell phone number to my assistant or nurse. If your surgery was ambulatory, I will call you after surgery, either that night or the next day. If you want to hear from me, please be sure to give the number where you can be reached.
Anesthesia
For patients undergoing arthroscopic surgery of the knee and ACL reconstruction, the procedure is most often done under a general anesthetic with you asleep. Our preferred method of anesthesia for total hip and total knee replacement, as well as for shoulder surgery, is regional anesthesia. With this method, a tiny needle is placed in the back or shoulder and a local anesthetic is given. The hips and legs, or shoulder and arm become numb, so that no pain is felt. Then, intravenous sedation medication is given so that you will sleep.
Before your operation, you will have the opportunity to discuss the type of anesthesia with our anesthesiologist. Our specialized anesthesiologists are highly skilled in modern anesthesia techniques, allowing us to perform even the most complex of procedures, under regional anesthesia with safety. These doctors are all Board Certified and stay with you throughout your surgery.
Your Surgeon and the Surgical Procedure
Rest assured that I alone perform your surgery! While I have a team of assistants helping me, each with their own special jobs to do, the surgical procedure itself is done by me; not by interns, residents or fellows. Before the operation begins, I will personally see you and talk with you. I have had surgery myself and I know how important this is.
On the day of surgery, several people, including myself, will ask you to identify the joint and the side of the body we are operating on (left or right or both). This is to make absolutely sure there is no misunderstanding. My nurse, physician or surgical assistant, and anesthesiologist will ask you the same question. This is normal procedure. I will write my initials "SFH" on the hip, knee or shoulder we are operating on with a skin marker.
Arthroscopic knee surgery is done through two tiny incisions on the front of the knee. After this procedure, you may bear as much weight as tolerated but usually a cane is necessary for the first day or two. You may move the knee within the limits of your comfort, and you should have 90° of bending or more on the day after your surgery. There are usually no restrictions as to weight bearing and movement of the joint. Recovery is 2-3 days, followed by about 4 weeks of physical therapy or exercise.
If your surgery involves ACL ligament reconstruction or muscle repair, then there may be additional incisions on the front of the knee. While in most cases you may still bear as much weight as tolerated and perform range of motion exercises as tolerated, you may have a brace applied to the knee for up to 6 weeks to protect the knee. You will also be asked to use a continuous passive motion (CPM) machine to help the movement of the knee. You will use a cane or crutches for a few days and then advance to no support as you become stronger. Recovery is about a week, followed by physical therapy for about 3 months. In rare circumstances, if a major tendon or fracture was repaired, you may need to be immobilized for a period of time, usually about 6 weeks.
If your arthroscopic surgery involves the shoulder, you will usually have three or more tiny incisions and you will be placed in a sling for comfort postoperatively. The procedure is done on an ambulatory basis and the sling may be removed whenever you are comfortable. You should try to move the shoulder as much as possible, to achieve a normal range of motion as soon as possible. Recovery is about 2-3 days, with physical therapy for about 3 months.
If a rotator cuff repair was carried out, either arthroscopically or in an open fashion, then your arm will need to be in a sling for six weeks. If an arthroscopic rotator cuff repair was carried out, then no specific physical therapy or range of motion exercises are prescribed. This is to allow for healing and to prevent disruption of the repair. If an open repair was carried out, indicating a large, complicated tear and repair, then passive movement and dangling pendulum-type exercises may need to begin soon after surgery (passive exercises mean that someone moves the arm for you). The reason for the difference in the post-operative recommendations is that with arthroscopic procedures, stiffness after surgery is rare. With open procedures, stiffness is more common and so passive exercises are prescribed. You may take the arm out of the sling to wash, dress and eat. You must read your post-operative instructions to be sure of the correct instructions. Failure to follow the prescribed protocol can result in disruption of the repair.
If your procedure is a joint replacement, you will have an incision on either the front of the knee or on the side of the hip. These operations require a stay in the hospital of 2 days. You should plan to be discharged on the 2nd day after surgery. For example, if your surgery is done on Tuesday, then plan to go home on Thursday. The social service specialist will arrange for a physical therapist and a visiting nurse to come to your home.
For total knee replacement we also prescribe the use of a continuous motion machine to aid in the movement of the knee while in the hospital. Most patients have at least 90° when they go home. You must have at least 90° of knee bending (to a "right angle") by 6 weeks after the operation. If not, we may have to "manipulate" the knee in order to gain motion and prevent permanent stiffness. This is done under anesthesia at the hospital, but is not another operation. We break up scar tissue by bending the knee for you. You must call us if your motion is not progressing.
After routine hip and knee replacement, normal walking is encouraged as soon as possible using crutches or a cane only if needed. If a walker is needed initially, you should try to progress to crutches or a cane as soon as possible. Most patients having joint replacement are recovered within 2-3 weeks, with physical therapy necessary for 3 months or longer. Depending on your job, you may return to work as early as 2-3 weeks.
As described above, I often prescribe a CPM machine and for all procedures I prescribe a motorized ice therapy unit (it will be described in detail below). If your insurance company will not pay for these important aids to your recovery, it is your choice whether or not to order it. We prescribe it because it improves outcomes, reduces your pain and swelling, and speeds your recovery. I hope you choose to order all we prescribe.
ABOUT GOING TO A REHABILITATION FACILITY: Many patients want to "go to rehab" after joint replacement surgery. Admission to a rehab facility depends on many factors, the most important of which is your insurance coverage. All of my patients are evaluated for either home or in-patient rehab when in the hospital. It cannot be arranged in advance. If authorization is denied, then you will be discharged home with support services. Based on my many years experience, almost all patients are safe and ready to go home on the second day after surgery.
Return to Work, Driving and Traveling
Since everyone's occupation is unique regarding specific duties, mode of travel, and distance. It is impossible to make absolute predictions about when to return to work. Generally, you may return to work as soon as you are comfortable. Depending upon how you get to work and what you do and the type of surgery you had, this may be as soon as 2 days for an arthroscopic procedure and 2-3 weeks for a joint replacement. If your job requires standing for long periods, heavy lifting or a lot of walking, then a longer recovery, up to 3 months, may be needed. Arthroscopic patients may drive as soon as they feel comfortable and safe. Joint replacement patients may begin to drive and travel at 4 weeks. Because of an increased risk of blood clots, air travel is not recommended until 6 weeks after joint replacement surgery. Remember that walking, going up and down stairs, and carrying packages will not damage the joint or your surgery. All patients should try to resume normal activities, including walking outside, as soon as possible.
People in the Operating Room
You will meet the rest of my "team" in the pre-operative holding area and the operating room. My physician assistants are Mary Anne Legarda, R-PAC and John J. Lichardi, R-PAC. Our OR nurse is Romy Esmenda, RN, and our OR scrub technician is Cesar Alonzo, ORT. Julian Macintosh, OT is our orthopaedic technician and assistant. In most cases, I also have a Surgeon Assistant as well. Again, please be assured that I alone perform your surgery. It is not done by assistants, interns, residents or fellows.
Because I am a designer of orthopaedic implants and instruments that are in use all over the world (manufactured by Stryker Orthopaedics), I often have visitors in the Operating Room. These are usually surgeons from either the USA or overseas, who have come to learn by observing my surgical techniques. With your permission, parts of your surgery may be recorded or photographed for teaching purposes. Of course, your privacy rights are respected and no individual identification is made.
There are also manufacturers' representatives in the Operating Room. They are not "scrubbed" and are not in the sterile field. They do not participate in the surgery or operate any equipment. They are there for inventory and instrument support only.
Prevention of Complications
Antibiotics are given routinely for all operations to help prevent infection. These are usually administered intravenously during the hospital stay.
Patients undergoing joint replacement must take medication (blood thinners) to prevent blood clots in the legs and lungs. Three alternatives are recommended as being effective: Aspirin, Lovenox or Coumadin. My first choice for you is Aspirin. It is easy to take, inexpensive and has fewer side effects than other alternatives. You will take one enteric coated 325mg aspirin tablet (Ecotrin or equivalent) twice a day, for 6 weeks. If you have a true allergy to aspirin (rash, hives, breathing difficulty, etc.) or a medical condition that requires it, then we would then use either Lovenox or Coumadin. These medicines are started in the hospital after surgery and continued by you at home. The dosage and duration of treatment varies depending upon which drug we use and your operation. Lovenox is given by self-administered injection (or by a family member). It is taught to you in the hospital and is very easy to do. After the Lovenox (for 10-14 days), you must then take one 325mg enteric coated aspirin twice a day (if you are not allergic) until you are 6 weeks after surgery. Coumadin is a tablet usually taken once a day. When you go home the dose must be monitored and adjusted based upon the results of blood tests done once or twice a week.
In the hospital, compressive air "leggings" are worn to reduce swelling and blood Indocin (Indomethacin) to prevent extra bone formation and a medication to protect irritating the Prilosec, Nexiumor similar drug).
Prevention of Blood Clots After Total Hip and Total Knee Replacement
Wound Care
After knee surgery, the initial operative dressing and bandage can be removed one or two days after the procedure. If arthroscopic surgery was performed, apply Band-Aids and either an Ace bandage or an elastic or neoprene knee sleeve. This helps to prevent swelling and gives more support. If you are more comfortable without it, and there is no significant swelling, then leave it off.
If you had shoulder surgery, the dressing can be removed a day or two after surgery and Band-Aids applied. In all cases, your sling or shoulder immobilizer may be removed for hygiene and washing. Be sure to follow instructions as to which movements are advised and which are to be avoided.
Patients who undergo total joint replacement will have their dressings removed while in the hospital.
Notify the office immediately if the wound becomes red, swollen or angry-looking, or if there is excessive drainage or pus. Also call us if you have severe pain or if you have a fever. If you feel that you must be seen immediately, go to the emergency department at Beth Israel Medical Center or your local hospital.
Showering
As a general policy, all patients with surgical incisions can shower as long as the wound is dry and sealed. If leakage or drainage occurs (other than a small amount of blood or yellow fluid) call our office. Afterwards, the wound should be patted dry.
Swelling
Following any surgery swelling of the area, including the thigh, knee, foot and ankle is common and can persist for several weeks or months. In rare cases the swelling may be permanent. Bruising of the area of surgery ("black and blue") is common and to be expected. Rarely, blistering may occur. If swelling is accompanied by pain, especially in the calf, this could be a sign of a blood clot. Call us if you have concerns about your postoperative progress or have any questions.
Numbness
It is also common to experience some "numbness" about the incision area. This is especially common after knee replacement on the lateral (outer) side of the knee incision. This may persist for weeks or months. This usually gets smaller and gradually subsides, but in rare cases it may be permanent. Numbness does cause any functional problem.
Cold Therapy for Control of Pain and Swelling
Application of ice to the surgical site is extremely helpful in reducing swelling and pain. I used a mechanical continuous cold therapy delivery system after my own surgery and it worked even better than oral medications to relieve local pain and discomfort. If you are an in-patient, cold therapy will be provided in the hospital for you. You may take home the wrap but you must purchase the pumping unit for use at home. We will give you information about how to get one at a reduced affordable price. In some cases your insurance will reimburse you. If you do not get the mechanical device, cover the area with a thin towel or cloth, and apply the ice in a plastic bag for about 20 minutes and repeat every hour as needed. The mechanical continuous system works much better and I urge you to get it. With the initial post-operative dressing, the cold may not get thorough.
Pain and Anti-Inflammatory Medication
Patients typically receive a prescription for a codeine-containing painkiller called Vicodin and an anti-inflammatory medication like Celebrex or Relafen. If you are allergic to Codeine or Aspirin, please let us know and we will substitute other drugs. Anti-inflammatory medications contain no aspirin but are similar, so allergic reactions can occur.
Do not take it if you have a history of easy bleeding or ulcers. A true "allergy" means a rash, hives, breathing difficulties, etc. All medications can have "side effects" and these can include drowsiness, constipation, headaches, stomach upset and more rarely, bleeding. While you may not need to take the pain medication, especially if you use the ice regimen, please take the anti-inflammatory drug if possible.
Phone and Office Follow-Up
Logistics may make it impossible for me to see you immediately after your surgery in the recovery area. For ambulatory patients, I will call you either the night of surgery or the next day. Please give the number where you can be reached to my assistant or nurse when they interview you at the hospital. If something unexpected, unusual or not previously discussed with you was found at the time of surgery, be assured that I will tell you about it in the hospital before you leave. Otherwise, you may assume that all went well, as was expected and planned, with no complications. If my call is answered by a machine, I will leave a message about your surgery.
Arthroscopic surgery patients will be seen in the office about 10 days after surgery and joint replacement patients between 2 and 3 weeks after surgery, usually by my assistant John J. Lichardi, RPA-C. This visit is to check your wound, possibly to remove the sutures and to ensure that you are making satisfactory progress. You might need to return in another week if the sutures are not ready to be removed. Your appointment with me will be about 3-4 weeks after arthroscopic surgery. A 3 month visit may be needed for some procedures such as ACL reconstruction or rotator cuff repair.
For joint replacement patients, you will be seen for a wound check and suture removal at 2-3 weeks and a follow-up visit with me at 6 weeks, 3 months and for yearly check-ups thereafter, to ensure continued success of your implant. X-rays are taken at these visits. We generally like to see you each year for the first 3 years, then at 5 years and every 5 years thereafter. If you have any problems or symptoms then of course come whenever you feel necessary.
Physical Therapy (Exercise and Rehabilitation)
Rehabilitation after orthopaedic operations is necessary to ensure satisfactory range of motion and to begin the process of restoring the strength of the joint. In fact, the therapy after the surgery is equally important as the surgical procedure itself. I recommend formal physical therapy under the supervision of a trained professional for all of my patients having joint surgery.
Even before starting your therapy, you can begin doing the general exercises provided to you. Elevation of the leg and applying ice to the surgical site will help to reduce swelling and pain. Usually, icing 5 or more times per day for 20 minutes is effective. You should discontinue this routine when it no longer reduces your discomfort.
The specific physical therapy prescription and recommendation will be given to you either in the office before the surgery or in the hospital before you leave. Patients undergoing joint replacement will have home therapy arranged while in the hospital.
Arranging for Physical Therapy: Each individual patient has unique needs, schedules and varying insurance plans. It is your responsibility to set up out-patient therapy in advance, before the surgery. My office cannot do this for you. Check with your insurance plan for a list of participating therapists. All patients should begin PT within the first week after the surgery, either at home or as an out-patient. If delayed, the risk of stiffness, weakness and a prolonged and less than satisfactory recovery is increased. For knee replacement patients, if the knee does not bend 90° (to a "right angle") within the first week, you must contact us. This degree of movement is needed to prevent permanent stiffness and loss of motion. If you had a hip replacement, do not begin any active 'abduction' exercises until you see me about 6 weeks after your surgery. If you do, damage to the repair of your muscles may occur which could result in pain and limp. Remind your therapist to follow my exact prescription.
Cold Therapy After Surgery
Important Instructions About Regaining Motion
After Total Knee Replacement
Instructions After Total Hip Replacement for the Physical Therapist
Instructions After Total Knee Replacement for the Physical Therapist
Living With Your Joint Replacement
Patients who undergo total joint replacement can return to most normal activities of daily living and enjoy many recreational hobbies, sports and exercises. Annual check-ups are recommended to make sure all is well. A wallet card in your packet will identify you as a joint replacement patient should the need arise for security screening. Importantly, the card advises you of the need for antibiotics when undergoing surgical, gynecological, urological and dental procedures. Please ask for one if you do not already have it.