Total Knee Replacement Patient Information Booklet

Surgical Program

Total Knee Replacement Patient Information Booklet

Patient Name ________________________________________ Surgeon

________________________________________

Please bring this booklet to all of your appointments and to your admission to the hospital

The information contained in this booklet is not specific medical advice, nor a substitute for medical advice. For your safety, it is advised that you speak with your doctor and healthcare team about your particular healthcare needs.

IMPORTANT: If your doctor or healthcare team gives you different recommendations than what has been provided in this booklet, please follow directions from doctor or healthcare team.

Acknowledgements: This booklet was developed with assistance from Ottawa Queensway Carleton Hospital and OASIS (Osteoarthritis Service Integration Systems) at Vancouver Coastal Health.

This booklet is last updated on February 11, 2019.

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TABLE OF CONTENTS PREPARING FOR YOUR KNEE REPLACEMENT SURGERY Preparing Your Body and Mind

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Appointments Log and Contact Information

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Readiness for Surgery Checklist

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Reading: Knee Anatomy & Hip Replacement Surgery

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THE JOURNEY OF KNEE REPLACEMENT Step 01: Surgeon Office Visit

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Step 02: Prehab Education Class

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Step 03: Pre-Anesthesia Clinic

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Step 04: Prepare for Surgery

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Step 05: Day Before Surgery

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Step 06: Day of Surgery

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Step 07: Hospital Stay

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Step 08: Discharge Home

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Step 09: Post-op Rehabilitation

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Step 10: Recovery

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APPENDIX Appendix 1.a Plan of Care - Inpatient Hospital Stay

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Appendix 1.b Plan of Care - Same Day Discharge

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Appendix 2 Equipment and Vendor Lists

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Appendix 3 Medication List

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Appendix 4 Community Support Directory & Potential Respite Care/Retirement Homes for Short Stay

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Appendix 5 Hip and Knee Patient-Reported Outcome Measures (PROMs)

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Appendix 6 Exercise Guide

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Exercise: Before Surgery

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Exercise: Weeks 0 - 2 After Surgery

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Exercise: Weeks 2 - 12 After Surgery

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Activity Recommendations After Joint Replacement

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Exercise Record

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THE JOURNEY OF TOTAL KNEE REPLACEMENT

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PREPARING FOR YOUR KNEE REPLACEMENT SURGERY____

Preparing Your Body and Mind Getting a new knee is major surgery and recovery takes time. With hard work you can get back to being active and enjoying life!

You may be anxious and excited as you wait for surgery. This is a good time to think about your feelings, lifestyle and habits, and make changes to help speed up your recovery.

Here are some ways to help you cope during this time:  Ask questions. Your health care providers are here to help  Share your concerns with family and friends  Make a list of things you need to do to be ready  Write your questions at the back of this book and carry it with you to all your appointments You may want to talk to your family doctor about smoking, weight, nutrition, exercise, travel, safety, etc.

This booklet will provide you with some essential information in optimizing your health in preparation for surgery and will guide you through this surgical experience step by step.

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Appointments Log and Contact Information

Surgeon Office Appointment

Date & Time

Contact Information

Date:

Surgeon is Dr. Office Address: Office Phone Number: Office Fax Number:

Time: Prehab Education Class

Date: Location: Brampton Civic Hospital Room ___________ 2100 Bovaird Drive East, Brampton, ON L6R 3J7

Time:

PREPARING FOR YOUR KNEE REPLACEMENT SURGERY

I can call the Pre-Anesthesia Clinic: Monday to Friday 8 a.m. to 4 p.m. at 905-494-2120 ext. 56591 if I am unable to make this appointment. My surgery may be cancelled or postponed if I am unable to attend this class prior to my surgical date.

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PreAnesthesia Clinic Appointment

Date:

Location: Brampton Civic Hospital Pre-Anesthesia Clinic 2100 Bovaird Drive East, Brampton, 2nd level of the South Building

Time: I can call the Pre-Anesthesia Clinic: Monday to Friday 8 a.m. to 4 p.m. at 905-494-2120 ext. 56591 if I am unable to make this appointment. My surgery may be cancelled or postponed if I am unable to make this appointment prior to my surgical date.

Surgery

Date:

Location: Brampton Civic Hospital Day Surgery 2100 Bovaird Drive East, Brampton, ON L6R 3J7 2nd level of the South Building, Room S.2.114

Time: I should arrive and register 2 hours prior to my scheduled time of surgery.

Follow-up Appointment

Date:



Time:



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Surgeon

Date: First Knee Class

Time:

Location:

Location:

PREPARING FOR YOUR KNEE REPLACEMENT SURGERY_____

Readiness for Surgery Checklist 2~3 Months Before Surgery Attended Prehab Education Class with care partner Prepare a complete medication list (see Appendix 3) or visit your community pharmacist for a MedsCheck (i.e. a list of current medications)

2~3 Weeks Before Surgery Attended Pre-Anesthesia Clinic appointment with care partner. Ensure you bring your complete medication list.

Arrangements for home equipment have been made; my home is ready for me to come home after surgery I have made arrangements for a responsible caregiver to take me home and help with my care for several days after my surgery Called my private insurance to assess if I am covered for physiotherapy services following my surgery I have access to specialty equipment if desired (i.e. Game Ready device)

Transportation arrangements have been made for day of discharge for post-op knee classes

Day Before Surgery Nothing to eat or drink after midnight.

Packed loose fitting clothing for going home after surgery Packed OHIP card and a piece of identification if still using the red and white card Labelled equipment ready to bring with me

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Reading: Knee Anatomy & Knee Replacement Surgery Knee Anatomy The knee joint is where the thigh bone (femur) meets the shin bone (tibia). The knee is a hinge joint that allows you to bend and straighten your leg. The knee cap (patella) is the attachment for muscles that help you straighten your knee.

PREPARING FOR YOUR KNEE REPLACEMENT SURGERY

Knee Disease

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The most common reason for joint replacement surgery is OSTEOARTHRITIS. Osteoarthritis results in the breakdown of cartilage on the ends of the bones. Osteoarthritis can cause joint pain and stiffness that may require joint replacement surgery.

Other diseases, such as rheumatoid arthritis or injuries can lead to joint damage. Talk to your doctor if you have questions about your joint health.

Total Knee Replacement Surgery Today, most patients who have knee replacement surgery can move their joint better, have less pain and are able to walk more comfortably than they were prior to surgery.

In total knee replacement surgery, the surgeon replaces the worn out joint with an artificial joint (prosthesis). This surgery takes about two hours to perform.

Once the new joint is in place, the muscles and ligaments are repaired. Your skin is closed with staples (metal clips that hold your skin together while the incision heals).

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THE JOURNEY OF KNEE REPLACEMENT_____

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Surgery Date & Time

⃝ Date for surgery agreed and surgery booked; please record the date and time on Page 6 ⃝ Decide upon a support person to help you before and after surgery. Make sure they

are

available for the date you have booked

The Total Knee Replacement Patient Information Booklet

⃝ This booklet will

be your guide throughout this surgical experience . It will help you to ensure you are well prepared for your upcoming surgery and post surgical care. Please bring this booklet to all of your appointments and to your admission to the hospital.

History and Physical Exam Form

⃝ Please remember to bring your history and physical exam form to your family doctor to complete. bring the completed form to your appointment at the Pre Anesthesia Clinic. The form should be completed within 30 days prior to your surgery to have the most up to date information.

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⃝ You must

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Pain Management

⃝ Your surgeon should have provided you with information related to ice application for postoperative pain management.

Devices

⃝ Your surgeon should have provided you the Cryocuff or Game Ready Devices referrals. ⃝ These devices are available for rental or purchase. See Appendix 2 for further information.

Contact Information NOTE: Please make sure that the surgeon has your correct contact information as this is the phone number the hospital will use to book all your appointments

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THE JOURNEY OF KNEE REPLACEMENT_____

The Surgical and Rehabilitation Programs at Osler provide a prehab education class designed to educate both patients and their care partners for this surgical experience.

NOTE: It is mandatory to attend the class or your appointment and surgery will be postponed or cancelled. We encourage you to bring a friend or relative (care partner) for additional support.

Prehab Ecuation Class Date & Time

⃝ Once

your surgery booked, you will receive a phone call from Pre-Anesthesia Clinic to arrange a date for the group education session. Please record the date and time on Page 6

Attend Prehab Education Class The class is located at Brampton Civic Hospital (2100 Bovaird Drive East, Brampton) The class is 60-minutes group session with time for Question & Answer. Please feel free to remain at the end and ask individual questions with the staff.

Please bring ⃝ Provincial health insurance card and proof of any additional health insurance. If you have the old red and white OHIP card, please bring a photo ID card. ⃝ Total Knee Replacement Patient Information Booklet (this booklet)

After Prehab Education Class

⃝ Prepare your home and organize meals ⃝ Rent or purchase equipment for your post surgery needs ⃝ Arrange transportation for your post-surgery needs (submit TransHelp application if needed) ⃝ Start exercise as instructed (please refer to Appendix 6: Exercise Guide)

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This important appointment will help prepare you for your surgery. This visit takes place two to three weeks before your surgery. Your visit may take approximately 3-4 hours to complete.

NOTE: It is mandatory to attend the appointment or your surgery will be postponed or cancelled.

Pre-Anesthesia Clinic Date & Time

⃝ Once

your surgery is booked, you will receive a phone call from Pre-Anesthesia Clinic to schedule your clinic visit. Please record the date and time on Page 6 ⃝ If you have any questions about your appointment, please call the Pre-Anesthesia Clinic: Monday to Friday 8 a.m. to 4 p.m. at 905-494-2120 ext. 56591. ⃝ Prepare a complete medication list (see Appendix 3) or visit your community pharmacist for a MedsCheck (i.e. a list of current medications)

Visit Pre-Anesthesia Clinic The clinic is located at Brampton Civic Hospital (2100 Bovaird Drive East, Brampton) 2nd level of the South Building (please take the “Leaf” elevators to the 2nd floor).

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Please bring

⃝ Total Knee Replacement Patient Information Booklet (this booklet) ⃝ Provincial health insurance card and proof of any additional health insurance. If you have the old red and white OHIP card, please bring a photo ID card. ⃝ History and physical form completed by your family doctor.

⃝ Your

prepared medication list and all of your current medications in their original package including vitamins and herbal products. Please include prescription and non-prescription medication like inhalers, sprays, ointments and eye drops ⃝ If your pharmacy prepares a dosette or blister pack, bring one that contains a week’s supply of medication and ask your pharmacist to prepare a list with dosing instructions of the medications ⃝ A list of medication allergies and all other allergies including the type of reaction

⃝ Your reading glasses, if required ⃝ A translator if you have difficulty understanding or speaking English ⃝ We recommend that you bring one family member or friend with you

to your appointment.

This person can be your designated Care Partner. This person has to be able to accompany you to your various appointments in the hospital and there is quite a bit of walking involved.

⃝ Given the length of the appointment, you may want to bring a snack with you.

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In the clinic 1) You will be registered by one of our clerks 2) A health assessment and pre-operative tests will be performed by a nurse. The nurse will take your health history and ask you to review your consent for surgery, history and physical form, and the anesthetic questionnaire. Please pay special attention to:  When to stop eating and drinking before surgery  Medication management before and after surgery  Date and place for your hospital admission  How to prepare for your surgery Tests that may be performed include:  X-ray  Blood work  ECG (electrocardiogram) 3) You will also see an anesthesiologist.

4) A consult with the pharmacist may also be part of your visit.

You will be asked:



If you smoke, consume alcohol, use recreational or street drugs on a regular basis. Please be honest, as this may affect your surgery and recovery time.

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If you have been hospitalized out of Canada in the past year prior to your surgery, please ensure you share this information with the registration clerk and nurses.

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If you have ever been told you had or have an Antibiotic Resistant Bacteria such as MRSA (Methicillin Resistant Staph Aureus) or ESBL (Extended Spectrum Beta-Lactamase producing bacteria), please tell the clinic staff.



If you are the caregiver for someone else, please let us know.

Soluprep™ soap sponge We advise you to purchase two “Soluprep” sponges which are recommended for use prior to surgery (the night before and the morning of) to reduce your risk of post operative infections.

They can be purchased at the Rexall Pharmacy at the Brampton Civic Hospital or at the gift shop at the Etobicoke General Hospital. It may be difficult to purchase these sponges at pharmacies outside the hospital; we strongly encourage you to purchase them following your clinic visit.

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1. Purchase or Rent Equipment Equipment you MUST bring to hospital on the day of surgery

⃝ Two-wheeled walker (four-wheeled walkers are NOT permitted). Leave it in your vehicle or with your care partner until instructed to bring it to the bedside. ⃝ Comfortable and loose fitting clothing

⃝ Non-slip running shoes ⃝ Long handled reacher and long shoehorn with name labels ⃝ Please make sure your name is on all belongings and equipment Equipment for home

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The equipment below is recommended:

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⃝ Raised toilet seat (with handles) OR commode chair over toilet ⃝ Long-handled reacher ⃝ Long-handle shoehorn ⃝ Sock aid ⃝ Long-handled sponge ⃝ Non-slip bathmat ⃝ Elastic shoe laces (otherwise use slip-on shoes with enclosed heel) ⃝ Hand held shower hose ⃝ Bathing—use a shower chair for a walk-in shower or a tub transfer bench for a bathtub Please be sure that     

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Equipment fits in your home and is in good working order before you have surgery.

Walkers, crutches and canes must be adjusted to your height.

Equipment is available at medical supply stores in the community (see Appendix 2).

Equipment may be rented and/or purchased. Suppliers may deliver to your home and/or install.

Costs may be covered by extended health plans – check your plan.

Friends and Family may also have equipment you could borrow.

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2. Find your care partner and organize meals Discharge Planner Based on your assessment at the surgeon’s office a social worker and/or discharge planner may call if there are any issues that may make it difficult for you to manage at home on discharge. If you are receiving services from Home and Community Care (LHIN) , please inform your Care Coordinator of the date of your surgery.

If you live alone, you should plan to have someone stay with you overnight and to help make meals for a few days. You could also make meals ahead of time and freeze them. If you are worried about being alone, you may want to think about “respite care”. You can make these arrangements yourself shortly after your surgeon’s visit. It may take up to six weeks to be accepted into one of these spots. Applications should be made well in advance to ensure this arrangement is in place prior to your surgical date. (see Appendix 4: Potential Respite Care/ Retirement Homes for Short Stay in the Brampton/Etobicoke and Surrounding Area) If you are the caregiver for someone else, please let us know at the time of your Pre-Anesthesia Clinic visit.

If you have financial concerns that interfere with your discharge plans or other worries/stresses, please let us know. We can offer support and connect you with other services that you may not know about.

Care Partner We strongly recommend that a friend, family member or care partner accompanies to all your appointments. You will be receiving lots of information during the various appointments and sessions. A care partner ensures that an additional person understands the process and expectations and can be a strong support during your hospital stay as well as your recovery at home. We strongly recommend that this be the same person for all appointments.

Our family presence policy also supports the visits from family and friends if you are staying overnight. Please review our Family Presence policy at http://www.williamoslerhs.ca/patientsand-families/preparing-for-your-visit-or-stay/flexible-visiting-hours-and-family-presence.

Please ensure that visitors are aware of Osler’s fragrance-free policy.

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3. Transportation If transportation is a problem following surgery, accessible transportation services may be available. This information will be reviewed during your pre-hab session. If you need to arrange a “disabled” parking sticker for your car, please make arrangements by contacting Service Ontario before your hospitalization and have your family doctor complete the form.

4. Prepare your home It is important to set up your home BEFORE your joint surgery. This will allow you to easily move around your home with a walker after surgery and reduce the risk of falls. hallways and rooms are free of clutter and tripping hazards (e.g. scatter rugs, footstools, etc.) ⃝ Add non-slip surfaces to outside stairs and walkways

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⃝ Ensure

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⃝ Install stair railings or make sure the existing ones are secure ⃝ Set-up a firm chair with armrests ⃝ Ensure that you have good lighting in hallways and other well used areas ⃝ Arrange for extra help with household tasks if needed (e.g. vacuuming, laundry) ⃝ Move frequently used household items to counter height (e.g. pots and pans).

Consider

moving items in the lower parts of the fridge/freezer to a higher shelf ⃝ Stock your freezer/pantry with healthy foods and snacks. If needed, private food/meal delivery services are available in many areas ⃝ Keep several ice packs in your freezer for possible joint swelling after surgery. Alternatively, you can use a bag of frozen peas. Ice should be applied 3 or 4 times a day for the next several weeks after surgery. Game Ready Device can also be used for this purpose. ⃝ Have a thermometer at home to check your temperature after surgery

⃝ Consider alternatives for pet care e.g. dog walking, changing cat litter

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5. Prepare your home - Bathroom

⃝ The

need for these bathroom equipment (see pictures below) will be discussed at your prehab education class as you may not need all equipment listed below. ⃝ Install an over toilet commode over your toilet to assist you to sit or stand. If you get up often during the night, you may place one next to your bed. Men may want to purchase a urinal

⃝ Remove sliding doors from your bathtub and replace with a shower curtain ⃝ Set-up a transfer bench (in a bathtub) or a shower chair (in a shower stall) ⃝ Use a non-slip bathmat both inside and outside the bathtub or shower ⃝ Install a hand-held shower hose in the bathtub ⃝ Grab bars in the bathtub/shower stall and by the toilet are very useful. Removable grab bars are available. DO NOT use towel racks or toilet paper holders to assist you to stand or sit

6. Prepare your home - Seating It will be easier for you to sit and get out of higher surfaces so it is important to choose a chair with a seat that is two inches above knee height. This includes chairs, beds and toilets  Use a firm foam cushion (high density) or wooden furniture risers to increase chair height. The cushion should be firm enough that it will not compress when you sit on it. Plan to take your foam cushion with you to adapt chairs outside of the house  Set up a firm chair with armrests (not a rocking chair)  Set up a table beside your chair for frequently used items  If your bed is too low, add another mattress or place the frame on wooden furniture risers

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7. Exercise Exercising before surgery will help you to have a faster and easier recovery. Do activities that put less stress on your joint. Try:  Exercises in water, such as swimming or water walking at a community pool  Cycling  Nordic pole walking  Gentle stretching and strengthening  Specific exercises suggested by a physiotherapist  Balance exercises (valuable in preventing falls) These activities will make your muscles strong, improve your endurance and help keep your joint moving. Exercising before surgery will also help you to build up your confidence and knowledge of the exercise you will do after surgery.

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Be sure to strengthen your arm muscles. You will need strong arms after your surgery to use walking aids, get in and out of bed and get on and off a chair. Do strengthening exercises for at least 3 weeks before surgery.

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For example: Push up through your arms while seated.

Work up to 10 repetitions 2 times each day.

If this exercise causes you discomfort or if you are new to exercise and/or have other health conditions, always talk to your family doctor before starting a new exercise program. If you don’t know how to get started, talk to a physiotherapist.

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8. Nutrition Good nutrition helps you to recover from surgery and reduces the risk of infection. Talk to your doctor, pharmacist or dietitian if you have any concerns. Important nutrients before and after surgery include: Protein Protein promotes healing after surgery. To meet increased protein needs, try to eat at least 3 servings from each of these food groups every day. For example:

    

Meat and alternatives 1 serving = 2-3 oz of meat, poultry or fish 2 eggs 3/4 cup beans 3/4 cup tofu 2 tablespoons peanut butter

  

Milk and alternatives 1 serving = 1 cup milk or soy beverage 2 ounces cheese 3/4 cup yogurt

Calcium and Vitamin D Calcium and Vitamin D are important for strong bones. Adults should have 2 to 3 servings of milk or calcium-fortified products a day. Talk to your doctor, pharmacist or dietitian about current supplement recommendations that are right for you.

Fiber and water It is important to have a regular bowel habit before joint surgery because constipation can be a complication of surgery. Include fiber in your diet, such as whole grains, bran, fruits, vegetables, beans and lentils. Spread the fiber throughout the day and drink 6 - 8 glasses of water or other low-calorie fluids a day.

For more information about nutrition, see Canada’s Food Guide: www.healthcanada.gc.ca/ foodguide Oral nutrition supplementation Choices for oral nutrition supplement should be considered for any patients not eating enough food and fluid to meet their nutritional needs. Oral supplementation may consist of the addition of food items high in energy and/or protein (i.e. butter, cream, milk); following a meal pattern (i.e.

3 meals and 3 snacks); adding of more nutrient dense fluids (milk based drinks, fruit juices and smoothies) and the use of oral nutritional supplements such as nutritionally complete pre-packed drinks (i.e. Ensure, Boost, Resource) or vitamin/mineral supplements. The goal of oral nutritional supplementation is to improve patient’s total food and fluid intake in order to advance clinical results. It is necessary that the total intake from regular food in addition to the interventions provide a balanced combination of energy, protein and micronutrients.

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9. Health tips before surgery Dental Work We recommend that dental work be done six weeks in advance of surgery (including cleaning and any dental procedure). Having dental work done closer to surgery may result in your surgery being cancelled due to risk of infection.

After your surgery, you must inform your dentist and other doctors that you have had a joint replacement surgery.

Infections or illness before surgery If you feel feverish (temperature 38°C or 100.4°F or higher) or develop a respiratory or any other infection during this period, you should notify the surgeon by calling their office. Should your surgery be delayed, every effort will be made to have you rescheduled as soon as possible.

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We encourage all patients to get the flu vaccine. The vaccine takes up to two weeks to take effect. To avoid illness during your recovery period, it is preferable to have the vaccination prior to your surgery.

Note: Notify your surgeon by calling their office before your surgery if you develop a cold, have any open wounds, have an active virus (e.g. shingles), or have any other illness. This is important for your well-being and the safety of others because there is a risk for everyone if you go to surgery with an infection.

Weight management Being overweight or underweight can affect your recovery from surgery. If you are overweight, moderate weight loss is a good strategy to reduce knee pain and to allow you to be more active.

Every pound you carry places 3-6 pounds of force on your knees and hips. If you are trying to lose weight before surgery, aim for a gradual loss of no more than one pound per week. Avoid fad diets as they may cause you to be undernourished and prolong recovery.

Approx. 1 POUND = 3-6 POUNDS OF FORCE on your knees and hips Being underweight can make it harder for your body to heal after surgery. It is important to eat well before surgery.

Talk to a dietitian if you are worried about being overweight or underweight before surgery. To find out more information on nutrition or specific nutrients see: Dietitians of Canada website: www.dietitians.ca

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1. Reminder Call You will receive a reminder call the day before your surgery. You will be reminded to come in to the Day Surgery Department at the Brampton Civic Hospital and to arrive two hours prior to your surgery time. If you have been instructed differently by your surgeon, please follow their instructions.

2. Checklist - Things to do before coming to the hospital

⃝ Have picked up your medical equipment and set up your home. ⃝ Label all of your equipment with your name and bring these items to the hospital (e.g. walker, long-handled reacher, long-handled shoe horn)

⃝ Make arrangements for transportation to and from the hospital ⃝ Confirm arrangements with your care partner to ensure they are prepared to stay with you for a few days after you leave the hospital

⃝ Pack your bag for the hospital. Bring only the minimum personal belongings necessary with you. Your visit/stay will be short, patient rooms are small, and there is limited storage

⃝ Have

dressing supplies for home: You can use 4x4 gauze and tape for your dressings.

Please refer to “Total Knee Arthroplasty Discharge Instructions” (Appendix 3)

⃝ Have ice, frozen gel packs, Cryocuff or Game Ready Device at home to control swelling.

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3. Checklist - What to bring to the hospital?

⃝ Health card and photo ID if you have the white and red OHIP card ⃝ All current medications in their original package, dosettes or blister packs.

Please also bring a current list of all medications (i.e. Appendix 3) or a medication list from your community pharmacy (i.e. MedsCheck).

⃝ A list of allergies, including the type of reaction ⃝ Walking shoes that tie on and wrap around your

heel but slip on easy. Shoes with Velcro

straps are also acceptable.

⃝ One set of comfortable clothing like jogging pants or shorts and a shirt that you can dress in during the day and a pair of loose fitting pants to wear home as your joint may be swollen

⃝ Toothbrush,

toothpaste, soap, deodorant, shaving cream, razor, brush or comb and

Kleenex™.

⃝ Two-wheeled walker with name labels.

Note: Four wheeled walkers with hand brakes are NOT to be used

⃝ Long handled reacher and long shoehorn with name labels ⃝ If you have sleep apnea and are using a CPAP/BiPAP machine at home, please bring in the machine, tubing and mask (all labeled with your name) the morning of your surgery

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DO NOT bring any valuables to the hospital.

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4. Preparation for Surgery You must follow these rules or your surgery may be cancelled:

⃝ Do Not eat any solid food after midnight the night before your surgery ⃝ You may drink one cup (250 ml or 8 oz.) clear fluid either apple juice, water or ginger-ale™ before leaving to come to hospital

⃝ You should take your regular prescription medications as directed by the anesthesiologists during your PAC visit. Bring your medications including any inhalers with you to the Hospital. preparation: Stop shaving in the operative area one week (7 days) before your surgery date. Shaving can cause tiny nicks in the skin that may allow germs to enter your body and cause an infection. Do not use bath scents, powders or body lotions

⃝ Skin

Skin preparation: 1) The night before surgery shower and wash your entire body using the first Soluprep™ soap sponge 2) The morning of surgery repeat your shower using the second Soluprep™ soap sponge Soluprep™ soap sponges are available at the Rexall pharmacy at the Brampton Civic Hospital or the gift shop at the Etobicoke General Hospital

⃝ If you are a smoker, stop smoking 24 hours before your surgery. ⃝ Do not drink alcohol 24 hours before surgery ⃝ On the day of surgery do not wear make-up, body piercings, nail polish, deodorant or contact lenses. Please do not wear or bring any scented products to the hospital.

⃝ Your care partner must come with you to the hospital on the day of

your surgery. You will also need someone available to come and drive you home following your visit/hospital stay.

You will not be able to drive your car yourself when you are discharged from the hospital.

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1. Arrive at Hospital

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Location: Day Surgery Department at the Brampton Civic Hospital 2100 Bovaird Drive East, Brampton, 2nd level of South Building

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Arrival Time: please arrive two hours prior to your surgery time. If you have been instructed differently by your surgeon, please follow their instructions.

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2. Surgery After you arrive at the hospital: 

 

  

Report in at Day Surgery Unit (DSU) Registration Desk in room S.2.114 One Care Partner can accompany you and stay with you once you are admitted. You may designate this Care Partner to be the person to call after surgery Staff will show you where to change into a hospital gown. Your clothes will be placed in a bag and labelled.

Your nurse will review your paper work, complete an assessment, start an IV and will give you any needed medications. She will review the events that will take place during your stay and answer any questions you may have.

In Day Surgery Pre Operative areas, you will be provided with a special gown to keep you warm. Keeping you warm helps to prevent post operative infections.

The surgeon, anesthetist and operating room (OR) nurse will see you and answer any questions that you may have. The surgeon will mark the limb that they will be operating on The anesthetist will make sure you are comfortable throughout the surgery, giving you medication through your IV that makes you relaxed and sleepy so you will not be aware of the procedure.  Most people who have joint replacement surgery have spinal anesthetic. This freezing goes into your back through a needle and makes you numb from the waist down and stops you from feeling pain. If you have a spinal anesthetic, you will go to the “block room” first. You will be cared for by an anesthesiologist and an anesthetic assistant while in the block room. You will then be transferred to the OR. You may not be able to move your legs for up to 4 hours after surgery  Some people may receive a general anesthetic. This is a combination of drugs that will make you unconscious during the surgery.

Surgery: Operating Room (OR)   

You will be transferred to the OR table Staff in the OR will place monitoring equipment on you The staff will perform a “time out” prior to starting your surgery. During this time, the surgeon will verify the surgical site once again and the staff will repeat the positive patient identification process.

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After surgery: Recovery Room  

  

 

Your operation can last from 1 ½ to 2 ½ hours Following surgery, you will be moved from the Operating Room to the Post Anesthetic Care Unit (PACU). This information will be displayed electronically in the Day Surgery waiting area where your care partner/family can track your transfer.

You will have an oxygen mask or nasal prongs on your face.

Your nurse will monitor your vital signs, including your pulse and blood pressure and will look at your leg and incision frequently.

Your nurse will check the circulation, sensation and movement of both legs. Your legs will feel heavy and will be difficult to move for a few hours after the spinal anesthetic. They will slowly return to normal.

If you feel any pain, nausea or itchiness tell your nurse. You will be given medication to help you feel better You may be drowsy after the surgery, as you become more alert we will encourage you to do ankle exercises and deep breathing exercises. These exercises will help to prevent post-operative complications

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Ankle Exercises Point your toes toward your head, then toward the foot of the bed. Make your feet go around in circles 5 times. This exercise should be done at least every hour while you are awake.

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Deep breathing exercises Take a deep breath in through your nose, and slowly blow out through your mouth. Repeat this 3 times. This should be done every hour while you are awake for the first day, then every 2 hours for the next 1-2 days. 

 

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If you have sleep apnea, you may be required to be monitored in the PACU for a longer period of time. If you have your own CPAP machine, you need to bring it with you to the hospital.

Your nurse may take a blood sample to check your hemoglobin You will have an X-ray of your knee done in the PACU before you are transferred to Day Surgery Post-op or to the inpatient surgical unit (Orthopedics or Short Stay).

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After surgery - Same Day Discharge 

If you were identified by your surgeon at the time of your initial office visit for going home the same day of surgery, you will be transferred to the post-operative area of the Day Surgery Unit, here you will continue to be monitored by the nurses and you will also see the physiotherapists and the surgeon again prior to discharge (see Appendix 1b for more detailed information related to your time in post-op Day Surgery).



The surgeon makes the ultimate decision on whether or not your are ready to go home the same day. If needed, you will be admitted for overnight stay.  If going home the same day, you will be transferred to the Day Surgery Post Op area (see Appendix 1b Same Day Discharge Plan of Care)  If staying in Hospital, you will be transferred to one of the inpatient surgical units. You may be admitted to the Orthopedic or to the Short Stay Surgical Unit (see Appendix 1a Inpatient Hospital Stay Plan of Care).



Please note that whether you are going home the same day or staying overnight, your healthcare team will help guide and determine when you have met the criteria for discharge.

Research has shown that patients who are discharged early actually recover better. Each of the appendices above has important information about your plan of care. Please review carefully.

After surgery - Admission to Inpatient Unit 

If you did not meet the necessary criteria for going home the same day when you saw your surgeon at their office, the surgeon has made a decision to admit you to hospital (see Appendix 1a for more detailed information on expected time in hospital and what you will experience during your stay). You will be transferred to your room when your nurse determines it is safe to move you and when your room is ready. Sometimes there are delays due to the late discharge of other patients.

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Admission to Inpatient Unit Overall your time in hospital is very short. Your healthcare team will work with you to make sure you are medically stable and able to leave the hospital.

Evening of surgery - On the Unit 

The team will assess your pain, pulse, blood pressure, circulation and tubes. You will have an IV, you may have a catheter to drain urine and a tube in your knee to drain fluid but not always.



For the most part you will be in bed but, with help of the team, you will sit at the edge of the bed if you are able.



You will be encouraged to deep breathe & cough and perform foot & ankle exercises.

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Post Op Day 1

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

Plan to go home today



The nurse and Acute Pain Service Team will assess your condition and work with you to ensure your pain is managed.



You may have blood tests done



You can start eating a regular meal.



Your knee bandages will be removed.



If you had one, your catheter may be removed; the drain in your knee may be removed.



You will be taught about anticoagulants which prevent blood clots and how to self-inject this medication as you may require this at home as well



The physiotherapist will assist you to a chair to sit and then progress you to walk with a walker. They will teach you about exercises you can do, both on your own and with help



Discharge Planner will continue to plan your discharge to ensure that you have arranged for all the equipment and appointments you need for home



You will be doing more of your own care: bathing, going to the washroom, getting dressed

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Rehabilitation   



Physical activity expands your lungs, reduces the risk of blood clots in your legs, reduces pain, starts your bowels moving and is a very important part of your recovery The physiotherapist and/or assistant will work with you throughout your hospital stay.

Your physiotherapist will teach you how to:  Walk with a walker and/or crutches  Do your daily exercises  Use the stairs safely Your physiotherapist will give you exercises to do in hospital and at home.

Exercises are a key component of your recovery. It is your responsibility to continue your exercises after you are discharged from hospital

Knee Precautions After knee surgery, it is recommended that you follow these rules for three months unless advised by your surgeon. These activity restrictions will help your joint to heal and reduce stiffness in the new joint.

DO sit on a raised chair or use a cushion. It will be easier to get on and off higher surfaces after surgery. Consider using a raised toilet seat.

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DO use long-handled aids, like a shoehorn and reacher, to help you get dressed or pick up items.

Pain Management in Hospital Ensuring that your pain is controlled will help you participate in physiotherapy, move around, better sleep, and have a speedy recovery.

In hospital, your anesthetist will offer you options for your pain management prior to, during, and after your surgery, i.e. nerve blocks, spinal injection, or general anesthesia. post-surgery you may be put on a combination of pain medications. If you are staying in the hospital, you will be followed by the acute pain service to manage your pain.

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In hospital, your nurse will ask you to rate your pain on either the number or FACES scale (see below). Pain is rated from 0 (no pain) to 10 (worst pain).

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Familiarize yourself with the pain scale. You should not let the pain get higher than 4 out of 10 (moderate level) before taking pain medication. If your pain gets above this, be sure to let your nurse know. You may have little or no pain lying in bed – but you will need to take the medication in order to exercise and get out of bed. You should be able to gradually reduce the amount of pain medication that you need over time.

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Protecting your skin from pressure injuries During and after your surgery, you are at risk for developing a pressure injury (bed sore, pressure ulcer). A pressure injury is skin breakdown that develops, usually over the tailbone and the heels, from sitting and lying in the same position for long periods of time or from sliding down in bed. Some key things that can be done to protect your skin are: avoid sitting in bed with the head of the bed higher than 30 degrees for long periods of time, reposition yourself or ask for help, about every 2 hours, when you turn on your side, put a pillow between your legs and when you lie on your back, use pillows under your lower legs, so your heels “float� off the bed.

Side Effects The use of narcotics is usually necessary after the surgery. Some side effects of pain medicines are: constipation, nausea, vomiting, drowsiness, dizziness, being itchy, and at rare times hallucinations, confusion and difficulty staying awake. Tell your nurse if you have any of these symptoms as there may be a need to change in your pain medication.

Addiction is usually not a concern with the short duration of narcotic use after surgery. If you have had an addiction please be sure to speak with your surgeon and nurse prior to your surgery.

Nausea/Vomiting Nausea/vomiting can be a problem after surgery, especially within the first 24 hours. It is most likely due to medication(s) given during and after surgery. However, if nausea/vomiting continues after 24 hours it may be due to constipation or side effects of narcotics such as Hydromorphone or Oxycodone. There are several medications available to help manage nausea/vomiting. Speak to your nurse if you feel nauseated.

Anticoagulant medications After knee replacement surgery, you are at risk for developing a blood clot in your leg. It is important to prevent these clots from forming and from travelling to the lungs. Blood clots can cause death if untreated. You will be given a daily blood thinning medication to reduce the risk of developing a blood clot. When you are discharged, you will be given a prescription for an oral blood thinning medication.

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Going Home 



   

Your planned discharge is on the same day of your surgery or no longer than two days after your operation. Most people will be discharged home. Arrangements for private respite care, if desired, should be made by you or your family before you are admitted to the hospital You will be going home. Be sure you have transportation arranged. Before surgery, it is important to make arrangements to have someone pick you up from the hospital when going home. Travel arrangements need to be flexible as you may be discharged any time during the day/early evening.

Be aware that artificial joints sometimes make grinding or clicking noises. Do not be alarmed – this is normal Your staples will be removed in 7-14 days during one of your knee classes or by your family doctor You will be given instructions for your removal of the surgical clips prior to discharge.

You will need to continue your physiotherapy exercises at home for at least 3-4 months and an outline of the home exercise program is shown in the home exercise section of this booklet (see Appendix 6). Be sure to continue to manage your pain at home so you are able to move around and exercise

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Medical Appointment

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Hospital

You

Before leaving the hospital, you will be given: 1) A follow up appointment with your surgeon in Fracture Clinic at Brampton Civic Hospital (BCH) or Etobicoke General Hospital (EGH) 2) Your first appointment to attend the Post-op Knee Class unless you meet criteria for home care support or have private physiotherapy coverage through your medical insurance

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You should make an appointment with your family doctor once you are back on your feet to review your general health

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Pain Management at home Pain is expected after surgery, even after you are discharged home and for days to follow. Remember not to let your pain get above 4 out of 10 on the pain scale, and be sure to take your pain medication as needed. You may have little or no pain lying in bed – but you will need to take the medication in order to exercise and get out of bed. You should be able to gradually reduce the amount of pain medication that you need over time.

Your pain should gradually decrease overtime. Most people have less pain over the next 6 to 12 weeks after surgery. If pain is preventing you from caring for yourself, sleeping and/or exercising, talk to your therapist or doctor. If your pain becomes increasingly worse or if you have pain in a new part of your body, seek medical attention immediately.

A combination of medicines will likely be used to manage your pain after surgery and at home.

This normally would include acetaminophen (e.g. Tylenol™) plus an anti-inflammatory (e.g. celecoxib or Celebrex™) and/or a narcotic (e.g. Hydromorphone, Oxycodone). You should take your acetaminophen and/or anti-inflammatory regularly and add additional narcotic pain medication if necessary. By taking a combination of these medicines, you may be able to reduce the side effects of any one of these medicines alone and have improved pain management. It is important to talk to your healthcare team to understand how and when to take these medicines to best manage your pain and symptoms.

Here are some non-medicinal ways to manage your pain Ice and cold compression can reduce pain and inflammation. Place an ice pack wrapped in a towel on your knee as directed by your physiotherapist, 20 minutes on and 20 minutes off.

For optimal results, elevate your leg on several pillows before applying ice.

Your surgeon may have given you a prescription for a cold compression device. This is a form of therapy involving a continuous circulation of cold water and intermittent compression therapy.

This therapy can help reduce pain, swelling, tissue damage, and muscle spasms. If you were able to obtain a cold compression device (i.e. Game Ready) please use this device as often as possible, it supports appropriate pain management and rapid recovery.

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Pace yourself. Do not push yourself. Regular rest is an important part of your healing process

Relaxation can increase your comfort by calming your mind and muscles.

1. Get into a comfortable position. Breathe in slowly.

2. Breathe out slowly and feel yourself begining to relax. Feel the tension leave your body.

3. Breath in and out, slowly and regularly, at whatever rate is comfortable for you.

Distraction: Focussing your attention on something other than the pain can make you less aware of the pain. Distraction may work well while you are waiting for the pain medicine to take effect.

1. Concentrate on your breathing as described in the relaxation exercise above.

2. Close your eyes and focus on an object or a quiet place.

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Think positively. You will become more and more comfortable as you recover from your surgery

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Outpatient Physiotherapy If you choose to attend outpatient physiotherapy at either Brampton Civic Hospital or Etobicoke General Hospital, you will be given your first outpatient physiotherapy appointment by the hospital staff before you are discharged home. This appointment will occur approximately 7 – 10 days after your surgery.

When you attend Osler’s outpatient physiotherapy program after your total knee replacement, you will receive an individual assessment with a physiotherapist. You will then be scheduled into a “knee class” twice weekly for the following 4-5 weeks. These classes are led jointly by a physiotherapist (PT) and a physiotherapist assistant (PTA) and each of your sessions will last 45 -60 minutes. During these sessions your exercise routine will be monitored, reassessments are completed, and your program will be progressed as appropriate. You will be discharged when you have achieved a level of independence that allows you to continue your exercise program more independently, in order to continue to work towards your functional goals.

You may also choose to receive therapy closer to home. If you have medical insurance benefits you may be eligible for private physiotherapy services. Advise your hospital physiotherapist before discharge so they can provide you with a signed referral form from your surgeon.

Your therapists will show you exercises to stretch and strengthen your joints and muscles and improve your walking and balance. As you recover, the exercises will progress. Doing the exercises assigned by your therapist will help you to move your new joint and enjoy greater independence. It is important to continue with the exercises for at least 1 year after your surgery.

It is recommended that you do some form of exercise for life in order to maintain general health.

Talk to your therapist if you have questions about your exercises or concerns about your progress. Also ask when you can resume leisure activities.

A reminder that it is your responsibility to arrange transportation to get to your outpatient physiotherapy appointment and knee classes.

Consider: 

Asking for assistance from friends, family, and neighbours



Submitting an application for TransHelp (Peel Region) or WheelTrans (Toronto)

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Travel Guideline Transportation There are many different ways to get around after surgery. Here are some options:  Friends/family vehicle  Taxi  Volunteer drivers with Community Support Services agencies  TransHelp (Peel) and Wheeltrans (Toronto). These are transit services for those who are unable to use the regular bus services. An application needs to be completed and it takes approximately 14 days for approval. Applications are available on line and must be completed by your family doctor.

Contact Service Ontario for a Temporary Disabled Parking form which you can bring to your family doctor to complete to receive a Temporary Disabled Parking Permit.

Talk with your healthcare providers about completing the necessary forms for these services before surgery.

Air travel

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It is not recommended to travel immediately after surgery. You may need to wait 6-8 weeks after surgery. Please consult your surgeon before you make travel plans.

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Please consider that after surgery you may have some extra challenges when travelling by plane. Be sure to give yourself extra time when flying. Your new joint may set off metal detectors at the airport. While on the plane, do ankle exercises every hour to help reduce the risk of blood clots. If you are flying home from the hospital, check with your air carrier to see if medical documentation is needed.

Driving You may be a passenger in a car but driving a vehicle is restricted after knee surgery. There are a number of factors that can impact your ability to safely return to driving. These include using mobility aids and taking prescription pain medicines (narcotics). Talk to your surgeon before driving. Most people start to drive approximately six weeks after surgery. Your insurance company may also have some driving guidelines post surgery. Ultimately, your surgeon will decide when it is appropriate for you to return to driving

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Car transfer It can be challenging to protect your knee while getting into some cars. Talk to your physiotherapist if you have questions about car travel. Please practice these techniques before your surgery.  A cushion on the seat may be more comfortable. A piece of plastic or a large garbage bag over the cushion or seat may help you to slide into the car seat more easily 

Park away from the sidewalk or curb so you are not stepping down from the curb to the car. If you have a high truck or sport-utility vehicle, you may need to park near the curb so that you do not have to climb up to the seat. Enter the car from the road level



The front passenger car seat should be pushed all the way back before you enter the car.



Walk toward car using the appropriate walking device.



When close to the car, turn and begin backing up to the front passenger car seat. Never step into the car! (see figure 1)



Reach with your right hand and hold the door frame or headrest. Place your left hand on the car seat or dashboard. (see figure 2)



Slowly lower yourself to the car seat. (see figure 3)



Slide yourself back onto the car seat.

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Swing your legs into the car. Try to move one leg at a time. Keep your toes pointed upward. (see figure 4)



Do NOT cross your legs! (see figure 5)



Reverse these steps to get out of a car.

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Activity Guidelines Walking   



You can expect to use walking aids, such as a walker, or cane for up to three months or longer after surgery By 4 to 6 weeks after your surgery, you should be walking with more strength and be able to walk longer distances Regular physiotherapy after your surgery will help you to get the most out of your new joint.

Physical activity will help you have a faster recovery and will get your blood moving. This will also reduce your risk of developing a blood clot Your weight bearing status will be determined by your surgeon. A common restriction is partial weight bearing  Partial weight bearing means that you can put 50% or less of your body weight through your affected leg. When walking with a walker, lead with the walker, then your operated leg and then the other leg.  Please use a gait aid until your first out-patient physiotherapy session

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Stairs

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You will likely practice the stairs with the physiotherapist prior to leaving the hospital so that you are able to manage stairs safely and independently.

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Getting into bed A firm mattress is recommended for sleeping. Avoid waterbeds, futons or low beds.

Sit at the side of the bed. It may be easier to get into bed on your stronger (non-operated or non-surgical) side  Slide back across the bed using your arms for support  If necessary, a half bed rail can allow you to get in and out of bed more easily. A half bed rail consists of a handle with 2 long metal rods that are placed between the mattress and the box spring. A half bed rail can be obtained through a local medical supply store  Lift your operated leg into bed or use a “leg lifter” (this may be the belt from your housecoat or a crutch turned upside down), hooked over your foot so that you can help lift the leg using your arms if needed 

Getting out of bed Slide your body to the edge of the bed  Use your arms to push yourself to a sitting position  Slide your operated leg off the bed  Bring your body to a sitting position at the bedside 

Sitting in a Chair Use a firm chair with arm rests  Back up to the chair until you feel the edge of the seat behind your knees  Move your operated leg forward so that your heel is even with your toes on your unoperated leg and reach back for the arm rests  Slowly lower yourself into the chair 

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Dressing yourself Socks:  Follow the instructions provided with your sock-aid to put on your socks Shoes:  Comfortable, flat, closed toe and heel shoes with non-slip soles are the safest option  Your shoes should be roomy since you will have some swelling in your feet after surgery  Elastic shoe laces can replace the laces in your regular shoes. This eliminates the need for bending over to tie a bow  A long-handled shoe horn will also be useful

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Bathroom safety

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Falls can happen anywhere but are most likely to occur in the bathroom. Here are ways to reduce the risk:  Do not rush. Plan to use the toilet often to avoid having to rush. Have a bedside commode if needed  When bathing, use a bench or chair, non-slip bath mats, grab-bars and/or a removable tub clamp  Make sure the route from your bedroom to the bathroom is well-lit  Wear sensible, non-slip shoes or slippers  If you feel dizzy or unsteady, do not get into the bathtub to avoid having a fall  You can always take a sponge bath and wash your hair in the kitchen sink if you do not feel up to taking a full shower Using the toilet 

 

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Make sure that the toilet seat has secure armrests or that you can install grab bars to help you stand or sit. DO NOT use towel racks or toilet paper holders to help you stand or sit down Toilet seat should be 2 inches above standing knee height Sit down as you would in a chair

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Bathtub transfer When you are allowed to bathe or shower: 

    

Use a tub transfer bench with a hand-held shower head or shower hose (in a bathtub) or shower chair (in a shower stall) for the first 3 months after surgery. DO NOT try to sit on the bottom of the tub  Sponge bathing is a safe option for those who are unable to get into or out of the tub or shower safely  If using a tub transfer bench, remove glass shower doors on your tub and replace with a shower curtain Place non-slip bathmat inside and outside the tub Your transfer bench or shower chair should be 2 inches above your standing knee height. If you are tall, you may need bench leg extensions on the bench or shower chair Sit down as you would in a chair. Slide back as far as you can on the seat. Then lift your legs over the edge of the tub Use long-handled aids to clean your feet and other hard-to-reach places e.g. long handled sponge, towel wrapped around sponge or use a reacher A hand-held shower hose will allow you to bathe more easily

Incision care You will have an incision at the site of your surgery. Your nurse will teach you how to care for your incision at home. While it is normal to have some redness and clear drainage from your incision, watch for signs of infection (page 45). You do not need a bandage unless there is drainage.

The edges of your skin will likely be held together with staples. Staples are metal clips that hold the edge of your skin together while your skin heals. Your staples will be removed 7-14 days after surgery.

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Sexual activity after knee replacement While many people don’t feel like participating in sexual activity while recovering from joint replacement surgery, the pain and stiffness from arthritis can affect sexual activity even before surgery. Many people’s sex lives improve after surgery because after the joint heals, it is usually free of pain and stiffness that may have previously affected sexual activity.     

You may return to sexual activity when you feel ready and comfortable and the incision is healed. This is often 4-6 weeks after surgery but this is a very individual decision You may need to consider trying some new positions. Talk to your partner As you may have less energy right after the joint replacement surgery, plan ahead to pace your activities and make time for sexual activity when you won’t be tired If you have questions or concerns about how to protect your new knee during sexual activity, talk to your physiotherapist or surgeon Visit the website: www.aboutjoints.com for illustrations of sexual positions to use after knee replacement

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It is important to maintain your joint precautions for six weeks. The most important position to avoid after knee surgery is kneeling directly on the operated knee. Also, do not squat and do not twist the operated knee.

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Complications After surgery, a few people have complications and need more medical treatment. Here are some possible complications:  Constipation  Deep Vein Thrombosis/blood clots  Swelling  Infection  Anemia  Joint loosening Constipation Constipation can be a problem after surgery. A change in your diet, less activity and taking pain medicine (narcotics) may make your constipation worse. It can be very uncomfortable and may be a problem after your discharge from hospital. Here are some ways to have regular bowel movements at home: 

Drink 6 - 8 glasses of water or low-calorie fluids a day



Eat fiber such as prunes, bran, beans, lentils, fruits and vegetables



Move around as much as you can – do your exercises!

You may need to take laxatives or stool softeners at home. If you have constipation, talk to your doctor or pharmacist. Constipation can be a serious problem, so do not ignore your symptoms.

Prevention of Deep Vein Thrombosis/Blood clots Deep vein thrombosis (DVT) or blood clots are one of the most common complications in knee replacement surgery. A DVT is a blood clot (thrombus) that develops in a deep vein, usually in the leg. This can happen if the vein is damaged or if the flow of blood slows down or stops.

When a clot forms, it can either partially or totally block the blood flow in that vein. A DVT can cause pain in the leg and can lead to serious complications if it breaks off and travels in the blood stream to the lungs.

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Blood Thinners (anticoagulants) Thinning of the blood for a short period (up to 35 days) is important to prevent the formation of these clots. You will be discharged with anticoagulant medication.

You will restart your blood thinner if you are on one of the following: apixaban (Eliquis®), dabigatran (Pradaxa®), rivaroxaban (Xarelto®) or warfarin (Coumadin®). This surgery does not take away the need for the blood thinner. The exact dose and timing will depend on your individual circumstance and will be ordered by the surgeon.

Symptoms of a DVT/blood clot can include:  Swelling of the leg  Warmth and redness of the leg  Pain that is noticeable or worse when standing or walking

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These symptoms are not always a sign of a DVT, but if you experience them, you should contact a doctor immediately.

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To reduce the risk of DVT/blood clots:  Remember to take your blood thinner medication exactly as prescribed and instructed by your doctor, nurse and pharmacist  Walk short distances at least once an hour (except when you are sleeping)  When you are sitting or lying in bed, pump your ankles and flex your leg muscles

Swelling It is normal to have some swelling in your leg after surgery and during your recovery. Swelling may increase as you become more active. To help reduce swelling:  Point and flex your feet hourly when awake  Lie down flat and raise your legs by placing pillows under the length of your leg  Do short periods of activity. Walk a few steps. Rest. Repeat  Place an ice pack wrapped in a towel on your joint. Cold compression devices may be used after knee replacement surgery.

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Infection Less than 1% of people have an infection around their new joint. An infection in the body can reach the new joint through the bloodstream. People who develop joint infections need antibiotics and, on rare occasions, further surgery. To prevent infection or incision problems, it is important to keep the incision and dressings dry. Do not touch or pick at the incision and be sure that the surrounding skin is always clean. Wash your hands often.

Artificial knees can become infected at any time, even several years after your surgery. It is important that if you have any skin infection or any other type of infection, at any time, you need to see your doctor for treatment right away.

Please contact your surgeon’s office directly with any concerns about your surgery. If you cannot reach your surgeon please call the fracture clinic at BCH at 905-494-6557 to be seen by the next available Orthopedic surgeon in the next available clinic. If you are a patient of Dr. Angelini, Dr. Gymorey, or Dr. McGonigal please call the Etobicoke fracture clinic at 416– 747-3400 x 32529.

If you cannot reach your surgeon or the fracture clinic then please call your family doctor or go to your nearest emergency department if you have any of these signs of infection:

Incision Infection:  The area around your incision is becoming more red, there is a red streak, or puffiness and the skin feels warm to the touch  New drainage (green, yellow or bad-smelling) from the incision site. It is common for new surgical incisions to have some drainage for the first 3-5 days after surgery but this will slowly stop and the incision should stay dry  There is increased pain, soreness or tenderness of the incision site and surrounding area  Fever above 38oC or 100.4oF  A tired feeling that won’t go away

Urinary tract infection:  Pain or burning when you urinate  Frequent or an urgent need to urinate  Foul smelling urine  Fever above 38oC or 100.4oF  Remember: Call your family doctor if you think you have a urinary tract infection

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Sore throat/chest infection:    

Swollen neck glands and pain when you swallow Frequent cough, coughing-up yellow or green mucous, shortness of breath or chills Fever above 38oC or 100.4oF Remember: Call your family doctor if you think you have a throat or chest infection

Call 911 immediately if you have:  

Shortness of breath Sudden chest pain

Anemia If you have signs of anemia, see your family doctor. You may need an iron supplement. The signs of anemia are:  Feeling dizzy or faint  Feeling very tired, pale and having no energy  Shortness of breath  Rapid pulse

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Joint loosening

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Over the years, the bond between the joint replacement and your bone may loosen. This can cause pain and make it difficult for you to move your artificial joint. To reduce the risk of this complication, avoid high-impact physical activities. If you notice increased pain in your artificial joint, talk to your doctor as soon as possible.

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Returning to work Allow yourself time to recover from surgery and focus on your rehabilitation before returning to work. Some people return to some form of work quickly after surgery but others need a longer time to heal and recover. This depends on factors such as health status and the type of work you do. Talk to a healthcare professional, such as a physiotherapist about what is right for you.

We hope you found the information in this booklet useful.

We wish you a speedy recovery and many happy years with your new joint.

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Appendix 1 Total Knee Replacement Plan of Care

APPENDIX

a. Inpatient Hospital Stay b. Same Day Discharge

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APPENDIX___ __

Appendix 1.a

Total Knee Replacement - Inpatient Hospital Stay Plan of Care Before your Surgery, your Pre-Anesthesia visit: Health Care Team will assess your readiness for surgery  Ask questions about your health  Perform blood work, ECG, x-rays  Coordinate the different team members  Anesthetist will review your anesthetic plan Education  Attend the prehab education class  Preparation for surgery, pre-op exercises; DO NOT eat or drink on the morning of surgery (review the specific guidelines)  Pain management after surgery  Other medications you may receive  Role of physiotherapist to assist with mobilization and exercise  Managing at home  Review Knee replacement Patient Information booklet (this booklet)  Date of discharge: Post-Op Day 1 (POD 1)  Equipment needs, on-going therapy with Outpatient knee classes You will:  Understand Pre-op instructions and events  Understand the usual Post-op care plan, plan for pain management and usual self-care Measures to prevent complications.  Understand the usual length of stay  Have an appropriate discharge plan in place  Have support from family and friends for transportation and help at home Day of Surgery-In Pre-Operative Surgery Unit Health Care Team will  Check all documents and prepare you for surgery: medications, IV’s, vital signs  Answer any of you or your family’s questions.

You will:  Follow preoperative instructions  Understand usual events/expectations of operative day and course following your surgery.

In the Recovery Room (PACU)      

You will be sleepy.

The nurses will be checking your condition frequently.

You will be encouraged to breathe deeply and cough to clear your lungs You may require an x-ray or additional blood work.

Your pain will be managed.

When you are stable you will be taken to your room.

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Appendix 1.a

Total Knee Replacement - Inpatient Hospital Stay Plan of Care On the Unit—Evening of surgery The team will assess your pain, pulse, blood pressure, circulation and tubes. You will have an IV, you may have a catheter to drain urine and a tube in your knee to drain fluid but not always.  For the most part you will be in bed but, with help of the TEAM, you will sit at the edge of the bed if you are able.  You will be encouraged to deep breathe & cough and perform foot & ankle exercises. 

Post Op Day 1          

Plan to go home today The nurse and Acute Pain Service Team will assess your condition and work with you to ensure your pain is managed.

You may have blood tests done You can start eating a regular meal.

Your knee bandages will be removed.

If you had one, your catheter may be removed; the drain in your knee may be removed.

You will be taught about anticoagulants which prevent blood clots and how to self-inject this medication as you may require this at home as well The physiotherapist will assist you to a chair to sit and then progress you to walk with a walker. They will teach you about exercises you can do, both on your own and with help Discharge Planner will continue to plan your discharge to ensure that you have arranged for all the equipment and appointments you need for home You will be doing more of your own care: bathing, going to the washroom, getting dressed

Discharge Day—Post-Op Day 1 or as directed by surgeon

APPENDIX

  

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You will be going home. Be sure you have transportation arranged.

Arrangements may be made for you to come to Physiotherapy classes as an outpatient.

Your staples will be removed in 7-14 days during one of your knee classes or by your family doctor

APPENDIX_ __ __

Appendix 1.b

Total Knee Replacement - Same Day Discharge Plan of Care Before your Surgery, your Pre Admit visit will include the following: Health Care Team will assess your readiness for surgery:  Ask questions about your health  Perform blood work, ECG, x-rays  Coordinate the different team members  Anesthetist will review your anesthetic plan Education  Preparation for surgery, pre op exercises *do not eat or drink on the morning of surgery (review the specific guidelines)  Attend the prehab education class  Pain management after surgery  Other medications you may receive  Role of physiotherapist to assist with mobilization and exercise managing at home  Total Knee Replacement Patient Information Booklet (this booklet)  Equipment needs, on-going therapy with Outpatient knee classes.

You will:  Understand Pre-op instructions and events  Understand usual Postop course, plan for pain management and usual self care measures to prevent complications  Have appropriate discharge plan in place  Have support from family and friends for transportation and help at home.

On the day of Surgery in the Pre-operative Surgery unit: Health Care Team will  Check all documents and prepare you for surgery: medications, IV’s, vital signs.  Answer any of you or your family’s questions You will:  Follow preoperative instructions  Understand usual events/expectations of operative day and course following your surgery.

You should bring crutches, walker to the hospital

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Appendix 1.b

Total Knee Replacement - Same Day Discharge Plan of Care In the Recovery Room (PACU)        

You will be sleepy.

The nurses will be checking your condition frequently.

You will be encouraged to breathe deeply and cough to clear your lungs.

You will lay with a pillow between your knees and under your leg when on your back.

You will be doing ankle exercises.

You may require an x-ray or additional blood work.

Your pain will be managed and may have sips of water.

When you are stable you will be taken to the Post-op Day Surgery area.

Post-op Day Surgery Unit The team will assess your pain, pulse, blood pressure, circulation, dressing and tubes. You will have an IV, you may have a catheter to drain urine and a tube in your knee to drain fluid but not always. You will be seen by the Physiotherapist.

You will continue to get pain medication if needed.

IV will be removed after last dose of antibiotic A Nurse will help you to sit at the edge of the bed for a few minutes if you are able.

You can start eating a regular meal You will be encouraged to deep breathe & cough and perform foot & ankle exercises.

Practice walking/stairs with crutches/walker Pillow position: between knees when side lying and under leg when on your back You will be going home. Be sure you have transportation arranged.

Plans for discharge home continue, be sure that you or your family have arranged for the necessary equipment rental, and that your home will be ready for you.  Arrangements may be made for you to come to Physiotherapy classes as an outpatient.         

Patient teaching/discharge planning will include:

APPENDIX

      

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Deep breathing, coughing and ankle exercises Dressing Pain management by mouth Physiotherapist will review exercise program and teach ambulation with cane/walker Follow-up appointments with surgeon Follow-up with outpatient physiotherapy You will be taught about anticoagulants which prevent blood clots as you may be required to take these at home as well

APPENDIX___ __

Appendix 2 Total Knee Replacement Equipment and Vendor Lists

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Appendix 2

Cold Compression Devices Knee Cryo/Cuff

Game Ready Device

APPENDIX

https://gameready.com/hot-cold-therapy-units-for-patients

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Note: Knee Cryo/Cuff or Game Ready device is offered for rental at the surgeon’s office.

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APPENDIX_ __ __

Appendix 2

Occupational Therapy Equipment List

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Appendix 2 Where to Rent or Purchase Equipment in Brampton and Surrounding Areas BMP Home Mobility Care 180 Sandalwood Pkwy East, Unit # B2A Brampton, ON 905-488-6398 1-866-829-0818 www.bmphomehealthcare.com

Medigas - Milton 8695 Escarpment Way, Unit 1 and 2 Milton, ON 905-636-4890 1-855-350-4381 www.medigas.com

First Choice Health Care 5130 Dixie Rd., Unit 5 Mississauga 905-624-3404

Motion Specialties 2130 Dundas St. East Mississauga, ON 905-804-0400 1-888-815-2593 www.motionspecialties.com

IDA Pharmacy - Brampton - Ebenezer Rd 4515 Ebenezer Rd. Unit110 Brampton, ON 905-794-5003 www.adapthomehealthcare.com Home Medical Equipment (HME) 77 Regis Cres. S. Toronto, ON 416-633-9333 www.hmemobility.com Medical Mart Home Healthcare 550 Matheson Blvd. W Mississauga 905-624-2011 1-800-379-4780 www.medimart.com

APPENDIX

Medics Mobility Inc. 3600A Laird Rd, Unit # 16 Mississauga, ON 905-608-0006 1-866-633-4290 www.medicsmobility.ca

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Shopper’s Home Health Care 1 Kennedy Rd S Brampton, ON 905-455-5939 www.shoppersdrugmart.ca Shopper’s Home Health Care 1077 North Service Rd, Unit 21 Mississauga, ON 905-281-0166 1-888-603-4369 www.shoppershomehealthcare.ca/stores/ store/493 Silver Cross – Toronto 14 Goodmark Place Toronto, ON 416-755-1164 silvercrossstores.com

APPENDIX___ __

Appendix 2 Where to Rent or Purchase Equipment in Etobicoke and Surrounding Areas Access Abilities-Etobicoke 154 Norseman St. Etobicoke, ON 416-237-9654 www.accessabilities.ca

Silver Cross – Toronto 14 Goodmark Place Toronto, ON 416-755-1164 silvercrossstores.com

Home Medical Equipment 77 St Regis Cres S Toronto, ON 416-633-9333 1-866-571-9333 www.hmemobility.com

Silver Cross - Toronto West – Mobility and Accessibility Equipment Store 225 The East Mall, Unit 16 Etobicoke, ON 416-915-4479 1-844-352-7677 www.silvercross.com

Hunt’s Healthcare Inc. 109 Woodbine Downs Blvd, Unit 7 Toronto, ON 416-798-1303 1-888-838-5146 www.huntshealthcare.ca

Wellwise - by Shoppers Drug Mart Six Points Plaza 5230 Dundas St W Etobicoke, ON 416-236-1201 1-888-603-4369 www.wellwise.ca/home

ProResp – Etobicoke 5525 Eglinton Ave W, Suite 112 Toronto, ON 416-798-0844 1-800-563-8981 www.proresp.com/locations/toronto/proresp Seniors Store 4974 Dundas St W Etobicoke, ON 416-231-1300 1-888-795-7718 www.seniorsstore.ca

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Appendix 2 Where to Rent or Purchase Equipment in Orangeville and Surrounding Areas BMP Home Mobility Care Heart Lake Town Center 180 Sandalwood Pkwy E, Unit B2A Brampton, ON 905-488-6398 1-866-829-0818 www.bmphomehealthcare.com

Canada Care Medical 4 Carson Court Brampton, ON 416-241-1133 1-866-882-9700 Service Dept: 613-234-1222 ext. 22 www.canadacaremedical.com Dynamic Health Care Solution 753011 Second Line EHS Orangeville, ON 519-942-8441 1-866-875-2877 www.dynamichcs.com

APPENDIX

Ontario Home Health Ontario Home Oxygen 170 Lakeview Crt. Unit 4 Orangeville, ON 519-941-1127 1-800-661-1912 www.ont-home-health.on.ca

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Where to Rent or Purchase Equipment in Woodbridge and Surrounding Areas

APPENDIX___ __

Appendix 2

a2z Mobility Inc. Home Health Care 1-241 Edgeley Blvd Vaughan, ON 905-761-9969 www.a2zmobility.ca AGTA Home Health Care And Nursing Medical Equipment Rentals 7695 Jane St, Unit 3 Vaughan, ON 905-760-2482 1-866-528-4753 www.agtahomecare.com Medigas - York Region 17705 Leslie St, Suite B Newmarket, ON 905-853-8744 1-800-263-9962 www.medigas.com Vaughan Wheelchair and Home Health Services 7700 Pine Valley Dr, Suite 4A Woodbridge, ON 905-264-6653 416-653-6646

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Appendix 3

APPENDIX

Medication List

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APPENDIX_ __ __

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APPENDIX

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APPENDIX___ __

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APPENDIX

APPENDIX___ __

Appendix 3

MedsCheck The MedsCheck program is a one-on-one interview between a pharmacist and the patient to review the patient’s prescription and non-prescription medications. The MedsCheck medication review will encourage patients to better understand their medication therapy and help to ensure their medications are taken as prescribed and that patients are getting the most benefit from their medications.

If you qualify for MedsCheck, you can set up a free meeting with your pharmacist to discuss:  What medications you are taking  How they work together and possible side effects  How to avoid bad interactions  How to use inhalers, needles, etc.

Your pharmacist will also answer any questions you have about your medication.

Who can use MedsCheck Ontario funds the MedsCheck program for:  anyone who takes three or more prescription medications for an ongoing, chronic condition  anyone diagnosed with either type 1 or type 2 diabetes (even if you are not taking diabetes medication)  any resident of a long-term care home If you can’t get to a pharmacy

Talk to your pharmacist about the MedsCheck at Home program. This program is for patients taking three or more chronic prescription medications who cannot make it to a pharmacy. This helps those who are sick, frail, elderly or living in isolated conditions. A pharmacist will visit your home to talk to you about your medications and answer your questions. The pharmacist can also help clean up your medicine cabinet and remove unused or old medication.

How to book a MedsCheck Ask your pharmacist. You can book a MedsCheck appointment once a year. Your pharmacist may also follow up with you if you:  are going into or coming out of the hospital  have had major changes in your medication  have a referral from your doctor What to bring Make sure you bring the following to your MedsCheck appointment:  all the medications you are taking, or a list of them  any non-prescription drugs, such as vitamins and/or herbal remedies  your valid OHIP card (not required if you live in a long-term care home) After your MedsCheck visit You and your pharmacist will sign and date your MedsCheck personal medication record (a list of all your medications). It is important that you or your caregiver bring this record with you when you meet with your doctor or for any hospital visits.

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Appendix 4 Community Support Directory &

Potential Respite Care / Retirement Homes for Short Stay

In Brampton / Etobicoke / Orangeville / Woodbridge

APPENDIX

and Surrounding Area

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APPENDIX___ __

Appendix 4

Community Support Directory Private Care Providers Bayshore

905-277-3116

CANES

416-743-3892

Home Instead

1-866-936-7457

Rely One

905-569-8800

Spectrum

905-272-2271

CBI We Care

905-275-0544

Community Supports Central West LHIN Home and Community Care www.centralwesthealthline.ca

905-796-0040

Lifeline

905-457-8635

MedEx in home labs

416-493-9797

CANES

416-743-3892

National home doctor service - Med Visit

416-631-3000

Telecheck Seniors Program

289-569-1201

Food Service Heart to Home Meals

1 800-786-6113

Grocery Gateway

1 877-447-8778

Meals on Wheels (via Peel Manor or VON)

Brampton: 905-453-4140 (press 6) Mississauga: 905-821-3254 Caledon: 905-857-7651

Transportation Services TransHelp Peel (application process required)

905-791-1015

CANES – Seniors Ride Connect

416-743-3892 ext. 278

Wheelchair Taxi Ontario

905-799-3648

A1 Taxi

905-453-6666

Bram City Cab

905-455-1000

Top Medical (wheelchair taxi and ambulance)

416-716-6167

There is no reciprocal relationship with the above organizations. These are resources only and can be selected by personal choice. This list is not inclusive. Additional resources are available upon request.

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Appendix 4

Potential Respite Care / Retirement Homes for Short Stay In Brampton / Etobicoke / Orangeville / Woodbridge and Surrounding Area The following are a list of potential places you or your loved one may consider for a short stay after undergoing an elective hip or knee surgery. Other options may be available, conducting your own research may also be beneficial. The information below is general information and all services and prices should be confirmed with each facility as they are subject to change. Should you have any questions or require further assistance feel free to contact the Discharge Coordinator at 905-494-2120 Ext. 57231.

Transitional Care  Prices range from $25-50/day  Availability is limited. Call as soon as surgical date is confirmed.  Transitional Care requires that you are a senior (age minimum varies).  Caledon Transitional Care requires that you reside in Central West LHIN. Caledon Transitional Care 9 McClellan Rd, Alton Includes meals, assistance with self care, and programs if available Contact Person: Anne McQuarrie Phone: 905-584-2300 Ext. 265 Main Building Phone: 519-940-9093 Richview Residence 1540 Kipling Ave, Etobicoke Includes meals, assistance with self care, programs if available Contact Person: Tenzing or Lisa Phone: 647-344-2734

APPENDIX

Lord Dufferin – Orangeville 32 First St., Orangeville Includes meals, access to assistance, *must be independent with ambulation to be considered* Contact Person: Patricia Phone: 519-941-8433 Ext. 222

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Etobicoke Services for Seniors - Central King Seniors Residence 2 Apartments: *Do not mix genders 15 King Street (Lawrence and Weston Road) 2 Bedroom (both private) 1447 Royal York Road Various Locations (1 private, and 1 semi private) Etobicoke Phone: 416-243-0127 Ext. 503 Intake Ext: 237 Contact Person: Nancy Cussen Price: sliding scale for people on fixed budgets, will be determined at time of booking Services: (Staffed 24/7) PSW with clients at all times to assist with all self-care, meal preparation, go to the day program (various activities, lunch and dinner served there) Require blister package for medications. Additional charge for laundry Approx. 3.50 per load

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APPENDIX___ __

Retirement Homes Brampton and surrounding area Prices range from $125/day and up Amica at Brampton 499 Main Street South, Brampton Contact: Jennifer (Community Relation Directors) Phone: 905 460-0080 Bramalea Retirement Residence 30 Peel City Centre Dr., Brampton Phone: 905-790-7900 Contact Person: Erika Simmonds Crescent Hill Place Retirement Home 3 Crescent Hill Dr S., Brampton Phone: 905-789-7632 * 905-216-4497 Greenway Retirement Home 100 Ken Whillans Dr., Brampton Contact Person: Ask for the Marketing Manager Phone: 905-799-7273 Includes meals, access to support Price Range $90.00-115.00 daily, Assisted Living Approx. $140.00 daily Woodhall Park Retirement Village 10250 Kennedy Rd. Brampton Contact Person: Adrienne Smith Phone: 905-846-1441 Ext. 35 Price Range: To be discussed with facility Chartwell Classic - Robert Speck Retirement Residence 100 Robert Speck Pkw, Mississauga Phone: 289-633-2154 Contact person: Adaire Seagrave or Shantel Prashad Price: Minimum length of stay 7 days, Maximum length of stay 90 days Heritage House Retirement Home 73 King St W, Mississauga Contact Person: Divinia Phone: 905-279-4800 Details: Short Stay/Respite $95 + HST per day (maximum 30 days) * partial care assisted living $225 per month and $450 for full care

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Retirement Homes Etobicoke and surrounding area Prices range from $125/day and up Revera Retirement Living - Etobicoke - Centennial Park Place 25 Centennial Park Rd. Etobicoke Phone: 416-565-7033 Contact person: Claire Price: 30 day minimum Services: 1st level nursing care (once weekly bath, medication administration, AM and PM care, personal laundry, access to nursing 24/7 and 3 snacks daily, bathing

Village of Humber Heights 2245 Lawrence Ave. W. Etobicoke Phone: 416 235-0201 Contact Person: Steven or Darla Ext. 6858 Services: Private suite, meals, snacks, medication admin, shower once/week, linen change, housekeeping

APPENDIX

Rivera - Kingsway Retirement 4251 Dundas St. W., Etobicoke Phone: 416 236-7575 Contact person: Susan Howard Vasani Price: *Only do monthly stays Services: 2 meals, daily tidy, full weekly clean, laundry, activities, DOES NOT INCLUDE PSW CARE

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APPENDIX___ __

Retirement Homes Orangeville and surrounding area

Avalon Retirement Lodge 355 Broadway Ave, Orangeville Phone: 519-941-3351 Permanent, short stay or respite stay accommodation available Respite care service includes physiotherapy, exercise and falls prevention classes and assisted personal care Chartwell Montgomery Village - Retirement Residence 155 Riddell Rd., Orangeville Phone: 519-943-5575 Lord Dufferin Centre - Retirement Residence 32 First St., Orangeville Phone: 519-941-8433

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Retirement Homes Woodbridge and surrounding area

Chartwell Pine Grove Retirement Community 8403 Islington Ave N., Woodbridge Phone: 905-850-3605 Villa Da Vinci Retirement Residence 7371 Martin Grove Rd., Woodbridge Contact: Angela Giusto - Community Relations Manager Phone: 905-264-9119 ext. 226 Chartwell Valley Vista Retirement 600 Valley Vista Dr., Vaughan Phone: 905 417-8900 Contact: Mary Manelli Price: Minimum of 2 week stay, maximum of 3 months stay Services: 1 hour of care daily, 1 load of laundry a week, shower once a week, will assist with other services, medication administration, escort to dining room, Physician there once weekly, 24 hour call bell pendant for assistance

APPENDIX

Amica Villa Del Sole 7890 Pine Valley Dr., Woodbridge Phone: 905-605-1648 Ext 221 Contact: Nesa Osmani

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APPENDIX___ __

Appendix 5 Hip and Knee Patient-Reported Outcome Measures (PROMs)

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Appendix 5

Hip and Knee Patient-Reported Outcome Measures (PROMs) What are patient-reported outcome measures (PROMs)?  Patient-reported outcome measures are survey tools that you fill out to tell your health care team how you are feeling and doing.  Your hip and knee PROMs let you tell your health care team about your:  pain  functional status (how well you are able to do your normal daily activities)  overall quality of life  orthopedic care How do PROMs help me and my health care team?  Your answers are used to measure how well you are doing before your surgery and how well you are healing afterwards.  PROMS track your progress over time.  This information helps to plan the best possible care for your unique needs.

When and where do I fill out the PROMs  PROMs can be completed at your orthopedic clinic where you have appointments about your surgery. There will be a tablet for you to use.  You can also complete your PROMs at home on any device that has a connection to the internet (i.e. Desktop computer, laptop computer, smartphone, etc.).  Complete your PROMs:  during Rapid Assessment Clinic visit  during Pre-Anesthesia Clinic visit  3-4 months after your surgery  1 year after your surgery  It will take you around 5 minutes to complete the PROMs survey.  You must answer all the questions. If you leave a question blank then you will not be able to go to the next question.  If you make a mistake you can click the ‘Back’ button and fix your mistake. Once you have clicked ‘Submit’ at the end of the survey, you cannot go back and correct your responses.

APPENDIX

Do I have to answer PROMs?  No, you do not have to complete PROMs, however you are encouraged to do so as the information from PROMS helps your health care team make treatment decisions and plan the best care for you.

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APPENDIX___ __

How is my health information collected and stored?  The information you give through your PROMs is collected and stored in a system called ISAAC (Integrated Symptom Assessment and Collection)  ISAAC is a secure web-based electronic platform. Only your health care team, staff who work with the ISAAC platform and Cancer Care Ontario can see your information.

What if I change my mind about sharing my personal health information?  If you no longer want to share your personal health information through PROMs then your hospital can remove your information from the ISAAC system.  The hospital may keep a copy of your information according to their hospital’s policy.  Contact your hospital's registration desk for more information.

Who can access my information?

The staff involved in treating you have access to your PROMs information.

Your information is also combined with the information of other patients treated in the clinic to see if there are any trends and for the purpose of quality control and provincial reporting Where can I get more information?  Your health care team or the registration desk staff can help if you have questions about PROMs or the ISAAC system.  The ISAAC Patient User Guide for Orthopedics is available on the CCO Health website (https://www.ccohealth.ca/en/person-centred-care/musculoskeletal).

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To complete Hip and Knee Patient-Reported Outcome Measures (PROMs) Accessing the ISAAC Patient Portal: https://orthopedic-isaacuat.ccohealth.ca/

The Terms of Use Page is displayed the first time you log into the application. After you have accepted the Terms of Use, you can log into the application to complete your survey assessments. The Terms of Use are only displayed once, unless the terms have been changed since you accepted them last.

APPENDIX

Please Note: You can view the Terms of Use anytime from the Patient Welcome Page

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APPENDIX___ __

Completing a Survey 1. Generally, an instructions page is displayed that tells you about the content and purpose of the survey and gives you instructions on how to complete that survey.

2. After you read the Instructions page, click on Continue. You will be directed to the Hip and Knee Screening Assessment page.

3. After you answer the screening question, click on Continue. You will be directed to a onepage mini instruction page.

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4. Once you have read the instructions, click on Continue and you will be brought to the first survey question. The surveys you will be presented with will depend on how you answered the Hip and Knee Screening Assessment. For example, if you selected “right hip” and “left knee”, the system will prompt you to complete a survey for your right hip followed by another survey for your left knee.

5. Read the question carefully. You can then select the answer that best applies to you and click on Continue to get to the next question (All questions are mandatory and the Continue button will become enabled only after you have selected an answer).

6. Follow the above process for all questions.

7. If you need to go back to change your answer for a previous question, you can click on the Go Back button.

8. When you are satisfied with your answers, select Continue (if you have more surveys to complete, you will be brought to the start of the next survey) to submit your survey responses.

APPENDIX

Please Note: If you do not click on the Continue button, your survey responses will not be saved for that survey. When you click the button, a pop-up with text reading "In progress..." will appear. This feature prevents multiple submissions.

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APPENDIX_ __ __

Completing Additional Surveys Additional surveys may be displayed based on your answer to a question in the current survey.

This means that while you are taking a survey, another survey may be added to your list of surveys to be completed based on your answers to a question or questions. The additional survey, if required, appears after you have completed your current survey.     

The Oxford Hip Score (OHS) survey is made up of 12 questions specifically created to measure function and pain with patients undergoing hip replacement surgery.

The Oxford Knee Score (OKS) survey is made up of 12 questions specifically created to measure function and pain after total knee replacement (TKR) surgery.

The EuroQol five-dimensional (EQ-5D) survey is made up of five questions focused on mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.

General Health Assessment is a 1 question survey that asks you to rate your overall health.

Post-Surgery Assessment is a 1 question survey that asks you to rate your satisfaction with your hip/knee surgery. If you have not yet had surgery, you should select the following option: “I have not had surgery yet”.

Logging Off and Quitting Logout before Survey Completion You can leave the ISAAC application from any page. However, if you leave the application during a survey, your survey responses are not saved. This means you will have to re-take the survey the next time you log in. A warning message is displayed when you try to quit during a survey.

Automatic Logout for Idle Sessions The ISAAC application has a built-in timeout feature. This feature will automatically logout patients that have not been active for a few minutes. This feature is to support patient privacy so that other people will not have access to your health information without your knowledge. This feature exists for all kiosks in the orthopedic centres.

If you are still using ISAAC, the program will give you a warning and allow you to continue without automatically logging you out of the session.

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Appendix 6 Exercise Guide

EXERCISE GUIDE

Total Knee Replacement

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EXERCISE GUIDE______

Exercises: Before Surgery 1. Knee Bending in Supine using Towel/Sheet 

Lying on your back flat with knees bent and feet flat on the bed/floor



Use a sheet or a towel to assist in bending the knee



Keeping your feet flat on the bed and slide it as far back as you can.



Hold for 5 seconds and straighten the leg back straight Hold ___5___ seconds.

Repeat ___10___ times.

Do ___3___ times per day.

2. Bridging 

Lying on your back with knees bent and feet flat on the bed/floor.



Squeeze your buttocks together and lift your bottom off of the bed/floor.



Hold 5 seconds and slowly return to the starting position.



If the previous exercise seems easy for you, do the same with one leg straight and off the bed as in the picture on the right Hold ___5___ seconds.

Repeat ___10___ times.

Do ___3___ times per day.

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Exercises: Before Surgery 3. Knee Straightening Over Roll 

Place large rolled towel under knee



Press back of knee down into rolled towel



Straighten leg Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

4. Knee Straightening in Chair   Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day 5. Hamstring Stretch in Sitting. 

Sit on edge of firm seat and place heel on step



Straighten leg and pull toes towards you



Keep back straight and bend forward until gentle stretch is felt on back Hold ___30__ seconds Repeat ___3___ times Do ___3___ times per day



Sit on chair with armrests

EXERCISE GUIDE

6. Chair Push-offs 

Place hands on armrests with elbows bent



Push through hands to straighten elbows and lift body up.

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Hold ___5__ seconds Repeat ___10___ times Do ___3___ times per day

EXERCISE GUIDE______

Exercises: Before Surgery 7. Standing Knee Raises 

Stand straight and hold on to the rail/counter on your non-operative side



Lift your operated knee to hip height slowly



Hold of 5 seconds, then gently lower the leg down Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

8. Standing Knee Bend 

Hold chair or firm counter for support



Stand on the non-operative leg

 Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day 9. Heel Raises 

Stand straight with feet shoulder width apart. Use the back of a chair if you have poor balance or hold a counter for support.



Rise up on toes.



Hold 5 seconds. Slowly return to starting position.

Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

10. Mini Squats on Chair 

Stand in front of a chair with equal weight through both feet.

Feet shoulder width apart



Lower your bottom towards the seat as if you are going to sit.



Pause for 2 seconds hovering over the chair seat. DO NOT SIT.



Come back to standing.

Hold ___2___ seconds Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 0 - 2 After Surgery 1. Knee Bending in Supine using Towel/Sheet 

Lie flat on your back with knees bent and feet flat on the bed.



Use a sheet or a towel to assist in bending the operative knee.



Keep your feet flat on the bed and slide your operative foot back as far as you can.



Hold for 5 seconds and straighten the operative leg.

Hold ___5___ seconds Repeat ___10___ times

Do ___3___ times per day

2. Knee Straightening Over Roll 

Place large rolled towel under the operative knee



Press back of knee down into rolled towel, lift your heel off the bed



Straighten leg Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

3. Passive Knee Straightening in Supine Lie in bed



Place your heel on a roll so that the back of the operative knee is off the bed by 2-3 inches.



Relax your leg.

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Hold ___30___ seconds Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 0 - 2 After Surgery 4. Static Quadriceps 

Lying on your back, tighten your thigh muscles, such that you are pushing the knee down to straighten Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

5. Foot and Ankle Pumps 

If you are lying down, move feet up and down.



If you are sitting, place feet flat on floor, lift toes up then lift heels up.

Repeat ___10___ times every waking hour

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Exercises: Weeks 2 - 12 After Surgery 1. Knee Bend in Supine Using Towel/Sheet 

Lie flat on your back with knees bent and feet flat on the bed.



Use a sheet or a towel to assist in bending the operative knee.



Keep your feet flat on the bed and slide your operative foot back as far as you can.



Hold for 5 seconds and straighten the operative leg.

Hold ___10___ minutes Do ___3___ times per day

2. Assisted Sitting Knee Bend  

Cross non-operative leg over operative leg.

 Hold ___15___ seconds Repeat ___3___ times Do ___3___ times per day

3. Step Lunge on Stair/Step 

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 Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 2 - 12 After Surgery 4. Standing Knee Bend 

Hold chair or firm counter for support



Stand on non-operative leg

 Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

5. Calf Stretch –Supine/Standing 

Wrap a towel/sheet around the ball of your feet.



Stand at wall with one leg ahead of the other .



Keep operative knee straight and pull your toes towards you.



Keep back leg straight with heel on floor and toes pointing forward.



Hold the stretch for 30 seconds.



Lean into the wall until stretch is felt in the calf of back leg Hold 30 seconds.

Easy

Hard

6. Passive Knee Straightening in sitting 

Sit on the chair.



Rest your operative leg on a stool/couch.



Relax your leg.

Hold __10___ minutes Do ___3___ times per day

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Exercises: Weeks 2 - 12 After Surgery 7. Hamstring Stretch in Sitting 

Sit on edge of firm seat and place operative heel on step.



Straighten operative leg and pull toes towards you.



Keep back straight and bend forward until gentle stretch is felt on back of thigh.

Hold ___30___ seconds Repeat ___3___ times Do ___3___ times per day

8. Forward and Back Weight Transfers     

Increase level of difficult: lift feet and step forward and back.

Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

9. Standing Knee Raises Stand straight and hold on to the rail/counter on non-operative side.



Lift your operative knee to hip height slowly.



Hold of 5 seconds, then gently lower the leg down.

Hold ___5___ seconds

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Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 2 - 12 After Surgery 10. One Leg Balance within Support/Walker 

Stand facing counter or table with a chair behind you for safety.



Stand on operative leg.



Lift non-operative leg off floor, keeping pelvis level and back straight.



Hold onto the counter or railing for extra safety.

Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

11. Knee Straightening Over Roll 

Place large rolled towel under operative knee



Press back of operative knee down into rolled towel, lift heel off bed.



Straighten leg Hold ___5___ seconds Repeat ___10___ times

Do ___3___ times per day

12. Knee Straightening in Chair   Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

13. Straight Leg Raise in Supine 

Lie on your back with non-operative leg bent and feet flat on the bed



Keep operative leg straight lift it 20cm off the bed and hold for 5 seconds.



Slowly relax and bring the leg down to relax Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 2 - 12 After Surgery 14. Mini Knee Bends   

Bend hips and knees slightly, keeping weight on your heels and knees over second toe.

 Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

15. Sit to Stand   

Press feet into the floor and stand up using legs, not arms.

 Hold ___5___ seconds Repeat ___10___ times Do ___3___ times per day

16. Stepping Up and Down Steps 

EXERCISE GUIDE

 

Slowly step up, leading with operative leg



Slowly step down, leading with non-operative leg

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 Repeat ___10___ times Do ___3___ times per day

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Exercises: Weeks 2 - 12 After Surgery 17. Side Stepping 

Stand next to low step.



Hold counter or railing for balance.



Slowly step up, leading with operative leg.



Slowly step down, leading with non-operative leg.

Tip: keep knees over second toe at all times Repeat ___10___ times Do ___3___ times per day

18. Split Squat (lunge) 

Hold counter for support.



Step forward with operative leg.



Slowly bend knee, keeping knee behind toes and over ankle.



Return to starting position.



Switch sides Repeat ___10___ times

Do ___3___ times per day

19. Bridging 

Lying on your back with knees bent and feet flat on the bed/floor.



Squeeze your buttocks together and lift your bottom off of the bed/floor.



Hold 5 seconds and slowly return to the starting position.



If the previous exercise seems easy for you, do the same with one leg straight and off the bed as in the picture on the right Hold ___5___ seconds.

Repeat ___10___ times.

Do ___3___ times per day.

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Activity Recommendations After Joint Replacement

The activity recommendations below are based on the results of a survey done by with members of the Knee Society in 2005. It was reported by Drs. Healy, Sharma, Schwartz & Iorio in 2008. 1

Allowed

Allowed with Experience

No Consensus

Not Recommended

Stationary cycling

Aerobics

Squash/racquetball

Jogging

Road cycling

Yoga

Singles tennis

Basketball

Golf

Ice skating

Weight machine

Football

Swimming

Cross-country skiing

Roller skating

Soccer

Normal walking

Downhill skiing

Weight lifting

Volleyball

Speed walking

Stationary skiing

Baseball

Hiking

Doubles tennis

Gymnastics

Canoeing

Horseback riding

Handball

Square dancing

Rowing

Hockey

Ballroom dancing

Rock climbing

Bowling

Fencing

Shuffleboard

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EXERCISE GUIDE

Healy WL, Sharma S, Benjamin S, Ioria R. Athletic Activity After Total Joint Arthroplasty.

J Bone Joint Surg Am. 2008;90:2245-2252.

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William Osler Health System is a hospital system that serves 1.3 million residents of Brampton, Etobicoke, and surrounding communities within the Central West Local Health Integration Network. Osler’s emergency departments are among the busiest in Canada and its labour and delivery program is one of the largest in the province. William Osler Health System Foundation builds and fosters relationships in order to raise funds to support William Osler Health System’s capital, education and research priorities at Brampton Civic Hospital, Etobicoke General Hospital and the new Peel Memorial Centre for Integrated Health & Wellness.

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