Your Orthopaedic Surgery with Dr. Harwin

Blood Issues: Donation Procedure and "Bloodless Surgery"

As Director of the Total Joint Replacement Bloodless Surgery Program at Beth Israel, it is my philosophy to try to avoid blood transfusions if possible. Patients undergoing arthroscopic procedures including ACL and rotator cuff repair will not require any blood for the surgery. Patients undergoing joint replacement procedures rarely require blood transfusion during the operation but in some cases (less than 10%) may need blood afterwards. Therefore, certain patients, who are at risk for transfusion and healthy enough to donate their own blood, may want to do so. My general recommendation is not to do so, since after donating blood, you become anemic, often making it necessary to give blood. Your blood is for you only and is either given back to you in the hospital or discarded. Pre-operative administration of Epoetin (Pro-Crit) to increase your blood count may also be recommended. Conservation measures such as a cell saver device and recovery drains are used when needed.

If you are one of Jehovah's Witnesses, and religious conviction will not allow you to receive blood transfusions or any blood products, please let us know. If necessary, joint replacements and revision surgery may be performed in a "bloodless" fashion. Patients interested in this option must follow our recommended protocol. This will be discussed on an individual basis.

How to Donate Your Own Blood Prior to Surgery
Information About Blood Conservation, Donation and Transfusion

Anesthesia

For patients undergoing arthroscopic surgery of the knee and ACL reconstruction, the procedure is most often done under a general anesthetic with you asleep. Our preferred method of anesthesia for total hip and total knee replacement, as well as for shoulder surgery, is regional anesthesia. With this method, a tiny needle is placed in the back or shoulder and a local anesthetic is given. The hips and legs, or shoulder and arm become numb, so that no pain is felt. Then, intravenous sedation medication is given so that you will sleep.

Before your operation, you will have the opportunity to discuss the type of anesthesia with our anesthesiologist. Our specialized anesthesiologists are highly skilled in modern anesthesia techniques, allowing us to perform even the most complex of procedures, under regional anesthesia with safety. These doctors are all Board Certified and stay with you throughout your surgery.

Your Surgeon and the Surgical Procedure

Rest assured that I alone perform your surgery! While I have a team of assistants helping me, each with their own special jobs to do, the surgical procedure itself is done by me; not by interns, residents or fellows. Before the operation begins, I will personally see you and talk with you. I have had surgery myself and I know how important this is.

On the day of surgery, several people, including myself, will ask you to identify the joint and the side of the body we are operating on (left or right or both). This is to make absolutely sure there is no misunderstanding. My nurse, physician or surgical assistant, and anesthesiologist will ask you the same question. This is normal procedure. I will write my initials "SFH" on the hip, knee or shoulder we are operating on with a skin marker.

Arthroscopic knee surgery is done through two tiny incisions on the front of the knee. After this procedure, you may bear as much weight as tolerated but usually a cane is necessary for the first day or two. You may move the knee within the limits of your comfort, and you should have 90° of bending or more on the day after your surgery. There are usually no restrictions as to weight bearing and movement of the joint. Recovery is 2–3 days, followed by about 4 weeks of physical therapy or exercise.

If your surgery involves ACL ligament reconstruction or muscle repair, then there may be additional incisions on the front of the knee. While in most cases you may still bear as much weight as tolerated and perform range of motion exercises as tolerated, you may have a brace applied to the knee for up to 6 weeks to protect the knee. You will also be asked to use a continuous passive motion (CPM) machine to help the movement of the knee. You will use a cane or crutches for a few days and then advance to no support as you become stronger. Recovery is about a week, followed by physical therapy for about 3 months. In rare circumstances, if a major tendon or fracture was repaired, you may need to be immobilized for a period of time, usually about 6 weeks.

If your arthroscopic surgery involves the shoulder, you will usually have three or more tiny incisions and you will be placed in a sling for comfort postoperatively. The procedure is done on an ambulatory basis and the sling may be removed whenever you are comfortable. You should try to move the shoulder as much as possible, to achieve a normal range of motion as soon as possible. Recovery is about 2–3 days, with physical therapy for about 3 months.

If a rotator cuff repair was carried out, either arthroscopically or in an open fashion, then your arm will need to be in a sling for six weeks. If an arthroscopic rotator cuff repair was carried out, then no specific physical therapy or range of motion exercises are prescribed. This is to allow for healing and to prevent disruption of the repair. If an open repair was carried out, indicating a large, complicated tear and repair, then passive movement and dangling pendulum-type exercises may need to begin soon after surgery (passive exercises mean that someone moves the arm for you). The reason for the difference in the post-operative recommendations is that with arthroscopic procedures, stiffness after surgery is rare. With open procedures, stiffness is more common and so passive exercises are prescribed. You may take the arm out of the sling to wash, dress and eat. You must read your post-operative instructions to be sure of the correct instructions. Failure to follow the prescribed protocol can result in disruption of the repair.

If your procedure is a joint replacement, you will have an incision on either the front of the knee or on the side of the hip. These operations require a stay in the hospital of 2 days. You should plan to be discharged on the 2nd day after surgery. For example, if your surgery is done on Tuesday, then plan to go home on Thursday. The social service specialist will arrange for a physical therapist and a visiting nurse to come to your home.

For total knee replacement we also prescribe the use of a continuous motion machine to aid in the movement of the knee while in the hospital. Most patients have at least 90° when they go home. You must have at least 90° of knee bending (to a "right angle") by 6 weeks after the operation. If not, we may have to "manipulate" the knee in order to gain motion and prevent permanent stiffness. This is done under anesthesia at the hospital, but is not another operation. We break up scar tissue by bending the knee for you. You must call us if your motion is not progressing.

After routine hip and knee replacement, normal walking is encouraged as soon as possible using crutches or a cane only if needed. If a walker is needed initially, you should try to progress to crutches or a cane as soon as possible. Most patients having joint replacement are recovered within 2-3 weeks, with physical therapy necessary for 3 months or longer. Depending on your job, you may return to work as early as 2-3 weeks.

As described above, I often prescribe a CPM machine and for all procedures I prescribe a motorized ice therapy unit (it will be described in detail below). If your insurance company will not pay for these important aids to your recovery, it is your choice whether or not to order it. We prescribe it because it improves outcomes, reduces your pain and swelling, and speeds your recovery. I hope you choose to order all we prescribe.

ABOUT GOING TO A REHABILITATION FACILITY: Many patients want to "go to rehab" after joint replacement surgery. Admission to a rehab facility depends on many factors, the most important of which is your insurance coverage. All of my patients are evaluated for either home or in-patient rehab when in the hospital. It cannot be arranged in advance. If authorization is denied, then you will be discharged home with support services. Based on my many years experience, almost all patients are safe and ready to go home on the second day after surgery.

People in the Operating Room

You will meet the rest of my "team" in the pre-operative holding area and the operating room. My physician assistants are Mary Anne Legarda, R-PAC and John J. Lichardi, R-PAC. Our OR nurse is Romy Esmenda, RN, and our OR scrub technician is Cesar Alonzo, ORT. Julian Macintosh, OT is our orthopaedic technician and assistant. In most cases, I also have a Surgeon Assistant as well. Again, please be assured that I alone perform your surgery. It is not done by assistants, interns, residents or fellows.

Because I am a designer of orthopaedic implants and instruments that are in use all over the world (manufactured by Stryker Orthopaedics), I often have visitors in the Operating Room. These are usually surgeons from either the USA or overseas, who have come to learn by observing my surgical techniques. With your permission, parts of your surgery may be recorded or photographed for teaching purposes. Of course, your privacy rights are respected and no individual identification is made.

There are also manufacturers' representatives in the Operating Room. They are not "scrubbed" and are not in the sterile field. They do not participate in the surgery or operate any equipment. They are there for inventory and instrument support only.

Prevention of Complications

Antibiotics are given routinely for all operations to help prevent infection. These are usually administered intravenously during the hospital stay.

Patients undergoing joint replacement must take medication (blood thinners) to prevent blood clots in the legs and lungs. Three alternatives are recommended as being effective: Aspirin, Lovenox or Coumadin. My first choice for you is Aspirin. It is easy to take, inexpensive and has fewer side effects than other alternatives. You will take one enteric coated 325mg aspirin tablet (Ecotrin or equivalent) twice a day, for 6 weeks. If you have a true allergy to aspirin (rash, hives, breathing difficulty, etc.) or a medical condition that requires it, then we would then use either Lovenox or Coumadin. These medicines are started in the hospital after surgery and continued by you at home. The dosage and duration of treatment varies depending upon which drug we use and your operation. Lovenox is given by self-administered injection (or by a family member). It is taught to you in the hospital and is very easy to do. After the Lovenox (for 10-14 days), you must then take one 325mg enteric coated aspirin twice a day (if you are not allergic) until you are 6 weeks after surgery. Coumadin is a tablet usually taken once a day. When you go home the dose must be monitored and adjusted based upon the results of blood tests done once or twice a week.

In the hospital, compressive air "leggings" are worn to reduce swelling and blood Indocin (Indomethacin) to prevent extra bone formation and a medication to protect irritating the Prilosec, Nexiumor similar drug).

Prevention of Blood Clots After Total Hip and Total Knee Replacement

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