Patient guide

What happens at the first visit?

The doctor first asks when the problem started, what it has made hard, and what treatment you have had so far. Then he examines the joint: he looks at your movement, swelling, pain and walking. An X-ray is often needed, and sometimes a blood test or an MRI (imaging with a magnetic field that shows soft tissue such as ligaments and the meniscus).

There is no reason to decide about surgery at this visit. The first visit is for understanding the problem and discussing the options.

What documents should you bring?

• Photo ID and your insurance booklet or card (if you have one)
• Earlier scans and reports. X-rays, MRI, CT scan: both the films or disc and the written result. If you only have the written result, bring that.
• Treatment records. Notes from earlier visits, the result of physiotherapy, and the hospital discharge note if you have had an operation before
• A list of medicines. The names of all medicines, supplements and herbs, even those without a prescription. It is best to bring the boxes or a photo of the labels.
• Long-term conditions. Diabetes, high blood pressure, heart disease, kidney or liver problems, clotting problems and any other illness
• Allergies. To medicines, disinfectants, latex or adhesive
• History of operations and anaesthetics, and any problem you had with them

If you do not have scans or documents, do not worry. The doctor will tell you what is needed.

What should you write down for the doctor?

Make a few lines of notes before the visit:

• Where exactly is the pain? When is it worse (stairs, walking, night, getting up from a chair)?
• When did it start? Was there a blow or injury before it?
• How far do you walk? Do you need a stick or walker?
• What have you done so far and with what result (physiotherapy, medicine, injections)?
• What matters to you (gardening, prayer and sitting, the stairs at home, sport, picking up a grandchild)?

Tell the doctor your own goals. Good treatment fits your life, not just your X-ray.

What questions should you ask?

• What exactly is my problem and what caused it?
• What are my treatment options? Please tell me all of them, with benefits and risks.
• What happens if I do not have surgery for now?
• If surgery is needed, when? How long will I be in hospital and how long will recovery take?
• What do I need to do before the operation (tests, stopping some medicines, stopping smoking)?
• What about the cost and insurance cover?

It is best to have someone with you. A son, daughter or friend can take notes and remind you later.

A few tips

• Wear comfortable clothes so the knee or hip can be seen easily.
• If you take a medicine that might matter for treatment (for example blood-thinning medicines), be sure to say so. Do not stop anything without your doctor’s advice.
• If you did not understand something, ask again. A repeated question is not a nuisance.

Which tests and which treatment you need is decided by the doctor after examining you.

Why does preparation matter?

A body that is better prepared before the operation usually recovers more easily afterwards. Preparation starts several weeks ahead. The surgeon and the anaesthetic team always give the exact instructions, and if they differ from this page, follow theirs.

A check of your general health

A few weeks before the operation, a general doctor or physician checks your overall health. The aim is to see whether your body is ready for the anaesthetic and the operation. You may be asked for:

• Blood and urine tests
• An ECG
• A chest X-ray

The results go to the surgeon. If you have a long-term condition, such as diabetes, high blood pressure or heart disease, it needs to be well controlled before the operation.

Medicines

• Prepare a complete list of your medicines and supplements, with names and how often you take them, and give it to the surgeon and the anaesthetist. This includes vitamins and herbal medicines.
• Some medicines need to be stopped or changed a few days or one to two weeks before the operation. Some (such as blood thinners, diabetes medicines and steroids) need a special plan before and after the operation.
• Do not stop or start any medicine on your own. The doctor will tell you which one and when.

Teeth, skin and infection

An infection elsewhere in the body can reach the new joint. To lower this risk:

• Have major dental work (extractions, gum treatment) done some time before the operation. Do not go to the dentist for a few weeks after the operation either, and put off even scaling, unless the doctor allows it.
• Tell the surgeon about any scratch, wound, spot or skin infection on the leg to be operated on. A skin infection may delay the operation.
• Have a shower the night before the operation. If the surgeon has recommended a disinfectant soap, use that.
• Do not shave the operation area yourself. If it is needed, the hospital will do it.

Smoking, diet and weight

• Smoking worsens blood flow, slows healing and may increase the risk of infection. Even cutting down or stopping a few weeks before helps. Ask your doctor to help you stop.
• Eat a balanced diet. If you are overweight, the doctor may suggest losing some, because extra weight puts more strain on the new joint. Plan weight loss with your doctor and do not go on a strict diet.
• Stop alcohol at least two days before the operation, and tell the doctor about anything else you use.

Exercise before the operation

If the doctor allows it, light exercise before the operation helps. For example, strengthening the upper body (for using a walker or crutches) and simple movements for the thigh muscles. Learn from the physiotherapist beforehand the movements you will need after the operation, so they are not strange to you afterwards. The physiotherapist or surgeon decides the amount and type of exercise.

The day before and the day of surgery

• Follow the fasting instructions exactly (from what time not to eat or drink).
• Ask which medicines to take on the morning of the operation.
• Write down a phone number and address for your companion, and decide who will come with you and stay with you after the operation.
• Take with you: ID and insurance card, the medicine list, your usual medicines (as instructed), comfortable non-slip slippers, loose clothes for going home, glasses, dentures and their case. Leave money and jewellery at home.
• Before you go, make sure your skin is healthy and that you have no fever or cold. If you become unwell, tell the surgeon before the operation.

What will happen after the operation?

Talk with the treatment team about how many days you will be in hospital, when physiotherapy starts, and what help you need at home. To get your home ready, see the page “Preparing your home”.

Which tests and which preparation you need depends on your situation and the surgeon’s plan.

Why before the operation?

After the operation you need several weeks of walking with a walker or crutches and help from a companion. If you get the house ready before the operation, you will not have to move things around in pain and tiredness when you come back. Most of these jobs are simple and can be left to the family.

Layout of the house

• Everything on one floor. If possible, keep the bedroom, toilet and kitchen on one floor for the first few weeks so that you go up and down stairs less. If the house has stairs, ask how to use them. For example, the good leg usually goes up first and the operated leg comes down first. The physiotherapist will show you.
• Clear the way. Take up small rugs, move cables to the wall, and keep the walking route empty. Falls in the first weeks are the biggest risk.
• Things within reach. Put things you use often (medicine, phone, glasses, the TV remote, a cup) between waist and shoulder height so you do not have to bend or stretch.
• Enough light. Put a dim light on the route to the toilet, especially at night.
• A suitable chair. A firm, fairly high chair with arms that is easy to get up from. For the knee, sources suggest a chair about 45 to 50 centimetres (18 to 20 inches) high, with a footstool. For the hip, a high chair that does not make you sit deep is better. The surgeon or physiotherapist will tell you the right height and type.

Bathroom and toilet

• Non-slip mats in the bathroom and on the shower floor
• Grab rails on the wall beside the toilet and shower (fixed firmly, not a towel hook)
• A shower seat and, if needed, a raised toilet seat
• A hand-held shower you can use while seated

If you have a dressing after the operation, showering must follow the treatment team’s instructions.

Walking aids

A few simple items make things easier:

• A walker, crutches or a stick. Try them before the operation and see whether you can move around the house and through the doors with them. The physiotherapist sets the right size.
• A reacher for picking things up from the floor
• A long shoehorn and a sock aid, especially after a hip operation, when bending is limited
• A bag or satchel with a large pocket so that your hands stay free
• A footstool, to keep the leg raised

Food and daily tasks

• One or two weeks before the operation, cook double quantities of simple meals and freeze half. Or arrange ready meals.
• Do the shopping you will need (food, cleaning products, tissues, medicine) beforehand.
• Keep dishes and kitchen items within reach.
• Plan for needing help with cooking, shopping, bathing and washing clothes for a few weeks, and share the tasks with the family.

A companion and help

• It is best if a family member or friend stays with you for the first few days after discharge. If you live alone, plan this well in advance.
• If that help is not possible, ask the hospital or a social worker about convalescence centres or nursing at home.
• Arrange transport. You cannot drive yourself for a few weeks.
• If you are working, talk to your employer before the operation about leave and the plan for returning to work.

Ask before discharge

• When does physiotherapy start, at home or as an outpatient?
• What should I not do (for example, after a hip operation, crossing the legs or bending too far)?
• Who do I call, and on what number?

Your surgeon’s instruction matters more than any general list. The advice depends on the type of operation and the surgeon’s method.

The main rule

The instructions of your surgeon and nurse about the dressing and showering come before any general text. How the wound is closed, the type of dressing and the stitches differ from patient to patient. This page gives only the general principles.

General principles of care

• Wash your hands. Before touching the dressing or the wound, wash your hands with soap and water. Your companion should do the same.
• Keep the wound dry. Sources say the wound must stay dry until it is fully closed. The doctor tells you about showering, covering the wound and when. Sitting in a bath or a pool is not allowed until your doctor says so.
• Dressing. In one source the dressing stays on the wound for about seven to ten days. Never change the dressing without being told to, and do not put cream or ointment on the wound yourself.
• Do not pick. Do not pick at spots, stitches or the scab.
• Stitches or clips. The time they are taken out differs by operation: sources give about two weeks after a hip, a few weeks after a knee, and in one source about ten days. Stitches under the skin that dissolve by themselves do not need to be taken out. The doctor tells you when and where they should be removed.
• Clothing. Soft, loose cotton clothes that do not rub the wound.
• Swelling and bruising. In the first weeks, swelling and bruising around the wound and leg are usually normal, and a little swelling may stay for months. Raising the leg and ice (over a cloth, not directly on the skin), as the treatment team directs, helps.

What is normal?

• Slight redness, warmth and tenderness around the wound in the first days
• Swelling and bruising of the leg and ankle
• A little clear or slightly bloody discharge in the first days (if it is not heavy)
• Numbness or tingling around the cut

If you do not know whether something is normal, call the treatment team. You are not a nuisance.

Signs of infection

Infection can be in the wound or deeper, around the implant. Contact your doctor or treatment centre soon if:

• You have a temperature of about 38 degrees or higher, chills, or a sudden feeling of heat and cold
• Redness, warmth, pain or swelling around the wound is increasing or not getting better
• Discharge, pus or a bad smell comes from the wound
• The edges of the wound open
• Joint pain increases and continues even at rest

An infection found early is usually easier to treat. Delay makes it harder. The doctor decides the treatment, and you should not take antibiotics on your own.

Do not forget clots

In the weeks after the operation, as well as the wound, look at your calves every day. Cramp-like pain, new or worsening swelling, or redness or tenderness in the calf can be a sign of a blood clot. The details of these signs are on the page “When should I call urgently?”.

After the wound has healed

• Avoid direct sun on the scar and, if your doctor advises, use sunscreen.
• The scar may be raised or slightly coloured for a while. This usually improves over time.
• If you have an implant, tell the doctor before any later dental treatment or other operation. The doctor decides whether preventive antibiotics are needed.

Why does movement matter?

After a joint replacement, regular exercise and walking are the main part of the treatment plan. They bring back the strength and movement of the joint, improve blood flow in the leg, and reduce the risk of a blood clot. Full recovery can take months. Compare each day with the day before, not with another patient.

Before doing any exercise, agree it with your surgeon or physiotherapist. The movements and the amount of weight on the leg differ for each patient.

The first week

• Ankle movement. Move the ankle up and down and rotate it (called “ankle pumps”). This simple movement improves blood flow. Sources say it continues until full recovery.
• Short walks. With a walker or crutches and the physiotherapist’s help. The treatment team tells you how much weight to put on the operated leg.
• First movements. Bending and straightening the knee, tightening the thigh and buttock muscles, raising the leg. The physiotherapist shows you exactly.
• Deep breathing. Regular deep breaths help the lungs.
• Stairs. Usually the good leg goes up first and the operated leg comes down first. Use the handrail.

The following weeks

• Daily exercise. Sources say that for the first while you may need to exercise two to three times a day, 20 to 30 minutes each time. The physiotherapist sets the exact programme.
• Walking. Increase the time and distance little by little. After a while you may move from a walker to a stick or a single crutch. In sources this change usually comes after a few weeks and must be approved by the surgeon or physiotherapist.
• Strengthening. Around weeks four to six, exercise with a band or light weights and a stationary bike with low resistance may start, but only with permission.
• Physiotherapy exercises should continue for at least two months. After that, regular walking and light exercise help you keep your strength.

After a few months

• Low-impact activities, such as walking, swimming, cycling, golf and dancing, are usually suitable.
• Running, jumping and high-impact sport are usually not recommended unless the surgeon allows them.
• Do not start any new sport without your doctor’s approval.

Precautions

• Avoid falls. A fall is one of the most dangerous events in this period. Wear closed, non-slip shoes, use your walking aid, and do not rush.
• Do not overdo it. Pushing too hard may increase swelling and pain. Sources say not to do “too much, too soon” and to expect good days and bad days.
• After a hip operation. Usually for the first few weeks (in sources about six to eight weeks) you should not cross your legs, raise the knee above the hip, bend too far forward, or turn the leg sharply inwards or outwards. The details depend on the surgical approach, and the surgeon or physiotherapist gives you the list.
• After a knee operation. Do not kneel on the operated knee until you have permission, and keep the operated leg raised to reduce swelling.
• Pain and swelling after exercise. Keep the leg raised and apply ice as directed (over a cloth, not directly on the skin). If it does not settle, tell the doctor.

Driving, work and travel

• Driving. Usually when you have stopped strong painkillers and the strength and reaction of the leg have returned. For the knee, sources give about four to six weeks. The surgeon gives permission.
• Work. From a few weeks to a few months depending on the type of work. One source gives six to twelve weeks.
• Air travel. Talk to your doctor before flying, because long sitting increases the risk of swelling and clots.
• Airports. The implant may set off a metal detector. Tell the officer.

When to tell the doctor

• Swelling or pain suddenly increases or does not ease after rest
• The leg cannot take weight
• Joint movement is getting worse instead of better
• Fever, redness or discharge from the wound
• Cramp-like pain or new swelling in the calf

If leg swelling comes with shortness of breath or chest pain, call 115 (the emergency number in Iran).

Your exercise programme should always be set by your own surgeon and physiotherapist.

Before anything else

This list does not replace the guidance of your treatment team. Before discharge, ask the surgeon or nurse:

• For which signs should I call, and whom and on what number?
• Whom do I call outside office hours?
• In what situation should I go straight to the emergency department?

Write the numbers on your phone and on a paper beside the bed. If you are worried, call; you are not a nuisance.

Call 115 at once or go to the emergency department

115 is the emergency number inside Iran. If you have any of these, do not wait. Do not drive yourself; ask someone to take you or call an ambulance:

• Sudden shortness of breath
• Sudden chest pain, especially if it is worse when you cough or breathe in
• Coughing up blood
• A very fast heartbeat, severe dizziness or fainting
• Confusion, sudden weakness on one side of the body, or difficulty speaking
• Heavy bleeding that does not stop with pressure
• Calf swelling and pain together with shortness of breath or chest pain

Why does this matter? A clot that forms in the leg veins may travel to the lung. This is called a pulmonary embolism and can put life at risk. If you see the signs above, do not wait for office hours. Take the medicines you use with you when you go.

Contact your doctor or treatment centre the same day

Signs of infection

Infection can be in the wound or around the implant. If you have any of these, tell them the same day:

• A temperature of about 38 degrees or higher, chills or cold sweats
• Redness, warmth or increasing swelling around the wound
• Discharge, pus or a bad smell from the wound, or the wound edges opening
• Joint pain that is increasing and is present even at rest
• A general feeling of being unwell after the operation

An infection found early is easier to treat. If you can, take a photo of the wound and show it to the treatment team.

Signs of a blood clot in the leg (deep vein thrombosis)

In the weeks after a joint operation, or after long immobility, the risk of a clot is higher. If you notice in one leg (usually the calf or thigh):

• Throbbing or cramp-like pain that has nothing to do with the wound
• New or worsening swelling in the calf, ankle or foot
• Redness or darker skin colour and tenderness to the touch
• Warmth in the calf

contact your doctor the same day or go to the emergency department. Do not put it off until “tomorrow”. If the same signs come with shortness of breath or chest pain, go to the section above (115).

Other signs

• Severe pain that is not controlled by the prescribed medicine
• Sudden inability to take weight or move the leg
• After a hip operation: the leg suddenly changes shape or length, turns to one side, or you feel a “pop” with severe pain (the joint may have come out of place)
• A fall or a blow to the new joint, even if nothing seems wrong
• New numbness or weakness in the leg or foot
• A cold, pale or bluish foot
• Vomiting or being unable to eat and drink
• Difficulty passing urine or severe constipation

A few suggestions

• Look at your wound and calves every day. You will spot small changes early.
• Moving the ankle and walking regularly, as directed, helps prevent clots.
• Take your temperature when you feel unwell.
• Take blood-thinning medicines only as your doctor directs. If you get unusual bruising or bleeding, tell them.

If you are not sure

If you do not know whether a sign is dangerous, call. A doctor or nurse would rather be told once for nothing than have a serious sign reported late.