Harris FAQ General

Adam I. Harris, M.D.

How long will I be in the hospital?
This is the most commonly asked question. Unlike some of my colleagues both in town and across the country, I don’t treat people like ingredients in a recipe. The length of the hospital depends upon both the patient’s capacity and their needs. You can imagine that the younger patient who lives in a single story house and has a large family available to help would in general go home before the older patient who lives alone and has 30 steps to their front door! Few of my patients under 80 years of age require a stay in a rehabilitation hospital. On average, patients who have an MIS total hip will stay one to three nights. Patients who have an MIS total knee will stay two to three nights. Patients who have a revision or re-do of a previous arthroplasty will stay one to two nights longer and are slightly more likely to need a stay in a rehabilitation hospital before going home.

The exact length of the stay is, in a sense, a "game" where the rules are made by the government and the insurance companies. You must stay in the hospital until you are medically stable. You cannot go home until you are safe to go home to your home environment. In general, if these two points are separated by a day, then you can stay an extra day in the hospital, then go home. If they are expected to be separated by several days, then you will be transferred to a rehabilitation facility. Experience with this procedure is that for those under eighty years of age, a rehab stay has been needed about two per cent of the time. Half of those over eighty do require a rehabilitation stay.

How soon after my surgery can I drive?
There is not a great scientific answer to this question. There are many people driving right now that have no business being on the road. I’m admittedly conservative on this issue. The real question is not whether you can operate the vehicle. The real question becomes, “When can you respond appropriately to an emergency?” If you are going to think twice about your hip or your knee before responding to the emergency in front of you, don’t get behind the wheel in the first place. When my kids were younger, I’d tell my patients that if they were going to drive early, call me at home so that I could keep them inside.

Can I get a handicapped license plate or placard?
For this one, the state makes the rules; the doctors just have to follow the rules. Probably, the Podiatrists have a better lobby in Austin than do the Doctors. There are strict rules regarding prescribing handicapped license plates and placards. Failure to follow these rules can result in the physician’s license to practice being “pulled”. Unfortunately, the state is unwilling to help in defining what constitutes “appropriate prescriptions”. The rules include criteria such as: “unable to walk without assistive devices”, and “unable to walk 200 feet”. (Emphasis is added from other state’s similar rules.) The bottom line on this is that most patients will not qualify for the placard after a few weeks, while the shortest term temporary placard is either three or six months.

Can I have both knees (or hips) replaced at the same time?
I don’t recommend replacing both sides at the same time. There are several good reasons for this. First, for knee replacements, doing both at the same time (with standard approaches) is associated with many times more than double the rate of strokes, heart attacks, and many lung problems when compared with doing one at a time. Secondly, MIS approaches take a little longer to do than standard approaches. Most surgeons who do both sides at the same time overlap some portions thus saving some time. With the somewhat longer MIS surgery, the net savings is not so great, and the total time under anaesthesia becomes an additional risk. Lastly, while the recovery seems to be reasonably quick after replacing both knees at the same time, I’m not convinced that the ultimate range of motion is as good as those who have the surgeries staggered.

When should I arrive at the Hospital?
In general, the hospitals will want you to arrive about two hours before your surgery. If your surgery is scheduled for early in the morning, please double-check this with the hospital. Occasionally, less time is required if your surgery is the first of the day.

May I go to the hospital the night before?
In general, some recent Federal regulations and subsequent insurance company rules have made "prior night admission" a thing of the past. Very few circumstances qualify for prior night admission. If your surgery is scheduled for early in the morning and you live a long distance from the hospital, very vary rarely, a hospital will allow a "courtesy admission." Please check with the hospital. These regulations vary from hospital to hospital but please don’t get your hopes up. The standard today is same day admission. Hospitals will tend to find hotels nearby for out of town patients.

Should I have blood tests done before surgery?
In the week or two before your surgery, your primary care physician and/or your insurance company may prefer that you have your preoperative laboratories done at your primary care physician's office or a designated lab. We will help to coordinate this, but please also check with your primary care physician or insurance company. If you have blood or other tests done before the surgery, please be sure that the results are forwarded to our office. We can provide a list of requisite studies. Your primary care physician should have our fax number. Our fax number is (210) 614-5103.

If at all possible, please do go to the hospital to have the hospital’s own lab draw a “type and screen” up to 10 days before your surgery. This eliminates one of the most common delays in getting the surgery started.

What about eating/meals and surgery?
Do not eat anything after midnight the night before your surgery. After midnight, you may drink water up until about four hours before the scheduled time of your surgery. (Again, the scheduled time of the surgery, not the time that you arrive at the hospital.) People with diabetes, please also read the section on medicines below carefully. It is better for you to show up well hydrated than dry and shriveled like a prune. Please know that you may drink water, as much water as you want, up to 4 hours before your surgery time. This is true regardless of who else might call to tell you to put nothing in your mouth. Some hospital employees have even told other patients that Dr. Harris wants you to have no water. This is just not true. You may have water.

What can I do to minimize my risk of infection?
First, the record of known infectious complications in this office is better than published reports. Unfortunately, the so-called “super bugs” have become very common in the community in some studies representing 30% or more of organisms cultured off otherwise healthy skin. Therefore, a shower or bath with a Chlorhexidine based soap (Hibiclens and others) may reduce your risk. Please be careful though! Some people are allergic to this soap. If you plan to wash the night before the surgery with Chlorhexidine, please try the soap a week or more before to be sure that you tolerate the soap. Rashes or blisters near the incision area will force postponement of the surgery. Chlorhexidine soaps are available at most drug stores, and many groceries.

Next, while losing weight is a good thing if you’re overweight, don’t scrimp on protein in the few weeks before the surgery. Adequate protein levels are important with regard to wound healing. For the most part, short term increases in cholesterol or lipids intake will not be significant in the long run. If you have concerns about “eating meat” please bring them up to your primary care physician. It is outside the realm of this office to make specific nutritional recommendations.

Tell Dr. Harris about any remote (away from the surgical area) infections. Boils, open wounds, and decaying teeth are a few examples. Check with your primary care physician about urinary tract and sinus or respiratory infections. Check with your dentist to be sure that you have no active infections in your mouth.

Lastly, if you shave in the area of the surgery on a regular basis, please don’t do so for seven to ten days before the surgery. Remember, that the hip surgery incision may be placed in the groin area. Many surgeries have been postponed for infected cuts and scratches in area of the surgery.

What about my medicines?

Medicines for Diabetes:
If you have diabetes and take either insulin or an oral hypoglycemic medication to control your blood sugar, in general, these medications should NOT be taken on the morning of your surgery. Please check with the physician who manages your diabetes. Sometimes, the doses of medicine given the night before should also be altered. The doctor who knows your diabetes best is the best one to make these recommendations.

Nonsteroidal Antiinflammatory Drugs:
During the ten days before your surgery, you should avoid nonsteroidal antiinflammatory drugs. These specifically include aspirin, Motrin, Advil, and most of the over-the-counter pain remedies. Mobic or Celebrex should be stopped 48 hours before the surgery. Tylenol is okay to take up to the night before the surgery. NOTE: Almost all over the counter pain relief medications have non steroidal anti-inflammatory compounds which are also blood thinners. Only acetaminophen (Tylenol) is a pain reliever that is not an NSAID.

Blood Thinners, NSAIDs (non steroid anti-inflammatory drugs) and Aspirin:
If you are on a blood thinner (i.e., Coumadin, aspirin, or Plavix), please check with your primary care physician. In the vast majority of cases, this medication can be stopped safely a few days (Coumadin – 5 days, aspirin or Plavix – 10 days) before the surgery and then resumed shortly after the surgery. Again, please check with your primary care physician if you have any questions about this type of medication.

Mega-Vitamins, Nutraceuticals, and other potential blood thinners
There is no problem with the use of ordinary multivitamins. Brands such as “one a day” or “Centrum” will cause no problems with bleeding, and are generally good for you, whether you’re having surgery or not. The so called “mega-vitamins” or “nutraceuticals” can increase your risk of excessive bleeding at and around the time of the surgery. Particular offenders include Vitamin E, Ginko, Ginger, and Garlic. Less well established, but also probable trouble makers include Glucosamine, Chondroitin Sulfate, and Fish Oil (Omega-3). All of these medicines should be stopped at least 10 days before the surgery. Vitamin C supplements are not a problem. Neither are Vitamin B complex supplements, but if you take the B complex supplements, also please take some supplemental iron. Bottom line here is that supplements other than regular multivitamins, Vitamins B, C, or iron should be stopped at least 10 days before surgery.

Heart and Blood Pressure Medications:
Blood pressure medicine, with regard to surgery, are broken into two different types. Some are diuretics, or water pills. Please do not take any medications that are purely diuretics on the morning of surgery. On the other hand, there are many blood pressure pills that are not water pills, or are combinations of water pills with other types of medicines. If you are taking any of these medications for high blood pressure, you should take these on the morning of the surgery with a small sip of water. Do not interrupt your usual schedule for these medicines.

Medicines for Rheumatoid Arthritis or Asthma:
Many antirheumatic medications are also antimetabolites. Methotrexate is an example. These drugs should be stopped prior to the procedure. Please check with your rheumatologist regarding optimal timing. Bronchodilators or inhalers should be taken on the morning of surgery.

Steroid Medications:
Steroid medications such as prednisone must be continued. They need not be taken the day of the surgery, as you should receive supplemental steroid medication in the hospital. If you have been on steroids by mouth for more than a week within the last year, please review this with me and the anesthesiologist and the nurses before your surgery.

Pills for Neuropathy, Chronic Pain, Peptic Ulcers, or Psychological issues:
For the most part, these medicines should not be interrupted. Please, if you are on any of these medicines, discuss them with this office and/or with your primary care physician.

When should I schedule my follow-up appointment?
The first follow-up appointment is between two and three weeks after the surgery. Your staples (if any) will be removed at this appointment.

How do I care for the wound(s)?
Elective surgical dressings should be removed two to three days after the surgery. Then, a clean, dry dressing should be placed once a day, or more often as needed. It is not unusual for there to be a few drops and up to a silver dollar-sized spot on dressings of blood or clear yellow fluid from the incision. You should clean the wound with sterile normal saline or dilute hydrogen peroxide (one part hydrogen peroxide to three or four parts water or saline). Please do not use full strength hydrogen peroxide or alcohol to clean the wound. These do more harm than good, particularly if used repeatedly. A thin film of antibiotic ointment is not harmful, but also not needed. If there is drainage and it is green or cloudy, increasing in volume, or more than a silver dollar's worth a day, or the wound appears an angry red, then call the office immediately.

Suggestions for the few days before the surgery:
1) Help yourself prevent constipation. All good pain medicines cause some constipation. If your bowels are less full, then you should have less trouble with constipation after the surgery. You might consider using an enema the night before the surgery, and/or sometime in the morning of the day before the surgery (not the day of the surgery), take one or two tablets of ducolax, a medication that is available over the counter.

2) Do you shave your legs or pubic hair (hip patients)? If so, please don’t do so for a week or so before the surgery. More than a few surgeries have been cancelled for razor induced rashes or nicks at or near the planned incision.

3) Do you enjoy gardening or do a lot of work outside? Please protect your legs from cuts and scratches. Again, open wounds on the leg can force postponement of your surgery.

4) Do you use any medicine for erectile dysfunction (Viagra, Cialis, Levitra, herbal remedies, and others)? If so, please do not use these shortly before the surgery. If the effects of the drug are still in your system, and you need certain medicines for your heart either during your surgery or thereafter, a dangerous drop in blood pressure may occur. The different drugs have different life spans. Please check with your primary care doctor.

Important points in closing for all Arthroplasty patients (joint replacement patients):

Blood Thinners:
Without some protection, after joint replacement, there is a significant risk that you’ll develop an abnormal blood clot in your leg. These clots can break off and cause all sorts of trouble, particularly in the lungs. Before either early mobilization or routine prophylaxis for these clots, 1% of elective patients died from this complication. With prophylaxis, the rate is around 0.02% in most studies. Therefore, after your joint replacement, you will be placed on a blood thinner. At present, Dr. Harris is working in line with the recommendations of the American Academy of Orthopædic Surgeons and using either short term Coumadin followed by plain aspirin, or plain aspirin from day one. Both are used in combination with early mobilization and sequential compression devices. A few patients will be better served by alternate drugs, and you may be asked to participate in a study looking for simpler and potentially safer medications for the same purpose. The duration of therapy may range from 10 days to 6 weeks. Other medications may be used for a shorter interval. You should refrain from using other types of blood thinning drugs while you’re on the prophylactic medicine. For example, anti-inflammatory medications, like aspirin, are platelet inhibitors. If you are using aspirin for prophylaxis, you may use non steroidal anti-inflammatory medications (NSAIDs), but not Vitamin E, Glucosamine, Garlic, etc. If you’re on a heparin like drug, you should not use NSAIDs, or Coumadin. This can be confusing. If you have any questions, please ask before adding a drug that could make your blood too thin.

Dental Hygeine and similar procedures:
Many things that we do during ordinary activities will cause some bacteria to float around in our blood system. Simple acts, like brushing your teeth will cause a detectable rise in the number of bacteria in the blood. For these ordinary activities, some very very sensitive tests are needed to detect the levels. For some activities, such as dental hygiene at the dentist’s office will spill a larger number of bacteria into the bloodstream. These bugs can take up residence on the metal of your prosthesis, and cause all sorts of problems.

Therefore, for these procedures, we suggest that you take a single dose of antibiotics 30 to 60 minutes before the procedure. Your dentist can give you the prescription, your primary care can also give the prescription, as can this office. I don’t care where you get the prescription, so long as you get and take the medicine.

Other procedures that stir up bugs probably include colonoscopy and endoscopy. Larger procedures, such as “standard” surgery should be accompanied by preoperative antibiotics anyway, and no special additional medications are needed to protect your prosthesis. These “extra” antibiotics immediately before dental and similar work are needed for only 2 years, unless your immune system is not up to snuff. If there is any question, during the first two years, ask the provider of the “other procedure” if he or she would give prophylactic antibiotics if you had a mechanical heart valve. If the answer is yes, then you should also have prophylactic antibiotics. Two years after the most recent joint replacement surgery, the risk for most people of taking more antibiotics becomes greater than the risk of getting an infection. Therefore, if you’re more than two years beyond the joint replacement, prophylactic antibiotics for ordinary dental procedures and the like are not needed.

It is a pleasure to participate in your health care. If you have other questions, please call.

Sincerely,

Adam I. Harris, M.D.