This BMJ article covers post-op management of shoulder, hip, or knee arthroplasty. A lot of this is obviously going to be managed by the surgical team in question, but there are invariably GP queries, so I thought it was worth making some notes.
Analgesia: Avoid NSAIDs where possible; they may interfere with bone healing. One study shows that patients who took Ibuprofen for post-op analgesia following a THR had higher rates of revision in the next ten years than patients who didn’t.
Patients are likely to need weak opiates + paracetamol for the first four to six weeks post-operatively. If pain is ongoing thereafter – especially at night – it should be investigated for malpositioning or infection; check inflammatory markers and X-ray and get orthopaedic review.
Wound ooze: Has normally ceased by the third or fourth day post-operatively, although may take longer in patients with diabetes, patients on anticoagulation, or obese patients. If a wound is still oozing slightly by day 10, that may indicate infection; get them reviewed by their surgeon. The same applies to slightly dehisced wounds.
Sutures: Wounds should have healed enough to remove sutures by 10 days. If an absorbable suture was used, it will often leave tags at either edge of the wound; these can be cut after 10 – 16 days.
Dressings: Keep the wound covered until the scar is fully healed and the sutures removed.
Suspected infection: Do not treat empirically even if you think the infection appears superficial; it’s very difficult to tell for sure, and patients with suspected infection post-arthroplasty need to be referred back to their surgeons for consideration of joint aspiration.
VTE prophylaxis: NICE recommends 4 to 5 weeks for THR and 10 to 14 days after TKR.
Physiotherapy: I assumed post-op physio was important for getting the joint functional in the short term, but it seems it’s a lot more even than that; post-op physio and rehabilitation (which should continue for approximately 13 weeks post-op) is extremely important for long-term function and for avoidance of complications.
Driving: Most organisations recommend avoiding driving for at least six weeks after any joint replacement. As always, patients should only restart when they can do an emergency stop.
Restrictions on movement: Are important to avoid post-op dislocation.
After TKR: Avoid kneeling or sitting cross-legged, especially for the first six weeks.
After shoulder replacement: Keep the arm in a sling for the first six weeks and avoid resisted internal rotation (shutting doors, pulling cord of blind), putting arm behind back, or letting arm fall to rest from beyond back. Avoid heavy lifting for six months.
After THR: Things get more complicated. Certain movements (flexion, adduction, internal rotation) are known to increase the risk of dislocation and are advised against, as hip dislocation post-op leads to dangerous pressure on the sciatic nerve. However, avoidance those movements in the post-op period has been shown to lead to reduced function. The article recommends avoiding these movements but advises going with the advice of the surgeon.
Longer-term restrictions: Some activities are more likely to lead to wear and loosening of the implant with a risk of earlier need of revision. Activities to try to avoid long-term include:
Hip or knee:
- Running or impact exercises
- Twisting sports or jobs
- Contact sports
- Sports requiring throwing motions (e.g. tennis)
- Hammering or other activities with similar moves
- Contact sports
- Other actitvities that increase the risk of falling onto outstretched arms.
Swimming is good exercise for anyone following a joint replacement. Cycling and walking should also be promoted following shoulder arthroplasty, and gentle walking and dancing following hip or knee arthroplasty.
Air travel: Carries a risk post-op, especially with long haul flights or with multiple flights in a short time. There’s also a risk of activating security alarms in the airport.