Total Joint Replacement Guide

A Patient’s Guide to Total Joint Replacement

The heart and science of medicine. WELCOME

We are very pleased that you have chosen us for your joint replacement surgery. We are committed to the highest quality care in the most collaborative, efficient and effective manner. The University of Vermont Health Network - Central Vermont Medical Center has brought providers together in our area to ensure you have an outstanding outcome. We feel strongly that your home is the best place for you to recover after surgery and will work with you to help plan for this. This will enable you to effectively heal and recover just prior to transitioning to outpatient care. We will work together prior to and after surgery to ensure your success. This guide has been developed to provide you with the information and resources that will support you through your joint replacement surgery and recovery. We urge you to read this thoroughly, and bring it with you to your surgery and all your appointments.

Sincerely, Your Hip and Knee Team CVMC Orthopedic Surgery, CVMC Rehabilitation Therapies, CVMC Care Management, Bayada Home Health Care, VNAs of Vermont CONTENTS

Preparing for Your Surgery ...... 3

Day of Surgery ...... 4

During the Procedure ...... 5

Recommendations for Your Total Joint Replacement Surgery ..... 6

Therapy after Your Joint Replacement ...... 9

After Surgery/Home Care...... 16

Antibiotic Use After Total Joint Replacement...... 17

Local Agencies and Resources ...... 18

Checklist: Are You Ready for Your New Total Joint?...... 19

2 PREPARING FOR YOUR SURGERY

• Make plans with friends and family to provide transportation and assistance at home for 10-14 days after surgery – your stay in the hospital may only last one to two days. • Arrange living space to minimize clutter and obstacles in your home environment • You might be called by an Occupational Therapist to talk about home modifications for safety. Consider living on your first floor: rails on stairs to get into your house; bathroom and bed on the first floor; bathroom grab bars; tub seat and toilet seat riser • Attend total joint class to learn more about your upcoming surgery: »»Confirm you are coming by calling CVMC Care Management at 802-371-4357 »»Our classes are offered at CVMC the first Thursday of every month, from 2:00 - 3:00 p.m. in the Board Room. • Perform pre-surgical strengthening exercises as covered in guide. Your surgeon may recommend Prehab with physical therapy so you are strong before surgery • Practice using walker or crutches • Have a thermometer available to use after surgery • Think about who you would like for home health services and outpatient therapy • Arrange for financial assistance if needed • Pre-operative visit with your PCP and other specialist recommended by your surgeon • Complete required blood work, x-rays and EKG (notify your surgeon’s office of any health changes) • Fill out the advance directive by downloading this form and bring it with you on the day of surgery: vtethicsnetwork.org/adforms.html • Talk to your surgeon, before surgery, to establish a plan regarding iron intake and use of blood thinners. Stop taking Aspirin, Motrin, Ibuprofen, Aleve & Naproxen one week before surgery • You will meet with your surgeon prior to surgery to discuss the details of your surgery • Follow all instructions (fasting, medications, etc.) given to you by the Same Day Surgery Department

3 DAY OF SURGERY

• Shower/bathe, shave & shampoo the night before or the morning of surgery • Arrive one hour prior to your surgery, wearing loose clothing »»Same day surgery will inform you the exact time to arrive »»Report to the Registration Desk in the main lobby of Central Vermont Medical Center (pre-registration can be done prior to surgery) • Leave all jewelry, valuables and medicines (except nebulizers and inhalers) at home • Things to bring with you: »»A complete list of current medications »»Toiletries, eye glasses, contact lenses »»Night clothes, bathrobe, slippers »»Book or magazines »»Insurance cards »»Means of payment for copay or deductible »»A copy of your advance directives/ living will/ health care proxy »»Any medical equipment essential to your stay (walker, crutches and/or CPAP) • Do not eat or drink after midnight the night before your surgery • Check in with patient registration upon arriving at the hospital »»Or pre-register online prior to surgery: cvmc.org/online- registration • Up to two family members are welcome to wait in the waiting room while you are in surgery/ recovery

4 DURING THE PROCEDURE

Generally, hip/knee replacement surgery follows this process: • You will be positioned on the table • A urinary catheter will be inserted in your bladder • The anesthesiologist will monitor your vital signs (heart etc.) • Skin will be cleaned & shaved as needed where the surgery will take place • The surgeon will make an incision in the hip or knee area and replace the damaged joints

NEW KNEE JOINT NEW HIP JOINT

5 RECOMMENDATIONS FOR YOUR NEW TOTAL KNEE REPLACEMENT

• After surgery, place pillows under your ankles/ calves (not knees) to encourage knee straightening • It is important to ice and elevate your operated knee for 15-20 minutes per hour throughout the day as needed for pain control and to decrease swelling until instructed otherwise • Use crutches or walker as advised by your physical therapist • You may have a Continuous Passive Motion (CPM) Machine • Most likely you will get up out of bed the night of surgery with assistance • Sit for short periods initially (30-60 minutes) and increase as tolerated • Walk 2-3 times daily with assistance of your healthcare professional and increase as tolerated

6 RECOMMENDATIONS FOR YOUR NEW TOTAL HIP REPLACEMENT (ANTERIOR APPROACH)

• Do not step backwards while turning toes outward with surgical leg • Do not lie on stomach • When turning in bed, roll towards operated hip • When walking, do not pivot on your operated leg • It is important to ice and elevate your operated hip for 15-20 minutes per hour throughout the day as needed for pain control and to decrease swelling until instructed otherwise • Most likely you will get up out of bed the night of surgery with assistance • Sit for short periods of times initially (30-60 minutes) and increase as tolerated • Walk 2-3 times daily with the assistance of your healthcare professional and increase as tolerated

7 RECOMMENDATIONS FOR YOUR NEW TOTAL HIP REPLACEMENT (POSTERIOR APPROACH)

• Do not cross your legs, keep a pillow between your legs when in bed

• Do not sit in too low a chair – keep knees slightly lower than your hips

• Do not lean forward while sitting in a chair – slide operated foot in front of you when getting in and out of a chair

• Do not bend forward to put on pants/socks or for hygiene, use a reacher, sock aid and long handled sponge

• Do not turn in your hip and knee when dressing and bathing

• Have hospital bed in a flat position several times a day to stretch the muscles in front of your hip and thigh

• When turning in bed, roll towards operated hip

• When walking, do not pivot on your operated leg

• It is important to ice and elevate your operated hip for 15-20 minutes per hour throughout the day as needed for pain control and to decrease swelling until instructed otherwise

• Most likely you will get up out of bed the night of surgery with assistance

• Sit for short periods of times initially (30-60 minutes) and increase as tolerated

• Walk 2-3 times daily with the assistance of your healthcare professional and increase as tolerated

8 THERAPY AFTER YOUR NEW JOINT REPLACEMENT

It is important to begin moving the new joint soon after surgery. Nurses may help you get out of bed the night of surgery. One of our therapists will meet with you the day after your surgery to plan your exercise program. We will teach you to get in and out of bed, make sure you understand your movement precautions, and be sure you are safe with your walking device. An occupational therapist may also treat you to ensure you can perform daily activities such as dressing. We will continue to work with you while you are in the hospital and help you transition to your home. Care will be provided by a home health physicalExercise therapist. Program For: Date:10/28/2016 TKR and THA exercises Page:1 You should perform the exercisesExercise below Program and on For: the following pages Date:10/28/2016 Comment:(as able before surgery and as directedTKR and THA by exercisesyour physical therapist Page:1 Therapist afterto mark surgery). what exercises are to be done by patient. IsoComment: knee ext sit (quad sets) Iso hip gluteal sets supine TherapistQUAD to markSETS what exercises are to be done by patient. Iso knee ext sit (quad sets) • Sit with legIso extended,hip gluteal kneesets supinesupported with towel roll. • Tighten quad muscles on front of leg, trying to push back of knee downward. Exercise Program For: Date:10/28/2016 Special Instructions: TKR and THA exercises Page:1• Do not hold your breath. • Perform 1 set of 10 repetitions, three times a day. Comment: • Hold exercise for 10 seconds Therapist to mark what exercises are to be done by patient. Iso knee ext sit (quad sets) Iso hip gluteal sets supine • Sit withGLUTEAL leg extended, SETS knee supported with towel roll. • Lie on back with legs straight. • Tighten quad muscles on front of leg, trying to push• back Lie onof back• Squeeze with legs buttocks straight. together. knee downward. • Hold and repeat. • Sit with leg extended, knee supported with towel roll.• Squeeze •buttocks Lie on back together. with legs straight. Special• Tighten Instructions: quad muscles on front of leg, trying to push• backHold of andPerform• repeat. Squeeze 1 setbuttocks of 10 Repetitions,together. three times a day. Doknee not downward. hold breath. • Hold and repeat. Hold exercise for 10 Seconds. PerformSpecial Instructions:1 set of 10 Repetitions, three times a day. Special Instructions:Perform 1 set of 10 Repetitions, three times a day. • Perform 1 set of 10 repetitions, three times a day. Do not hold breath. Hold exercise for 10 Seconds. • Hold exerciseHold exercisefor 10 seconds for 10 Seconds. Perform 1 set of 10 Repetitions, three times a day. Iso knee flx sit (hamstring sets) AROM hip/knee flx (heel slides) Hold exercise for 10 Seconds. Iso knee flx sit (hamstring sets) AROM hip/knee flx (heel slides) • Sit with leg extended, knee supported with towel roll. • Lie onHAMSTRING back with legs SETS straight. • Tighten quad muscles on front of leg, trying to push back of • Squeeze buttocks together. • Sit with leg extended, knee slightly bent. knee downward. • Hold and repeat. • Without moving leg, tighten muscles on back of leg, Special Instructions: Perform 1 set of 10 Repetitions, three times a day. trying to push heel down. Do not hold breath. Hold exercise for 10 Seconds. Perform 1 set of 10 Repetitions, three times a day. Special Instructions: • Perform 1 set of 10 repetitions, three times a day. Hold exercise for 10 Seconds. • Hold exercise for 10 seconds Iso knee flx sit (hamstring sets) AROM hip/knee flx (heel slides) • Sit with leg extended, knee slightly bent. • Lie on back with legs straight. • Without moving leg, tighten muscles on back of leg, trying to • Slide heel up to buttocks. 9 push heel down. • Return to start position. • Sit with leg extended, knee slightly bent. • Lie on back with legs straight. Perform• Without 1 moving set of 10 leg, Repetitions, tighten muscles three timeson back a day. of leg, trying to Perform• Slide heel 3 sets up toof buttocks.10 Repetitions, three times a day. push heel down. • Return to start position. Hold exercise for 10 Seconds. Perform 1 set of 10 Repetitions, three times a day. Perform 3 sets of 10 Repetitions, three times a day.

Hold exercise for 10 Seconds.

• Sit with leg extended, knee slightly bent. • Lie on back with legs straight. • Without moving leg, tighten muscles on back of leg, trying to • Slide heel up to buttocks. push heel down. • Return to start position. Perform 1 set of 10 Repetitions, three times a day. Perform 3 sets of 10 Repetitions, three times a day.

Hold exercise for 10 Seconds. Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc.

Comment: Therapist to mark what exercises are to be done by patient. Iso knee ext sit (quad sets) Iso hip gluteal sets supine

• Sit with leg extended, knee supported with towel roll. • Lie on back with legs straight. • Tighten quad muscles on front of leg, trying to push back of • Squeeze buttocks together. knee downward. • Hold and repeat. Special Instructions: Perform 1 set of 10 Repetitions, three times a day. Do not hold breath. Hold exercise for 10 Seconds. Perform 1 set of 10 Repetitions, three times a day. THERAPY AFTER YOUR JOINT REPLACEMENT Hold exercise for 10 Seconds. Iso knee flx sit (hamstring sets) AROM hip/knee flx (heel slides) HEEL SLIDES • Lie on back with legs straight. • Slide heel up to buttocks. • Return to start position.

SpecialExercise Instructions: Program For: Date:10/28/2016 Exercise Program For: Date:10/28/2016 •TKR ExercisePerform and THA Program1 set exercises of 10 For: repetitions, three times a day.Page:Date:210/28/2016 TKR and THA exercises Page:2 TKR and THA exercises Page:2 AROM ankle DF/PF (elevated ankle pumps) AROM knee ext (SAQ) sit AROM ankle DF/PF (elevated ankle pumps) AROM knee ext (SAQ) sit AROM ankle DF/PF (elevated ankle pumps) AROM knee ext (SAQ) sit ELEVATED ANKLE PUMPS • Lie on back with foot elevated up on a pillow. • Sit with leg extended, knee slightly bent. • Lie on back with legs straight. • Move foot up and down, pumping the ankle. • Without moving leg, tighten muscles on back of leg, trying to • Slide heel up to buttocks. push heel down. Exercise Program• Return toFor: start position. Date:10/28/2016 TKR and THA exercises Page:2Special Instructions: Perform 1 set of 10 Repetitions, three times a day. Perform 3 sets of 10 Repetitions, three times a day. • Perform 1 set of 20 repetitions, three times a day. Hold exercise for 10 Seconds. AROM ankle DF/PF (elevated ankle pumps) Exercise ProgramAROM knee For: ext (SAQ) sit Date:10/28/2016 TKR and THA exercises Page:2 SHORT ARC QUADS • Lie on back, with involved leg bent to 45 degrees, AROM ankle DF/PF (elevated ankle pumps) • AROMLie on backknee with ext (SAQ)foot elevated sit up on pillow. supported• Lie with on back, a pillow, with involvedas shown. leg bent to 45 degrees, supported • Lie on back with foot elevated up on pillow. • Lie on back, with involved leg bent to 45 degrees, supported •• Move Lie on foot back up with and footdown, elevated pumping up theon pillow.ankle. • Straightenwith• Lie leg a on pillow, at back, knee. as with shown. involved leg bent to 45 degrees, supported • Move foot up and down, pumping the ankle. with a pillow, as shown. Perform• Move foot1 set up of and 20 Repetitions,down, pumping three the times ankle. a day. • Return to•with Straighten start a pillow, position. leg as at shown. knee. • Straighten leg at knee. Perform 1 set of 20 Repetitions, three times a day. •• Return Straighten to start leg position.at knee. Perform 1 set of 20 Repetitions, three times a day. • Return to start position. Special Instructions:Perform• Return 3 to sets start of position. 10 Repetitions, three times a day. • Perform Perform3 sets of 3 sets10 repetitions, of 10 Repetitions, three threetimes times a day. a day. AROM lumbar bridging bil AROMPerform hip 3 setsflx (SLR) of 10 supineRepetitions, knee three bent times a day. AROM lumbar bridging bil AROM hip flx (SLR) supine knee bent AROM lumbar bridging bil AROM hip flx (SLR) supine knee bent Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. BRIDGING • Lie on back with foot elevated up on pillow. • Lie onExcept back, as towith user involved supplied materials, leg bent Copyright to 45 1995-2014degrees, BioEx supported Systems, Inc. • Move foot up and down, pumping the ankle. with a pillow, as shown. • Lie on back with knees bent. Perform 1 set of 20 Repetitions, three times a day. • Straighten leg at knee. • Lift buttocks off floor. • Return to start position. • Return to start position. • Lie on back with foot elevated up on pillow. Perform• Lie on back,3 sets with of 10 involved Repetitions, leg bent three to 45times degrees, a day. supported • Move foot up and down, pumping the ankle. with a pillow, as shown. AROM lumbar bridging bil AROM hip flx (SLR) supine knee bent Special Instructions: Perform 1 set of 20 Repetitions, three times a day. • Straighten leg at knee. • Maintain neutral spine. • Return to start position. • Perform 3 sets of 5 repetitions, twice a day. Perform 3 sets of 10 Repetitions, three times a day. AROM lumbar bridging bil • AROMLie on backhip flx with (SLR) knees supine bent. knee bent • Lie on back with uninvolved knee bent as shown. • Lie on back with knees bent. • Lie on back with uninvolved knee bent as shown. •• Lift Lie buttocks on back offwith floor. knees bent. •• Raise Lie on straight back with leg uninvolvedto thigh level knee of bent bent leg. as shown. • Lift buttocksSTRAIGHT off floor. LEG RAISE • Raise straight leg to thigh level of bent leg. •• Return Lift buttocks to start off position. floor. •• Return Raise straightto starting leg position. to thigh level of bent leg. • Return to start position. • Return to starting position. Special• Return Instructions: to start position. • Lie on backPerform• Return with 3 to uninvolvedsets starting of 5 Repetitions,position. knee bent twice as a shown. day. Special Instructions: • Raise straightPerform leg 3 setsto thigh of 5 Repetitions, level of bent twice leg. a day. MaintainSpecial neutralInstructions: spine. Perform 3 sets of 5 Repetitions, twice a day. Maintain neutral spine. • Return to starting position. PerformMaintain 3 neutral sets of spine.5 Repetitions, twice a day. Perform 3 sets of 5 Repetitions, twice a day. Perform 3 sets of 5 Repetitions, twice a day. Special Instructions: • Perform 3 sets of 5 repetitions, twice a day. • Lie on back with knees bent. • Lie on back with uninvolved knee bent as shown. • Lift buttocks off floor. • Raise straight leg to thigh level of bent leg. • Return to start position. • Return to starting position. Special Instructions: Perform 3 sets of 5 Repetitions, twice a day. • Lie on back with knees bent. • Lie on back with uninvolved knee bent as shown. Maintain neutral spine. 10 • Lift buttocks off floor. • Raise straight leg to thigh level of bent leg. •Perform Return 3to sets start of position. 5 Repetitions, twice a day. • Return to starting position. Special Instructions: Perform 3 sets of 5 Repetitions, twice a day. Maintain neutral spine. Perform 3 sets of 5 Repetitions, twice a day.

Issued By: CVMC Rehab Signature: ______Issued By: CVMC Rehab Signature: ______TheseIssued exercises By: are to beCVMC used only Rehab under the direction of a licensed, qualified professional. Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc.

Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. Exercise Program For: Date:10/28/2016 THERAPY AFTERTKR YOUR and THA JOINT exercises REPLACEMENT Page:3 Exercise Program For: Date:10/28/2016 TKR and THA exercises Page:3 AROM hip abd uni supine AROM hip ER/abd sidelying HIP EXTENSIONS AROM hip abd uni supine • Lie on backAROM on hipfirm ER/abd surface, sidelying legs together. • Move leg out to side, keeping knee straight. • Return to start position.

Special Instructions: • Use a pillow case to reduce friction. Exercise Program For: Date:10/28/2016 • Perform 3 sets of 5 repetitions, twice a day. TKR and THA exercises Page:3

AROM hip abd uni supine AROM hip ER/abd sidelying Exercise Program For: Date:10/28/2016 • Lie on back on firm surface, legs together. • Lie on side with knees bent, feet together. TKR and THA exercisesHIP SIDELYING Page:3 • Move leg out to side, keeping knee straight. • Lie on side• Lift with top kneesknee upward. bent, feet together. • Return to start position. • Lower and repeat. • Lie on back on firm surface, legs together. • Lift top knee• Lie onupward. side with knees bent, feet together. • Move leg out to side, keeping knee straight. •• Lift Repeat top knee exercise upward. lying on other side. AROM hip abd uni supine AROMSpecial hip Instructions: ER/abd sidelying • Lower and repeat. • Return to start position. • Lower and repeat. Use a pillow case to reduce friction. • Repeat exercisePerform on3 sets other of 10 side. Repetitions, twice a day. Special Instructions: • Repeat exercise lying on other side. Perform 3 sets of 5 Repetitions, twice a day. Rest 1 Minute between sets. Use a pillow case to reduce friction. Special Instructions:Perform 3 sets of 10 Repetitions, twice a day. • Perform 3 sets of 10 repetitions, twice a day. Perform 3 sets of 5 Repetitions, twice a day. Rest 1 Minute between sets. • Rest 1 minute between sets. AROM hip abd uni sidelying AROM knee ext (LAQ) sit

AROMHIP hip LIFTS abd uni sidelying AROM knee ext (LAQ) sit • Lie on back on firm surface, legs together. • Lie on side with knees bent, feet together. • Lie on uninvolved side, with lower knee bent for • Move leg out to side, keeping knee straight. • Lift top knee upward. stability. • Return to start position. • Lower and repeat. • Keep knee straight on involved leg, lifting leg upward. • Repeat exercise lying on other side. Special Instructions: • Return to start position and repeat. Use a pillow case to reduce friction. Perform 3 sets of 10 Repetitions, twice a day. • Lie on back on firm surface, legs together. • Lie on side with knees bent, feet together. Special Instructions: •Perform Move leg 3 setsout toof side,5 Repetitions, keeping knee twice straight. a day. •Rest Lift top1 Minute knee upward.between sets. • Return to start position. • Lower and repeat. • Do not roll trunk forward or backward • Perform 3 sets of 5 repetitions, twice a day. Special Instructions: • Repeat exercise lying on other side. UseAROM a pillow hip abd case uni to sidelyingreduce friction. PerformAROM knee 3 sets ext of (LAQ)10 Repetitions, sit twice a day. Perform 3 sets of 5 Repetitions, twice a day. Rest• Lie 1on Minute uninvolved between side, sets. with lower knee bent for stability. • Sit, with involved leg bent to 90 degrees, as shown. • Keep knee straight on involved leg, lifting leg upward. • Straighten leg at knee. (Use other leg to assist if needed) •• Lie Return on uninvolved to start position side, withand lowerrepeat. knee bent for stability. •• Sit, Return with toinvolved start position. leg bent to 90 degrees, as shown. AROM hip abd uni sidelying •AROMSpecial KeepKNEE kneeknee Instructions: straightEXTENSIONSext (LAQ) on involvedsit leg, lifting leg upward. •Perform Straighten 1 set leg of at 10 knee. Repetitions, (Use other twice leg a to day. assist if needed) • Return to start position and repeat. • Return to start position. Do not roll trunk forward or backward. • Sit, with involved leg bent to 90 degrees, as shown. Special Instructions: • StraightenPerformHold leg exercise at 1 knee.set of for (Use10 10 Repetitions, Seconds. other leg twice to assist a day. if Perform 3 sets of 5 Repetitions, twice a day. Do not roll trunk forward or backward. needed) • Return toHold start exercise position. for 10 Seconds. Perform 3 sets of 5 Repetitions, twice a day. Special Instructions: • Perform 1 set of 10 repetitions, twice a day. • Hold exercise for 10 seconds. • Lie on uninvolved side, with lower knee bent for stability. • Sit, with involved leg bent to 90 degrees, as shown. • Keep knee straight on involved leg, lifting leg upward. • Straighten leg at knee. (Use other leg to assist if needed) • Return to start position and repeat. • Return to start position. Special Instructions: Perform 1 set of 10 Repetitions, twice a day. Do not roll trunk forward or backward. • Lie on uninvolved side, with lower knee bent for stability. •Hold Sit, withexercise involved for 10 leg Seconds. bent to 90 degrees, as shown. •Perform Keep knee 3 sets straight of 5 Repetitions, on involved twiceleg, lifting a day. leg upward. • Straighten leg at knee. (Use other leg to assist if needed) • Return to start position and repeat. • Return to start position. Special Instructions: Perform 1 set of 10 Repetitions, twice a day. 11 Do not roll trunk forward or backward. HoldIssued exercise By: for 10CVMC Seconds. Rehab Signature: ______Perform 3 sets of 5 Repetitions, twice a day. These exercises are to be used only under the direction of a licensed, qualified professional. Issued By: CVMC Rehab Except asSignature: to user supplied ______materials, Copyright 1995-2014 BioEx Systems, Inc. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc.

Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. THERAPY AFTER ExerciseYOUR Program JOINT For: REPLACEMENT Date:10/28/2016 TKR and THA exercises Page:4

AROMSEATED knee KNEE flx uni FLEXIONsit AAROM knee flx sit w/self • Sit in chair, moving heel of the involved leg under chair, Exercise Program For: Date:10/28/2016 through full range, as shown. TKR and THA exercises Page:4 • Return to start position.

AROM knee flx uni sit Special Instructions:AAROM knee flx sit w/self • Perform 3 sets of 10 repetitions, twice a day.

Exercise Program For: Date:10/28/2016 TKR and THA exercises Page:4

• Sit in chair, moving heel of involved leg under chair, through • Sit in chair. AROM knee flx uni sit AAROMfullASSISTED range, knee as shown. SEATEDflx sit w/self KNEE FLEXION • Move heel of involved leg under chair. • Return to starting position. • Sit in chair.• Place other leg in front and push back. • Hold stretch, relax, and repeat. Perform 3 sets of 10 Repetitions, twice a day. • Move heel of involved leg under chair. Exercise Program For: Date:10/28/2016 Perform 1 set of 10 Repetitions, twice a day. TKR and THA exercises Page:4• Place other leg in front and push back. • Hold stretch,Hold exercise relax, and for 10 repeat. Seconds. • Sit in chair, moving heel of involved leg under chair, through • Sit in chair. AROM knee flx uni sit fullAAROM range, knee as shown. flx sit w/self Special Instructions:• Move heel of involved leg under chair. • ReturnAROM to startingankle PF position. bil stand • Perform AROM•1 Placeset of hip other 10 flx repetitions, standleg in frontbent kneeand twice push a back.day. Perform 3 sets of 10 Repetitions, twice a day. • Hold exercise• Hold forstretch, 10 seconds. relax, and repeat. Perform 1 set of 10 Repetitions, twice a day.

Hold exercise for 10 Seconds.

• Sit in chair, moving heel of involved leg under chair, through • Sit in chair. full range, as shown. AROM• MoveHEEL ankle heel RAISES PF of bil involved stand leg under chair. AROM hip flx stand bent knee • Return to starting position. • Place other leg in front and push back. • Stand, using chair for balance. • Raise up on toes, through full range. Perform 3 sets of 10 Repetitions, twice a day. • Hold stretch, relax, and repeat. • Return to start position and repeat. Perform 1 set of 10 Repetitions, twice a day. Special Instructions: Hold• Stand, exercise using chairfor 10 for Seconds. balance. • Stand with hand on table or chair for support. • Sit in chair, moving heel of involved leg under chair, through • Sit in chair. • Perform 3 sets of 10 repetitions, twice a day. full range, as shown. • Move• Raise heel upof oninvolved toes, through leg under full range.chair. • Lift leg up as high as possible, bending knee. • Return to starting position. • Place• Return other toleg start in frontposition and and push repeat. back. • Lower leg. AROM ankle PF bil stand AROMPerform hip 3 sets flx standof 10 Repetitions, bent knee twice a day. • Repeat with other leg. Perform 3 sets of 10 Repetitions, twice a day. • Hold stretch, relax, and repeat. Perform 3 sets of 10 Repetitions, twice a day. Perform 1 set of 10 Repetitions, twice a day.

Hold exercise for 10 Seconds.

• Stand, using chair for balance. • Stand with hand on table or chair for support. AROM ankle PF bil stand •AROM RaiseSTANDING hipup on flx toes, stand MARCHESthrough bent knee full range. • Lift leg up as high as possible, bending knee. • Return to start position and repeat. • Stand with• Lower and leg.on table or chair for support. Perform 3 sets of 10 Repetitions, twice a day. • Lift leg up• Repeat high as with possible, other leg. bending knee. • Lower leg.Perform 3 sets of 10 Repetitions, twice a day. • Repeat with other leg.

Special Instructions: • Stand, using chair for balance. • Stand with hand on table or chair for support. • Perform 3 sets of 10 repetitions, twice a day. • Raise up on toes, through full range. • Lift leg up as high as possible, bending knee. • Return to start position and repeat. • Lower leg. Perform 3 sets of 10 Repetitions, twice a day. • Repeat with other leg. PerformIssued By: 3 sets ofCVMC 10 Repetitions, Rehab twice a day. Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems,12 Inc. • Stand, using chair for balance. • Stand with hand on table or chair for support. • Raise up on toes, through full range. • Lift leg up as high as possible, bending knee. • Return to start position and repeat. • Lower leg. Perform 3 sets of 10 Repetitions, twice a day. • Repeat with other leg. Perform 3 sets of 10 Repetitions, twice a day.

Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. THERAPY AFTER ExerciseYOUR Program JOINT For: REPLACEMENT Date:10/28/2016 TKR and THA exercises Page:5

AROMSTANDING hip ext standHIP EXTENSION AROM hip abd uni stand • Stand, hold onto table or wall for balance. • Extend leg backward, keeping knee straight. • ExerciseReturn to Program start position. For: Date:10/28/2016 TKR and THA exercises Page:5 Special Instructions: • Perform 3 sets of 10 repetitions, twice a day. AROM hip ext stand AROM hip abd uni stand

Exercise Program For: Date:10/28/2016 TKR and THA exercises Page:5

• Stand, hold onto table or wall for balance. • Stand holding on to counter if needed. AROM hip ext stand AROM• STANDINGExtend hip abd leg unibackward, HIP stand ABDUCTION keeping knee straight. • Keep knee straight, moving involved leg outward. • Return to start position. • Stand holding• Return onto to start counter position. if needed. Perform 3 sets of 10 Repetitions, twice a day. • Keep kneeSpecial straight, Instructions: moving involved leg outward. • Return toKeep start trunk position. upright. Exercise Program For: Date:10/28/2016 Perform 3 sets of 10 Repetitions, twice a day. Special Instructions: TKR and THA exercisesAROM knee flx uni standing Page:5 AROM knee squat bil partial • Keep trunk upright. • Stand, hold onto table or wall for balance. • Perform •3 Stand sets ofholding 10 repetitions, on to counter twice if needed. a day. AROM hip ext stand •AROM Extend hip leg abd backward, uni stand keeping knee straight. • Keep knee straight, moving involved leg outward. • Return to start position. • Return to start position. Perform 3 sets of 10 Repetitions, twice a day. Special Instructions: Keep trunk upright. Perform 3 sets of 10 Repetitions, twice a day. • Stand, hold onto table or wall for balance. • Stand holding on to counter if needed. • Extend leg backward, keeping knee straight. AROM• KeepSTANDING knee straight,flx uni KNEE standing moving FLEXION involved leg outward. AROM knee squat bil partial • Return to start position. • Return to start position. • Stand, bend involved leg toward hip through full range. • Return to start position. Perform 3 sets of 10 Repetitions, twice a day. Special Instructions: • Do not bend leg at hips. Keep• trunkStand, upright. bend involved leg toward hip through full range. • Stand on both legs. Perform• Return 3 sets to startingof 10 Repetitions, position. twice a day. Special Instructions:• Use wall or secure object to maintain balance if needed. • Do not bend leg at hips. • Perform •3 Bend sets knees of 10 to repetitions, 45 degrees. twice a day. AROM knee flx uni standing AROMPerform knee 3squat sets of bil 10 partial Repetitions, twice a day. • Return to starting position. • Stand, hold onto table or wall for balance. • Stand holding on to counter if needed. Perform 3 sets of 10 Repetitions, twice a day. • Extend leg backward, keeping knee straight. • Keep knee straight, moving involved leg outward. • Return to start position. • Return to start position. Perform 3 sets of 10 Repetitions, twice a day. Special Instructions: Keep trunk upright. •Perform Stand, bend3 sets involved of 10 Repetitions, leg toward twicehip through a day. full range. • Stand on both legs. AROM knee flx uni standing •AROM ReturnSTANDING knee to starting squat PARTIALposition. bil partial SQUATS • Use wall or secure object to maintain balance if needed. • Do not bend leg at hips. • Stand on• bothBend legs.knees to 45 degrees. Perform 3 sets of 10 Repetitions, twice a day. • Use wall •or Return secure to startingobject position.to maintain balance if needed. Perform 3 sets of 10 Repetitions, twice a day. • Bend knees to 45 degrees. • Stand, bend involved leg toward hip through full range. • Stand on both legs. • Return to start position. • Return to starting position. • Use wall or secure object to maintain balance if needed. • Do not bend leg at hips. • Bend knees to 45 degrees. Special Instructions: Perform 3 sets of 10 Repetitions, twice a day. • Return to starting position. • Perform 3 sets of 10 repetitions, twice a day. Perform 3 sets of 10 Repetitions, twice a day. Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems,13 Inc. • Stand, bend involved leg toward hip through full range. • Stand on both legs. • Return to starting position. • Use wall or secure object to maintain balance if needed. • Do not bend leg at hips. • Bend knees to 45 degrees. Perform 3 sets of 10 Repetitions, twice a day. • Return to starting position. Perform 3 sets of 10 Repetitions, twice a day.

Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. THERAPY AFTER ExerciseYOUR Program JOINT For: REPLACEMENT Date:10/28/2016 TKR and THA exercises Page:6

AROMCHAIR vestib SQUATS sit to stand head neutral AROM knee step ups • Begin in sitting position. Exercise Program For: Date:10/28/2016 • Keep head facing forward. TKR and THA exercises Page:6 • Slowly stand. • Sit and repeat. AROM vestib sit to stand head neutral AROM knee step ups Special Instructions: • Perform 3 sets of 5 repetitions, twice a day. • Rest 1 minute between sets. Exercise Program For: Date:10/28/2016 TKR and THA exercises Page:6

• Begin in sitting position. • Stand with involved leg on step. AROM vestib sit to stand head neutral AROM• STEP-UPSKeep knee head step facing ups forward. • Shift weight over knee. • Slowly stand. • Stand with• Step involved up slowly. leg on step. • Sit and repeat. • Step back down leading with involved leg. • Shift weight over knee. Exercise Program For: Date:10/28/2016 • Repeat. Perform 3 sets of 5 Repetitions, twice a day. • Step up slowly. TKR and THA exercises Page:6 Perform 5 sets of 5 Repetitions, twice a day. Rest 1 Minute between sets. • Step back down leading with involved leg. • Begin in sitting position. • Repeat. • Stand with involved leg on step. AROM vestib sit to stand head neutral AROM• Keep knee head step facing ups forward. • Shift weight over knee. •Stretch Slowly Gastrocstand. uni standing Special Instructions:Stretch• Step Soleus up slowly. stand • Sit and repeat. • Perform 5 sets• Step of 5back repetitions, down leading twice with a involvedday. leg. Perform 3 sets of 5 Repetitions, twice a day. • Repeat. Perform 5 sets of 5 Repetitions, twice a day. Rest 1 Minute between sets.

• Begin in sitting position. • Stand with involved leg on step. • Keep head facing forward. • ShiftStretchCALF weight GastrocSTRETCH over knee. uni standing Stretch Soleus stand • Slowly stand. • Step up slowly. • Stand facing wall, hands on wall. • Sit and repeat. • Step back down leading with involved leg. • Step forward with foot of uninvolved leg, leaning hips toward wall. Perform 3 sets of 5 Repetitions, twice a day. • Repeat. Perform 5 sets of 5 Repetitions, twice a day. • Keep rear leg straight with heel on floor. Rest 1 Minute between sets. • Stand facing wall, hands on wall. • Stand, one leg in front of the other. • Begin in sitting position. • Stand with involved leg on step. • Step forward with foot of uninvolved leg, leaning hipsSpecial toward Instructions:• Face wall, hands on wall for support. • Keep head facing forward. • Shiftwall. weight over knee. • Perform •1 Slowlyset of bend 3 repetitions, knees, keeping twice heels a onday. floor, as shown, until • Slowly stand. • Step up slowly. Stretch Gastroc uni standing Stretch• Keep Soleus rear leg stand straight with heel on floor. • Hold exercisestretch foris felt. 20 seconds. • Sit and repeat. • Step back down leading with involved leg. Perform 1 set of 3 Repetitions, twice a day. • Repeat with other leg in front. Perform 3 sets of 5 Repetitions, twice a day. • Repeat. Perform 1 set of 3 Repetitions, twice a day. PerformHold 5 exercise sets of 5for Repetitions, 20 Seconds. twice a day. Rest 1 Minute between sets. Hold exercise for 20 Seconds. • Stand facing wall, hands on wall. • Stand, one leg in front of the other. • Face wall, hands on wall for support. Stretch Gastroc uni standing Stretch• StepSOLEUS Soleus forward CALFstand with STRETCHfoot of uninvolved leg, leaning hips toward wall. • Stand, one leg• Slowly in front bend of knees, the other. keeping heels on floor, as shown, until • Keep rear leg straight with heel on floor. • Face wall, handsstretch on is wallfelt. for support. • Repeat with other leg in front. Perform 1 set of 3 Repetitions, twice a day. • Slowly bend knees, keeping heels on floor, as shown, until stretch Performis felt. 1 set of 3 Repetitions, twice a day. Hold exercise for 20 Seconds. • Repeat with other leg in front. Hold exercise for 20 Seconds. • Stand facing wall, hands on wall. • Stand, one leg in front of the other. Special Instructions: • Step forward with foot of uninvolved leg, leaning hips toward • Face wall, hands on wall for support. • Perform 1 set of 3 repetitions, twice a day. wall. • Slowly bend knees, keeping heels on floor, as shown,• Hold until exercise for 20 seconds. • Keep rear leg straight with heel on floor. stretch is felt. Perform 1 set of 3 Repetitions, twice a day. • RepeatIssued with By: other legCVMC in front. Rehab Signature: ______PerformThese 1 exercises set of are3 Repetitions,to be used only under twice the directiona day. of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems,14 Inc. Hold exercise for 20 Seconds. • Stand facing wall, hands on wall. •Hold Stand, exercise one leg for in 20 front Seconds. of the other. • Step forward with foot of uninvolved leg, leaning hips toward • Face wall, hands on wall for support. wall. • Slowly bend knees, keeping heels on floor, as shown, until • Keep rear leg straight with heel on floor. stretch is felt. Perform 1 set of 3 Repetitions, twice a day. • Repeat with other leg in front. Perform 1 set of 3 Repetitions, twice a day. Hold exercise for 20 Seconds. HoldIssued exercise By: for 20 Seconds.CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc.

Issued By: CVMC Rehab Signature: ______These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user supplied materials, Copyright 1995-2014 BioEx Systems, Inc. THERAPY AFTER ExerciseYOUR Program JOINT For: REPLACEMENT Date:10/28/2016 TKR and THA exercises Page:7

AROMLUNGE hip/knee flx (fwd lunges) • Stand. • Step forward as shown, keeping trunk vertical. • Push back to start position. • Repeat.

Special Instructions: • Perform 1 set of 10 repetitions, twice a day.

• Stand. • Step forward as shown, keeping trunk vertical. • Push back up to starting position. • Repeat. Perform 1 set of 10 Repetitions, twice a day.

• You will choose a home health agency to contact you with a plan to visit the day after your discharge • You will have an appointment date and time for follow up with your surgeon (usually four weeks after surgery) • You will be told and should know your movement and weight bearing precautions • You most likely will be taking a blood thinner to prevent leg clots for 2-4 weeks after surgery • Your hospital nurse and your home care provider will review the following in more detail: »»Signs and Symptoms of infection include: warmth, redness, drainage of the wound & a temperature greater than 101.4. »»Narcotics and Bowel Function: narcotics can slow bowel function and most people return to their normal bowel function within a week. »»Showering – see instructions provided when you leave the hospital to determine when you can shower »»Swelling management as instructed by your home health professional • Prevention of total joint infection – see next page

The home health agency will work with you on a smooth transition to an out-patient therapist. This usually happens 2-4 weeks after surgery.

You are ready to transition to out-patient therapy when:

1. You are able to safely enter and exit your home 2. Your surgical wound is healing well 3. You are able to safely walk and move from one place to another such as chairs/bed in your home 4. You are able to get in and out of a car safely 5. You have reliable transportation 6. You are medically stable

16 ANTIBIOTIC USE AFTER TOTAL JOINT REPLACEMENT

Patients with major joint implants may require certain precautions to prevent infections of the implant. Since we cannot avoid all episodes of bacteria in the bloodstream, efforts are made to identify these episodes and use prophylactic antibiotics. We currently recommend antibiotics for “high risk” patients: • Anyone who is within 2 years of joint replacement • Life-long in patients who may have one of the following conditions: »»Rheumatoid arthritis »»Lupus »»Insulin-dependent diabetes »»Previous joint infections »»Hemophilia »»Immunosuppresed from medications such as steroids or because of certain illnesses

We use these antibiotics when these “high risk” patients are having “high risk” procedures: • Dental extractions • Periodontal (gum) procedures • Dental implants • Root Canals • Prophylactic cleaning when bleeding is anticipated • Cystoscopy (look in the bladder) • Surgical drainage of skin infections

We use the following antibiotic regime: • Cephalexin (Keflex), Cephradine or Amoxicillin 2 Grams by mouth (orally) 1 hour before the procedure. • If severe allergy to penicillin use Clindamycin 600mg 1 hour before the procedure • If you cannot take pills, use Cefazolin 1gram or Ampicillin 2 grams intramuscularly or intravenously 1 hour before the procedure.

17 LOCAL AGENCIES AND RESOURCES

University of Vermont Health Network – Central Vermont Medical Center Care Management Department - 802-371-4357

LOCAL HOME HEALTH AGENCIES Central Vermont Home Health and Hospice - 802-223-1878 Bayada Home Health Care - 802-655-7111 Lamoille Home Health and Hospice - 603-298-6417 Visiting Nurse and Hospice for VT and NH - 802-888-4651 Visiting Nurse Association of Chittenden and Grand Isle - 802-658-1900

LOCAL SKILLED NURSING AND REHABILITATION FACILITIES Woodridge Rehabilitation and Nursing - Sheri Speirs - 802-371-4712 Berlin Health and Rehabilitation Center - Erin Berry - 802-229-0308 Rowan Court Health & Rehabilitation Center - Debi Arleth - 802-476-4166 Mayo Healthcare - Warren Hathaway - 802-485-3161

LOCAL REHABILITATION SERVICES FACILITIES UVM Health Network - Central Vermont Medical Center Physical Therapy • Occupational Therapy • Speech Language Therapy Locations in Barre, Berlin, Montpelier, Northfield, Waterbury and Waitsfield 802-371-4242 Choice Physical Therapy Berlin - 802-223-4200 The Rehab Gym Barre - 802-479-4000 Concentra Berlin - 802-223-7499

MEDICAL EQUIPMENT COMPANIES AND RESOURCES Keene Medical 81 River Street #104, Montpelier, VT - 802-223-0665 The Medical Store Suite 1, 1284 US 302, Barre, VT - 802-476-3135 Wayward Wheels (to loan used equipment free of charge – please call in advance) 1 Sunnyside Terrace, Montpelier, VT - 802-229-0093

18 CHECKLIST: ARE YOU READY FOR YOUR NEW TOTAL JOINT?

I have read “A Patient’s Guide to Total Joint Replacement

I spoke to an Occupational Therapist on the phone about going home after the surgery as recommended

I have scheduled my Total Joint Replacement Class

I attended the Total Joint Replacement class

I am attending Prehab classes (as recommended)

My home is ready – clutter removed and I can safely enter with sturdy handrails etc.

I have my medicine list up to date and I will bring it will me to the hospital

I have pre-registered prior to my surgery date

My Advance Directive is filled out and I will bring it to the hospital with me

I have family members who will be available to help the day of surgery and when I am home

I have chosen a home health agency

I have thought about who will be providing my outpatient physical therapy

I know where to get the medical equipment that was recommended such as toilet seat riser, shower seat, reacher and sock aid

19 UVM Health Network - Central Vermont Medical Center

Orthopedic Center 1311 Barre-Montpelier Road, Suite 400 Berlin, VT 05602

UVMHealth.org/CVMC/Ortho