Your surgery is finished and we now move onto the post operative phase of your recovery. These are the things you need to know and answers the most commonly asked questions.

After your surgery was finished I injected local anaesthetic both into the knee, and into your incisions. As a result most people only have mild pain when they wake up from surgery. The duration of effect of the anaesthetic is usually between 6 and 18 hours. When the anaesthetic wears off you may have a significant increase in your pain. For this reason, unless you have an allergy to the medication, I would like you to take a 5mg endone tablet thisevening before bed even if you do not have significant pain so that you don’t wake up in the middle of the night with pain. Also take one of these tablets when you wake up in the morning. After that, use this medication sparingly and only if you have significant pain that is not well controlled with your other medication. Common side effects of opiod medications include nausea and vomiting, constipation, itch, and drowsiness. You should not drive if you are taking these medications.

For the first 10 days post surgery I would recommend taking regular paracetamol (1 gram = 2 x 500mg tablets, every 4-6 hours) and regular anti inflammatory (either neurofen 400mg three times a day with food OR meloxicam 7.5mg twice a day with food if neurofen irritates your stomach). We will talk about ceasing these medications at your post op appointment depending on how you are recovering.

You can take the large bulky bandage and the wool underneath the bandage off your knee the day after your operation. Underneath this are four small waterproof dressings. Leave these on until you see me for your post-operative appointment. You can shower once a day with these on but try not to get them too wet. You cannot swim or have a bath in the first 3 weeks. If they do fall off or get wet, contact my rooms and we can give you some more. Ice the knee regularly in the first 4 weeks to help control swelling. A wetsuit/neoprene compression garment will also help control swelling – you can purchase these from your local chemist.

I will catch up with you at about the 2 week mark post op to check the wounds, talk about pain management and discuss the surgical findings You will be in a brace for the first 6 weeks after your surgery – this is mostly to protect the meniscus repair. Initially the brace will be locked at 30 degrees, after two weeks we will increase it to 0-60 degrees and after 4 weeks we will increase it to 0-90 degrees. You will also be on crutches for 6 weeks after the operation – you can touch your foot on the ground for balance but you are not to weight bear as such.

At the 6 week mark you can start to weight bear and wean off the crutches and out of the brace over the next 3-10 days. By 8 weeks you should be mobilizing without the brace and crutches. Book in to see your physio at the 6 week mark post-op. Very broadly speaking your rehab will be as follows:

6 weeks in a brace and crutches doing lots of straight leg raises weeks 6-10 is about getting back to a normal gait pattern and regaining your motion weeks 10-18 is about regaining strength with closed chain exercises you can start in line jogging on level ground at the 6 month mark you can start sprinting at 9 months you can return to training for pivoting sports at 9-12 months you can return to competition sports at 12-24 months The high risk periods for rerupture are between 6 and 12 weeks and in the first year on returning to pivoting sports. If you stick with the prescribed therapy program you should be fine.

If you are under 20 and/or female you are in a high risk group for rerupture and I will talk to you about delaying your return to competition sports. If you don’t trust your knee or your quads bulk is not back to normal you should definitely delay team sports. For high risk patients I recommend a formal return to sport assessment with a physio. You need to have a good relationship with your physiotherapist – you will be seeing a lot of them over the next few months.

Deep vein thrombosis is rare post ACL reconstruction, but can happen. The main indicators of DVT are calf pain and swelling that is getting worse not better. If you have this let me know and I will arrange a USS. Small below knee DVTs typically do not require formal treatment. Clots that involve the vein behind the knee, or higher, require treatment with blood thinners for 3-6 months.

Infections are also very rare. Signs of infection include: discharge from the wound, fevers, and pain that is getting worse and worse post surgery instead of slowly getting better. Call me if you are concerned about infection. Well done getting this far. We’ve got a long way to go but you’ll get through it. See you in a couple of weeks.

Regards, Luke McDermott.

ACL RECONSTRUCTION POST OP INFORMATION Your surgery is finished and we now move onto the post operative phase of your recovery. These are the things you need to know and answers the most commonly asked questions.

After your surgery was finished I injected local anaesthetic both into the knee, and into your incisions. As a result most people only have mild pain when they wake up from surgery. The duration of effect of the anaesthetic is usually between 6 and 18 hours. When the anaesthetic wears off you may have a significant increase in your pain. For this reason, unless you have an allergy to the medication, I would like you to take a 5mg endone tablet thisevening before bed even if you do not have significant pain so that you don’t wake up in the middle of the night with pain. Also take one of these tablets when you wake up in the morning. After that, use this medication sparingly and only if you have significant pain that is not well controlled with your other medication.

Common side effects of opiod medications include nausea and vomiting, constipation, itch, and drowsiness. You should not drive if you are taking these medications. For the first 10 days post surgery I would recommend taking regular paracetamol (1 gram = 2 x 500mg tablets, every 4-6 hours) and regular anti inflammatory (either neurofen 400mg three times a day with food OR meloxicam 7.5mg twice a day with food if neurofen irritates your stomach). We will talk about ceasing these medications at your post op appointment depending on how you are recovering.

You can take the large bulky bandage and the wool underneath the bandage off your knee the day after your operation. Underneath this are four small waterproof dressings. Leave these on until you see me for your post-operative appointment. You can shower once a day with these on but try not to get them too wet. You cannot swim or have a bath in the first 3 weeks. If they do fall off or get wet, contact my rooms and we can give you some more. Ice the knee regularly in the first 4 weeks to help control swelling. A wetsuit/neoprene compression garment will also help control swelling – you can purchase these from your local chemist. I use a brace and crutches for the first two weeks after an ACL reconstruction as a precaution until you get good quads control back. During this two week period you can take the brace off for sleeping and showering but if you are up and about please wear the brace. The crutches are for support so as your pain settles you can put more and more weight through the knee. You can discard the crutches around the house once you can comfortably weight bear but when you are out and about in public keep the crutches for support.

After 2 weeks we will get rid of the crutches. The main exercise to concentrate on during the first 14 days is straight leg raises. Do lots of them, its good for your quads. I will catch up with you at about the 2 week mark post op to check the wounds, talk about pain management and discuss the surgical findings. Make a plan to see your physiotherapist soon after this appointment. Deep vein thrombosis is rare post ACL reconstruction, but can happen. The main indicators of DVT are calf pain and swelling that is getting worse not better. If you have this let me know and I will arrange a USS. Small below knee DVTs typically do not require formal treatment. Clots that involve the vein behind the knee, or higher, require treatment with blood thinners for 3-6 months. Infections are also very rare. Signs of infection include: discharge from the wound, fevers, and pain that is getting worse and worse post surgery instead of slowly getting better. Call me if you are concerned about infection.

Very broadly speaking your rehab will be as follows: 2 weeks in a brace and crutches doing lots of straight leg raises weeks 2-6 is about getting back to a normal gait pattern and regaining your motion weeks 6-16 is about regaining strength with closed chain exercises you can start in line jogging on level ground at the 4-5 month mark you can start sprinting at 6 months you can return to training for pivoting sports at 7-9 months you can return to competition sports at 9-12 months The high risk periods for rerupture are between 6 and 12 weeks and in the first year on returning to pivoting sports. If you stick with the prescribed therapy program you should be fine. If you are under 20 and/or female you are in a high risk group for rerupture and I will talk to you about delaying your return to competition sports. If you don’t trust your knee or your quads bulk is not back to normal you should definitely delay competition pivoting sports. For high risk patients I recommend a formal return to sport assessment with a physio. You need to have a good relationship with your physiotherapist – you will be seeing a lot of them over the next few months.

Well done getting this far. We’ve got a long way to go but you’ll get through it. See you in a couple of weeks.

Regards, Luke.

We have completed the surgery and now move on to the recovery phase of your treatment. Below is a guide to prepare you for what is in store with answers to the most commonly asked questions.

The surgery is typically done with both a general anaesthetic and a nerve block. The nerve block involves injecting local anaesthetic around a leash of nerves in your neck. When you wake up your whole arm will be numb. You have not had a stroke – it is the nerve block working. It typically provides very good pain relief for 8-16 hours after the surgery. You will typically feel sensation return, starting from your fingertips and then moving towards the shoulder. The block can occasionally affect the ability of the diaphragm on that side of your lungs to be weak and this can make people feel breathless. Let your nurse know if that is the case and we will keep some oxygen running overnight. Rarely the pupil in the eye on the side of your surgery will dilate (get bigger) and this may cause some mild blurring of vision. These issues will cease once the block has worn off. Until the block has completely work off you must not remove your sling.

The surgery you have had has not involved reattaching structures so we do not need to protect the shoulder from a movement point of view as such. I generally recommend wearing the sling pretty much full time for the first 3-5 days to let the dust settle. This is really done as a pain relieving measure. You can take it off for showering during this period. After 3-5 days, if your pain allows it, you can remove the sling for light waist level activities. Avoid any lifting or strenuous activity for at least the fist 3-4 weeks.

From the day after your operation I want you to start finger and wrist movement exercises. A squeeze ball is good – use it in the same hand as your operated shoulder.

For the first 2 weeks your pain management is as follows:

1. regular paracetamol or panadol osteo (breakfast, lunch and dinner)
2. anti-inflammatory (ibuprofen 400mg breakfast, lunch and dinner) OR meloxicam 7.5mg (breakfast and dinner)
3. endone 5mg every 6 hours as required – use as much of this as you need BUT AS LITTLE AS YOU CAN

The dressings on your wounds are waterproof and generally work well. You can shower once a day but have the water hitting you from the opposite side. If the dressings do get wet underneath, or fall off, replace them with some waterproof ones from your local chemist or call my rooms and I can provide some. Sleeping is often an issue after shoulder surgery. Most patients report feeling more comfortable if they are semi reclined or propped up a bit. If you have a recliner use it. If not use an extra couple of pillows. You can also take an over the counter sleeping tablet such as restavit. This is an anti histamine. Some people get quite a hangover effect from this medication so start with half a tablet and see how you go. You could safely use a full tablet a night for the first couple of weeks after your operation if it works and it is not giving you any side effects.

I will catch up with you at the 2 week mark post-op. This appointment is to check your wounds, to make sure your pain is adequately managed and to discuss the surgical findings. I want you to start some formal physiotherapy after this appointment. Certainly after the 2 week mark you should be spending most or all of your time out of the sling. You can sleep out of the sling whenever you want to – some people like the sling for sleeping, others don’t – it’s up to you.

I will generally then catch up with you in another 6 weeks to see how you are going. By this stage your shoulder will still ache a bit but you should have near full range of motion and things should be improving. It takes a full 12 weeks to fully settle after an arthroscopic decompression and you should continue physiotherapy until you are happy with the outcome.

You can start swimming after 4 weeks, surfing after 6-8 weeks (provided you can comfortably swim) and you can ease back into your golf game (putting to short game to abbreviated back swing to full back swing) after 4-6 weeks. If you have any other sports specific questions please ask but essentially as your pain settles you can do whatever you want to, so long as it is not aggravating pain.

If I did a biceps release, you may experience some ache in the biceps muscle and some bruising in the upper arm. The bruising will settle over a few weeks but the ache in the muscle can take 8-10 weeks to fully settle. Don’t worry – it will go away. As your biceps is settling you can gradually increase your lifting limit. There is no set amount you can or can’t lift - your pain is the guide.

Well done getting to this point. See you soon. Call the rooms if you have any worries or concerns.

Regards, Luke.

We have completed the surgery and now move on to the recovery phase of your treatment. Below is a guide to prepare you for what is in store with answers to the most commonly asked questions.

The surgery is typically done with both a general anaesthetic and a nerve block. The nerve block involves injecting local anaesthetic around a leash of nerves in your neck. When you wake up your whole arm will be numb. You have not had a stroke – it is the nerve block working. It typically provides very good pain relief for 8-16 hours after the surgery. You will typically feel sensation return, starting from your fingertips and then moving towards the shoulder. The block can occasionally affect the ability of the diaphragm on that side of your lungs to be weak and this can make people feel breathless. Let your nurse know if that is the case and we will keep some oxygen running overnight. Rarely the pupil in the eye on the side of your surgery will dilate (get bigger) and this may cause some mild blurring of vision. These issues will cease once the block has worn off. Until the block has completely work off you must not remove the sling.

I will check in on you the day after your surgery but if your pain isn’t too bad you can go home the day after your operation. For the first 6 weeks after a rotator cuff repair you will need to wear a sling (including whilst sleeping). From the day after your operation I want you to start finger and wrist movement exercises. A squeeze ball is good – use it in the same hand as your operated shoulder. You can loosen the sling off 3-4 times a day to allow your elbow to straighten – as long as your elbow is touching your side you are not at risk of damaging the cuff repair.

For the first 2 weeks your pain management is as follows:

1. regular paracetamol or panadol osteo (breakfast, lunch and dinner)
2. anti-inflammatory (ibuprofen 400mg breakfast, lunch and dinner) OR meloxicam 7.5mg (breakfast and dinner)
3. endone 5mg every 6 hours as required – use as much of this as you need BUT AS LITTLE AS YOU CAN

The dressings on your wounds are waterproof and generally work well. You can shower once a day but have the water hitting you from the opposite side. If the dressings do get wet underneath, or fall off, replace them with some waterproof ones from your local chemist or call my rooms and I can provide some.

Sleeping is often an issue after rotator cuff surgery. Most patients report feeling more comfortable if they are semi reclined or propped up a bit. If you have a recliner use it. If not use an extra couple of pillows. You can also take an over the counter sleeping tablet such as restavit. This is an anti histamine. Some people get quite a hangover effect from this medication so start with half a tablet and see how you go. You could safely use a full tablet a night for the first couple of weeks after your operation if it works and it is not giving you any side effects.

I will catch up with you at the 2 week mark post-op. This appointment is to check your wounds, to make sure your pain is adequately managed and to discuss the surgical findings.

Usually I start very gentle shoulder therapy after this appointment. From weeks 2-6 you should continue hand, wrist and elbow range of motion exercises. You can also start (provided I give you the all clear) PASSIVE shoulder range of motion and pendulum activities with the guidance of your physiotherapist. Passive movements are ones where you are not lifting your arm yourself – the therapist, your partner, your other arm or a pulley system is doing the work. The function of these exercises really is to keep things moving so you don’t get too stiff. Occasionally for large or massive tears I will delay the start of passive range until the 3 or 4 week mark.

After 6 weeks you can start to wean the sling and start using the arm more. From weeks 6 to 12, I set a somewhat arbitrary lifting limit of 1kg with the affected shoulder. Start reaching for the cup on the high shelf, washing with the operated arm etc. This 6 week period is all about trying to regain as much motion as possible without stressing the repair site with resistance activity. You can drive once you can comfortably lift your arm to shoulder height and hold it there – usually this is at the 7 or 8 week mark post op. If you don’t think your reaction a time/ability is back to normal don’t drive a car – please be sensible about this. Swimming is resistance, so unfortunately no swimming until 12 weeks. By the 12 week mark we aim to get about 140 degrees of elevation. Don’t expect full motion by 12 weeks – if you get it that’s great – but that is relatively uncommon.

After 12 weeks we begin resistance work. Unusual clicks, catches, aches and pains around the shoulder are very common until you are about 6 weeks into the resistance phase ie. 4 and a half months post op! Don’t worry, these go away once your strength returns and the ball and socket recentre. Remember the muscle was not attached for some time pre surgery and then we rested it for another 3 months so it takes time to get the strength back. Once you have near full range of motion you can start doing some freestyle. Once you can swim a few hundred metres comfortably you can get back on your big surfboard in small surf if you enjoy this form of recreation. If you are a golfer you can start putting after 8 weeks. You can start working on your long game after 14 weeks but tee the ball up, don’t hit out of long grass or bunkers and very gradually increase your backswing. If you have any other sports specific questions please ask.

About 85-90% of the recovery happens over the first 6 months. People improve post rotator cuff surgery out to 18 months. It’s a big chuck out of your life but almost invariably the results are worth it.

Regards, Luke.

Your surgery is finished and we now move onto the post-operative phase of your recovery. The first part of this document talks about what to do whilst in hospital and the second part talks about your at home recovery and what to expect over the next few months. I’ll tell you what you need to know, and answer the most commonly asked questions.

MONDAY: on returning to the ward you will probably be feeling a bit drowsy but shouldn’t be in too much pain. Often people will feel a bit itchy from the spinal anaesthetic. If the itch is really annoying press your buzzer and ask for something to help it. Nausea is also very common and you are written up for plenty of things to help this. Just press your buzzer and let the nurse looking after you know so they can help. As the spinal wears off keep your feet and ankles moving. Drink some water and try and sit up for dinner tonight. There are lots of machines and checks tonight so you probably won’t get a great sleep, but tomorrow night most of that stuff will be gone and you can have a sleeping tablet if you would like one.

TUESDAY: usually today the pain isn’t too bad because the spinal anaesthetic and the anaesthetic I put around your knee are still working. The worst of the pain is usually tonight and tomorrow morning. This morning the nurses will remove your urinary catheter and take the bandages off your knee and start icing the knee to help control swelling. You will get a blood test and an X-ray. You should be getting some form of blood thinner (I most commonly use either aspirin or clexane depending on your risk profile). The physiotherapist will see you this morning with the aim to get you out of bed and start walking – initially with the help of a walking frame. I would like you to get out of bed at least twice today and try sitting out of bed for your lunch and dinner. I would also like you to have a shower and put on some normal clothes – don’t wear the hospital gowns through your stay – they are ugly and too revealing. You should be wearing your stockings and using the foot or calf pumps when you are resting in bed for any period greater than 20 minutes or so.

You have a nerve block in the front of the thigh. If you feel your pain increasing the first thing to do is press the button on this device and give yourself a dose of anaesthetic (you can self administer a dose every couple of hours). Wait 5-10 minutes. If the pain has settled down don’t do anything else. If the pain hasn’t settled, press your buzzer and ask for some more pain relief. If the drip is still in your arm by thisevening let your nurse know and this will be removed. Unfortunately through the afternoon and night your pain will increase – sometimes significantly…

WEDNESDAY: this morning is the worst part of your recovery generally. By lunchtime the pain starts to reduce again. It’s cruel to be kind but I still want you to go for a walk this morning – it makes you breathe deeply and keeps the blood moving to reduce your risk of DVT. I would like you to be using crutches (rather than the big frame) today – make this a goal. If you haven’t used your bowels since surgery let me know and we can give you something to help this if you are starting to feel uncomfortable. Keep going with your icing regularly. If you feel the nerve block isn’t doing much for you let me know and we will take it out. If you feel it is working well for you we can leave it in until tomorrow. Start thinking about when you want to go home – usually either tomorrow or the next day. Have you got physio arranged for next week yet?

THURSDAY: Hopefully you aren’t feeling too bad by this stage and are in a bit of a routine of pain relief and exercises. Guided by you and your physiotherapist we will start talking about discharge. I never want anyone to feel like they are being kicked out of hospital but I also don’t want you in hospital if you feel you could be doing the same things at home. If you can manage your pain with tablets, have someone to help you at home, don’t have too many steps and are feeling confident on crutches I am happy for you to go home any time from now. If you live alone, are really struggling to get going, have lots of steps or are a bit on the frail side then we may need to get you to rehab.

When you go home:

• take regular pain relief
• keep your wound dry (you can shower with the dressing on)
• ice your knee regularly (a 1kg bag of peas is perfect and easy)
• do regular exercises and see your physiotherapist
• gradually increase your walking distances

Good luck and see you at your post op appointment!

I am going to remind you what we spoke about prior to the surgery. It is a six month recovery from a knee replacement. Very generally speaking, the first two weeks are miserable. By six weeks you will be down to moderate pain, often still needing a stronger painkiller to help you sleep at night. By 3 months you will be good, but not great, and hopefully by 6 months you will be great. Don’t say I didn’t warn you…

The inflammatory response to the insult of the surgery takes 6 months to settle. With this inflammatory response comes pain, swelling, tightness and a feeling of stiffness if you sit or lie for an long period. One of the indicators that the inflammatory response is settling is the colour of your wound. As the wound turns from red to pink to white the inflammation is settling. Once the wound turns white the inflammatory response has finished. You can make improvement in your range of motion up until this point. Once the wound has completely matured, that is about as good as the knee will ever move. Keep your exercises going until this point.

When you go home your post op pain control is as follows:

1. paracetamol – 2 x 500mg tabs every 4-6 hours; or panadol osteo, 2 tabs every 8 hours
2. an anti inflammatory – either neurofen 2 x 200mg tablets after breakfast, lunch and dinner; celebrex 100mg after breakfast and dinner; meloxicam 7.5mg after breakfast or dinner
3. endone 5mg as required – please watch these doses carefully to make sure they are reducing with time; stop them as early as your pain levels allow – certainly aiming to be off endone altogether by 6 weeks; sometimes I will add an additional long acting opioid to this mix if the pain levels are high.

I also want you to take half as aspirin a day for 2 weeks (if you are not on other blood thinners) to thin the blood and reduce he risk of DVT and PE.

Night time is often when people experience the worst of their pain (as lots of other stimuli the brain receives during daylight hours (light, noise, movement etc) are not there to interrupt the pain stimuli. If you are struggling to sleep because of pain, in addition to your pain relief you could trial an over the counter sleeping tablet called RESTAVIT. It is an anti histamine. Some people get quite a hangover effect from it the next day so start with half a tablet initially. You can increase this to a full tablet at night if you are not getting the hangover from it.

Two weeks after the surgery you can remove the dressing. Usually I will be seeing you for your first post op appointment around this time. Once the wound is uncovered begin wound massage 3-4 times a day. You can use any cream or oil that doesn’t irritate your skin. It is the action of massaging the wound and tissues that is more important than what you use.

You can get into a bath or a pool three weeks after your operation provided the wound has healed nicely.

From weeks 2-8 concentrate on:

1. weaning off all your opioid type pain relief (ie endone)
2. weaning off the crutches as your confidence and stability permit
3. lots of wound massage
4. bending and straightening exercises
5. gentle strength work after 4 weeks including your stationary bike

There is no set time or distance that you can or can’t walk. Gradually increase this as your pain and swelling allow. It is a fine line – don’t do enough and you will have a stiff knee, do to much and the inflammation will flare. Let pain be your guide. Throughout the recovery your pain should be mild-moderate only and manageable. If it is more than moderate pain then you need to back off a little on the exercises and take some more pain relief. This is different for everybody. Suffice to say you must always keep gently pushing yourself and the knee until the 6 month mark.

Your surgery is finished and we now move onto the post operative phase of your recovery. These are the things you need to know and answers the most commonly asked questions.

After your surgery was finished I injected local anaesthetic both into the knee, and into your incisions. As a result most people only have mild pain when they wake up from surgery. The duration of effect of the anaesthetic is usually between 6 and 18 hours. When the anaesthetic wears off you may have a significant increase in your pain. For this reason, unless you have an allergy to the medication, I would like you to take a 5mg endone tablet this evening before bed even if you do not have significant pain so that you don’t wake up in the middle of the night with pain. Also take one of these tablets when you wake up in the morning. After that, use this medication sparingly and only if you have significant pain that is not well controlled with your other medication. Common side effects of opiod medications include nausea and vomiting, constipation, itch, and drowsiness. You should not drive if you are taking these medications.

For the first 10 days post surgery I would recommend taking regular paracetamol (1 gram = 2 x 500mg tablets, every 4-6 hours) and regular anti inflammatory (either neurofen 400mg three times a day with food OR meloxicam 7.5mg twice a day with food if neurofen irritates your stomach). We will talk about ceasing these medications at your post op appointment depending on how you are recovering.

You can take the large bulky bandage and the wool underneath the bandage off your knee tomorrow. Underneath this are two small waterproof dressings. Leave these on until you see me for your post-operative appointment. You can shower once a day with these on but try not to get them too wet. You cannot swim or have a bath in the first 2 weeks. If they do fall off or get wet, contact my rooms and we can give you some more.

Deep vein thrombosis is rare post knee arthroscopy, but can happen. The main indicators of DVT are calf pain and swelling that is getting worse not better. If you have this let me know and I will arrange a USS. Small below knee DVTs typically do not require formal treatment. Clots that involve the vein behind the knee, or higher, require treatment with blood thinners for 3-6 months.

Most people do not require crutches after a knee arthroscopy as the surgery does not destabilize the knee in any way. On rare occasions, if the post operative pain is too significant, crutches may be used for a few days to facilitate easier mobility. Occasionaly if cartilage grafting has been undertaken crutches may be a requirement of your early recovery.

You are allowed to drive once you can walk comfortably unaided, are no longer requiring opiod pain killers, and when you honestly believe your reaction time is back to normal. Usually this is between 5 days and 2 weeks post op.

Do not do too much to soon after your knee arthroscopy. Even though the incisions are small I have opened the joint and manipulated structures inside your knee. If you do too much too soon after your operation the knee will remain sore and swollen for longer. Instead of you being happy with the knee after 4-6 weeks it will take 8-12 weeks to settle. I generally recommend rest, icing the knee and small walks only during the first 2 weeks. Using one of the neoprene/wetsuit compression garments that are available from most chemists for the first 6 weeks can help to control swelling.

Not all knee scopes recover the same way. Sometimes people have little or no pain, and other times the pain can be quite significant. The differences in recovery relate to how much work was done inside the knee, how accessible the pathology is inside the knee, post operative bleeds inside the knee (which can be very painful), how much underlying arthritis is present in the knee and different pain and inflammatory responses people have. If there is something that doesn’t feel or seem right to you during your recovery please call the rooms and I will either call you back or arrange to see you in the short term. Don’t worry, we’ll get you through it!

See you for your post-op appointment.

Regards, Luke McDermott

It is safe for you to return home in a normal vehicle. No ambulance transfer is required as a rule. I recommend you sit in the passenger seat at the front of the vehicle with the seat as far back as it can go and in a reclined position.

On returning home I encourage the use of a crutch, stick or other walking aid until you feel very safe on your feet and are not at risk of falling. Continue with the straightening exercises 3-5 times daily, and the bending exercises 3-5 times daily. If you are going to be seated for long periods of time, continue to wear your compression stockings. If you are mobilizing and remaining active you do not need to wear these stockings during the day.Some regular ice on the wound can help with swelling and discomfort.

I would encourage you, as your pain tolerates to wean you pain medication in the following order:

1. First aim is to cease use of opiods such as endone or targin. On discharge you are normally written up for targin twice daily. As you feel your pain settling, halve the night time dose – these tablets can safely be split. A few days later, halve the morning dose. As the pain settles further, cease the night time dose and then aim to cease the morning dose. I prefer you to be off opiod medication altogether after 2-4 weeks.
2. Once you have managed to wean the opiods you can then wean the anti-inflammatory (Mobic).
3. Cease paracetamol last. If you take pain medication for other ailments this protocol may need to be altered. For the first 4 weeks after the surgery I encourage you to sleep on your back. If this is not feasible and you need to sleep on your side this is safe but you should place a pillow between your legs. You should arrange to see your physiotherapist at about the 2 week mark post surgery and you will need to see them weekly for approximately 6 weeks after that.

WHAT COMPLICATIONS DO I NEED TO WATCH OUT FOR?

1. DVT and PE: One risk of joint replacement surgery is the risk of deep vein thrombosis. The symptoms of a DVT include (but are not limited to) swelling in the calf and leg (which is also normal after a THR), an ache in the calf, or a heavy feeling in the leg. If you are experiencing this I will generally arrange an ultrasound of the calf veins. A DVT can also lead to pulmonary embolus (PE) where a clot lodges in the veins of the chest. This can cause symtpoms of chest pain, shortness of breath, cough and a fast heart rate. If you are experiencing these symptoms please let me know. If your chest pain or shortness of breath is severe you should dial 000 and attend your nearest emergency department.

My DVT Management looks like this:

• . Chemical prophylaxis: I predominantly use 300mg of aspirin a day for 6 weeks. In people who are high risk for DVT I may consider the use of other agents such as clexane or xeralto. I do not use these medications as a first line agent as they may be associated with a higher infection risk and do not reduce the risk of other cardiovascular events which may occur post operatively. Once you have managed to wean the opiods you can then wean the anti-inflammatory (Mobic).
• 2. Mechanical prophylaxis: while you are in hospital I will utilize the use of compression stocking and sequential compression devices (SCDs).
• 3. An important part of managing your DVT risk is early activity and walking.


2. Infection: A deep infection is a serious complication. Signs of infection include:
• worsening redness around the wound or discharge from the wound
• 2. pain that is progressively getting worse instead of better
• 3. fevers of sweats (please check your temperature and contact if >38°

If you have these concerns please contact the rooms and I will likely arrange a blood test and plan to see you. If anyone, such as your local doctor, suggests that you need tablet antibiotics because of concerns you may have a wound infection then I need to see your wound as soon as possible and before you start the antibiotics.

A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. Following a hip replacement please advise your dentist prior to any procedures where bleeding in the mouth is likely to be encountered. Also please see your general practitioner if you develop skin infections or abscesses as early treatment with antibiotics is essential.

This information is not exhaustive and if you have further questions I would be happy to answer them.

The main goals of your post-operative rehabilitation are:

1. protect the joint to prevent dislocation: need to avoid combined external rotation (arm rotated out) and abduction (arm out from body
2. allow for healing of the subscapularis: the subscapularis muscle is under tension in a position of external rotation. If this muscle does not heal daily tasks like reaching behind your back and pushing up off a chair may be difficult
3. restore a functional range of motion
4. restore strength

TOTAL SHOULDER POST-OP PHYSIOTHERAPY PROTOCOL

This protocol is designed as a guide to you and your physiotherapist. Your progression through the post surgical period is case dependent and may be altered and need to be modified according to your underlying medical issues, physical findings or the presence of post-operative complications. Please let me know if you or your physiotherapist have specific concerns regarding your ability to comply with the protocol.

This protocol is specific to a Standard Total Shoulder Replacement and, while similar, has specific differences to that for Reverse Total Shoulder Replacement. If you have had a reverse TSR please see the specific information download for that procedure.

The start of this protocol is delayed for 3-4 weeks following a revision or in the presence of poor bone stock. I will let you know if this is the case.

PHASE ONE

Immediate post-op to week 6 – GOALS:

1. wound healing and management of swelling: ice and anti-inflammatories
2. prevention of dislocation
3. healing of subscapularis (through prevention of tension on subscapularis)
4. maintain passive range of motion
5. maintain full finger, wrist and elbow range of motion
6. independent dressing and transfers (with adjustments)

Precautions:

1. sling is work for 6 weeks post-operatively
2. sling may be removed for exercises and showering
3. when lying on your back the elbow should be supported by a towel
4. no active exercises (you lifting the shoulder
5. no supporting of body weight, pulling, or pushing with the shoulder
6. keep wound dry for 2 weeks; no pool for 4 weeks

Exercises weeks 2-6:Exercises should be performed with the help of your physiotherapist until you have the correct technique and are confident. Isometric deltoid contractions can be done in combination with the exercises in the downloadable information from week 2 onwards.

PHASE TWO

From week 6-12 – Active Range of Motion + Early Strengthening - GOALS:

1. continue progression of passive range of motion
2. weaning from sling by week 7-8
3. gradually restore active range of motion
4. continue with wound massage and swelling reduction
5. re-establish dynamic shoulder and scapular stability

Precautions:

1. avoid combined shoulder abduction and external rotation
2. weight lifting restriction during this period is 500g
3. no supporting of body weight, or forceful pulling or pushing is permitted

PHASE THREE

After 12 weeks – GOALS:

1. Strengthening
2. Enhance endurance
3. Enhance functional use of arm

Exercises with Physiotherapy:

1. begin theraband activities and progress bands as pain + strength tolerates
2. progress strengthening to include weight bearing through arm, pulling etc.
3. may gradually return to gym and recreational activities by 4-6 months

The therapy protocol lasts for 6 months. You will make improvements from a pain, range and power point of view out to 12 months from the operation.

The diagrams and exercises given here are a guideline. Additional exercises may be suggested by your physiotherapist. Provided they adhere to the general guidelines of passive range for the first 6 weeks, active from weeks 6-12, and no resistance till after 12 weeks they are likely to be appropriate. The restriction of external rotation to neutral for the first 6 weeks is also critical.

I will generally see you 2 weeks, 6 weeks, 12 weeks and 24 weeks after the surgery.

This information is not exhaustive and if you have further questions I would be happy to answer them