Why Choose Joint Orthopaedic Centre?

• Our treatment process uses a team coordinated approach
• Our rapid mobilization program promotes early discharge with the aim of accelerating the rehabilitation process.
• Our patients have 24 hour access to orthopaedic care.
• Our aim is a customer-focused service environment.
• We use state-of-the-art, leading technology.
  

And our most important benefit: the JOC Pain Management System

Introduction
The Ideal Vision
The Process
Post-operative Pain Management
Mobilization
Home Care
Post-operative surveillance and rescue

Introduction

Quick recovery after surgery can only happen if it doesn’t hurt too much, so effective pain management is one of our main priorities. We expect to be able to keep you very comfortable after your surgery: consequently you should be able to be up and about just a few hours after surgery and you may go home if you wish very soon afterwards.

We manage this by attacking the pain pathway at three points:

1. at the operative site with anti-inflammatory medications
2. along the pain nerves with long acting local anaesthetics
3. centrally with low dose opioid pain medications such as fentanyl and panadeine forte.

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The Ideal Vision...

Imagine you lived in Fairyland and had developed osteoarthritis in your hip or knee and to fix it you needed surgery.

The best solution to the problem would be to visit your local Fairy Godmother, have her wave a magic wand, and hey presto, your hip would be fixed immediately, without pain, without complications, without having to wait around to recover and without expense. After your eyes recovered from the flash you could just give her a peck on the cheek and get on with that game of tennis you had been putting off for a while.

Unfortunately, Fairy Godmothers are in short supply in the real world but if I were facing hip or knee surgery I would like my doctors to approach this ideal as closely as possible. With this in mind, we have been searching for ways to improve the outcomes after hip surgery. In particular we wanted to

• make it pain free,
• reduce infection and thromboembolic complications,
• improve immediate and long-term mobility,
• reduce recovery time and,
• improve patient satisfaction

A consequence of this endeavour, but not the main focus, has been

• reduced hospital stay and
• reduced cost.

The Key to achieving these objectives has been

• Careful preparation
• Minimally invasive surgery
• Meticulous pain management
• Enthusiastic post-operative mobilization and
• Early return to the comfort of home care

Realizing the ideal of complete pain control, immediate mobilization and early release from hospital has been made possible by two developments. The first is the development of minimally invasive approaches and limited surgical techniques. The second is meticulous pain management for the entire post-operative period.

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The Process

Pre-operative education, Preparation and planning
Minimally invasive surgery and Intra-op Pain Management
Post-op Pain Management	Acute Rehabilitation	Home Care

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Post-operative Pain Management

Post-operative pain is one of the major outcomes of surgery and relief of the patient’s distress is an important goal in its own right. Severe pain often leaves the patient permanently scarred and terrified of even minor surgery. Meticulous pain management is pivotal in achieving acute rehabilitation. Our objectives are

• No pain or low levels of discomfort for entire peri-operative and convalescent period
• Side effects eliminated or reduced to negligible levels
• Acute rehabilitation and early discharge.

The Kohan – Kerr technique places meticulous pain management at the centre of immediate post-operative care and it is central to achieving our stated goals. We believe that pain management should be a process rather than an event and, in essence, our technique seeks to control pain for the entire post-operative period by graded interventions tailored for the severity of the pain.

In addition, we seek to control the pain peripherally rather than centrally so as to shorten the entire painful experience and to avoid the pitfalls of other techniques. To make it work it is necessary to provide a pain management service that extends through the entire post-operative and convalescent period and to adopt suitable pain management techniques

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Mobilization

Mobilization immediately after surgery is desirable because it

• Improves early mobility
• Reduces DVTs and PEs
• Improves outlook and confidence

Immediate mobilization is possible if

• Prosthesis is stable
• No pain
• No drug side effects
• No physiological disturbances
  - Anaemia
  - Hypoglycemia

Hip replacement or resurfacing procedures that use a large anatomical femoral component lend themselves to early mobilization. Once the prosthesis has been cemented in place it is stable and the patient can begin walking immediately. With adequate pain control, and functioning musculature it is possible for patients to walk within an hour or so after the procedure is completed. Early and complete mobilization is thought to markedly reduce the incidence of post-operative thromboembolic complications and improve early recovery of full joint movement.

Physiotherapy assistance with early mobilization is important, especially since patients often need to be mobilized while the surgical team is still occupied in the operating room. The physiotherapist also has a role in pre-op. education (including but not limited to the use of crutches and walking sticks and the provision of a mobilization program), teaching coping techniques such as managing stairs, toilet, and exiting bed, and providing a safety checkout for independent mobility. Nonetheless, we do not consider that the attendance of a physiotherapist is essential and physiotherapy must not be allowed to unreasonably delay discharge. If the physio can’t make it in time – don’t wait - do it yourself.

In the first few days after leaving hospital the best physiotherapy, in my opinion, is just to walk around the house every few hours and to carry on with the normal activities of daily living.

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Home Care

Our prime focus has been to improve the outcomes after hip surgery and early discharge from hospital has been a side effect of our efforts. Nonetheless, there are some distinct advantages associated with leaving hospital as soon as is practicable.

‘Hospitals are but an intermediate stage of civilization the ultimate object is to nurse all the sick at home’
- Florence Nightingale. The Times April 14th 1876

Hospitals can be dangerous places. The risks patients are exposed to include

• Infection with resistant organisms
• Medication errors
• Enforced bed rest
• Iatrogenic illness from overzealous interference

If the patient

• has no pain and we are confident they will not develop pain,
• is independently mobile,
• is otherwise well, and has a suitable home environment,

then the hospital can make little further positive contribution to his outcome and he should be discharged to the comfort of his own home. Early discharge fosters an expectation of wellness and placing patients in charge of their own management forces them to abandon the “sick role”, both of which are positive contributors to full recovery. Finally, of course, early discharge significantly reduces the cost to the patient, often an important factor for them.

Our full discharge criteria are listed below.

• Adequate pain control
• Independent mobility, appropriate attitude
• Hb. > 100 mg/L
• No or adequately managed co-morbidity
• No Quad weakness or neuropraxias
• Suitable home and adequate assistance
• Close proximity
  

Post-operative surveillance and rescue

It is not reasonable to send patients home immediately after surgery and expect them to fend for themselves entirely. They must feel they have support at all times and appreciate that if they strike trouble help is immediately at hand by contacting the team. They will need some help at home and we insist on having a responsible adult with them on the first post-op night to comply with college guidelines for day surgery.

Surveillance by the surgical team must not cease on discharge from the hospital. All the usual checks that used to happen in the hospital must now extend to the home. Our usual routine is as follows

• Post-op ward round by Surgeon, Anaesthetist and Nurse before discharge.
• Phone in when they get home (Anaesthetist or Nurse)
• Anaesthetist phones at least once per day for three days to check on pain management and log of analgesic use
• Nurse assistant follows up patient by phone about day 4 or 5
• First post op office visit to nurse assistant at seven days post-op.
• Post-op consultation with surgeon at day ten

A rescue plan must be in place if the patient gets into any difficulty such as uncontrolled pain, haemorrhage, or severe continuing nausea and vomiting. The vital link is communication – the patient must have a series of phone numbers to call if they need help so that they can be sure of contacting help at any time 24 hours per day. A well-oiled procedure for recovery to hospital needs to be in place should the need arise.

Although these arrangements would seem onerous on the surgical team, I personally have had only three calls between midnight and dawn over three years and 100 patients, and we not had to recover any patients to hospital in the first three post operative days. Far from being onerous these arrangements dramatically improve the team-patient relationship and are satisfying for both patients and team members alike.

Notwithstanding the above considerations not all patients can or should be discharged early. The most common reasons for discharge later than 12 hours are no transport, remote location, no help, unsuitable house, cultural expectations and third party payers.

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