Fast Track rehab is a technique for early mobilisation after knee and hip replacement surgery. This is an important component of your recovery and forms part of a comprehensive recovery programme that Dr Lawrie employs to give you the best recovery possible after your joint replacement.
Joint Replacement Rehabilitation can be divided up into stages, each equally important.
Stage 1 Pre-Hab
This stage covers about 6 weeks prior to surgery. This is when pre-operatively planning for the surgery occurs. All patients are reviewed by your Anaesthetist Dr Scolaro and typically Chest Physician Dr Craig Wright (and or other medical specialists e.g. a cardiologist) to ensure it is safe to perform major surgery from a medical point of view. Sometimes adjustment of medical therapy is necessary before surgery. This process significantly reduces the risk of medical complications such as heart problems, blood clots, bleeding issues, diabetes management etc.
During Pre-Hab it is particularly important to work with your physio on preconditioning of the joint for surgery. In the knee restoring quadriceps function and producing a good straight leg raise goes a long way to improving outcomes. Gait retraining, muscle strengthening of the hip and knee are of great value. Pain control during this stage is very helpful so you are able to perform your exercise programme. Pre-education is also an important component of this stage. The physiotherapists will also train you on what exercises you will be doing through your recovery, how to get around the house, get in and out of bed, use crutches etc. and gaining an understanding of what will happen after surgery both early on and once you get home. It is very important to establish a good relationship with your physiotherapist as recovery typically takes 4-6 months in total for your hip or knee replacement. One of the most important aspects of stage 1 is to have a realistic expectation of what a joint replacement recovery means and everyone plays a role here, your surgeon Dr Lawrie, your physio, your anaesthetist, your physician everyone plays there part.
Stage 2 Peri-Operative Stage
This is the time you spend in hospital. The typical length of stay for a knee or hip replacement is 2 to 4 days. (studies from Europe show an average length of stay for Fast Track rehab of 2.1days with discharge to home). An important concept is that Joint replacement patients aren’t sick or unwell they are recovering from surgery so the goals are different to treating sick, medical patients.
To achieve safe discharge a number of goals must be achieved. They are;
- Good pain control
- Dry, clean wound controlled swelling
- Independantly mobility around the ward
- Good gait control with crutches
- With knee Replacements a good straight leg raise and bend past 90 degrees
- Hip replacements need good hip control and transfers in and out of bed.
To achieve this the anaesthetic technique we use is a spinal aesthetic with sedation that wears off shortly after the surgery is completed and a multimodal local anaesthetic injection throughout the affected joint. The injection is a staged technique through the three layers of the joint from the deepest level up to the skin which provides excellent pain relief for about 12 hrs. In the knee we place a small epidural cannula into the knee and the following morning Dr Scolaro injects a further bolus of local anaesthetic which again lasts about 12 hrs. Hip Replacements don’t need this second injection. We also use a medication that prevents blood clots from being resorbed, Tranexemic acid at the time of surgery and again 8hrs later which greatly reduces bleeding without increasing the risk of blood clots. This allows us to keep the use of narcotic pain killers to a minimum.
Once the spinal anaesthetic wears off usually an hour or two after surgery the physiotherapist will have you out of bed for a short walk and to get the joint moving and the muscles e.g. your quadriceps for a knee replacement firing off.
The physiotherapist will visit at least twice a day while you are in hospital and get you up and about quickly along with the help of the nursing staff. It is not a race but studies show the quicker you achieve the above milestones the less pain and less complications will occur. By keeping your muscles working well, walking early, avoiding narcotics patients are able to rapidly progress with the function and mobility. This reduces complications such as blood clots, chest infection, constipation, urinary retention etc. Most patients find that thursday morning the joint is more sore as the local anaesthetic has worn off completely and need some pain relief to get going. By thursday afternoon pain is back under control and they are on track with their rehab.
Most patients are ready for discharge between two to four days after surgery. Any appliances you need at home will be arranged for your before hand e,g, a high toilet seat for hip replacement patients.
On discharge the ward physiotherapists will liaise with your original physiotherapist for ongoing care, which will occupy your time for the next several months. Your physio and your GP will have copies of your operation notes as will you to refer to.
Most patients on discharge will remain strong pain killers and crutches for 2 weeks or more before achieving a safe gait pattern and changing to more simple pain relief. Hip replacement patients are usually not allowed to travel in a car till 6 weeks after surgery unless there is an emergency so a home exercise programme is organised for you ( this is part of the pre-hab phase). Sometimes home phyiso is available.
Knee replacement patients typically attend their usual physiotherapist on a weekly basis for the first 6 weeks. You will see Dr Lawrie at 6 weeks after surgery. For hip replacement patients you should be going for short walks, most will be off crutches, have strong abductor muscles and good gait control.
At 6 weeks knee replacement patients should have a good straight leg raise with only small lag, bend form 0-120 degrees with good gait and little limp.
Ongoing physio is usually necessary for the next 6weeks with individualised treatment depending on how you are doing.