Hip Replacement

Instruction for

Joint Replacement
Patient

2 Soi Soonvijai 7, New Petchburi Rd., Bangkok 10310 Thailand Tel. +66 2310 3000
E-mail: [email protected]

เอกสารเผยแพ รเฉพาะสมา ิชกโรงพยาบาลก ุรงเทพ

Bangkok Hip and Knee Center Bangkok Internation Hospital
Open Daily 07.00 a.m. - 05.00 p.m. Tel. +66 2310 3731, +66 2310 3732

Approved quality

by JCI

Thank you for choosing to undergo Hip or knee replacement surgery at Bangkok Hip and Knee Center.
This instruction is aimed to assist patients and family with information about technology and treatment plan
to acquire knowledge and understanding, ultimately to better surgical outcomes and quick rehabilitation.

The following information will provide you to understand the practice care for joint replacement patients,
including what will possibly happen during hospitalization and after discharge for home. However; each
individual patient is unique so specific and different care will be provided to meet such individual need. This
instruction will help the patients to learn about joint replacement surgery and practice guideline for pain
management then the patient can quickly recover from the surgery.

Our team promptly provides assistance and responses to your inquires about joint replacement surgery
and together serves you throughout the surgery. We all wish to see you well recover and resume your normal
life. Once again, thank you very much for your great confidence and trust in our team.

Doctor team, Bangkok Hip and Knee Center
1. Dr.Wallob Samranvedhya
2. Dr.Sombat Rojviroj
3. Dr.Boonyarak Visutipol
4. Dr.Sarit Hongvilai
5. Dr.Phonthakorn Panichkul

Table of Contents

3 13

Medical Care team Post-operative care
• Activities and exercise
5
Post surgery
Roles and Responsibilities • Post-operative rehabilitation
of patient
25
7
Practice guideline for cares
Pre-operative preparation after discharge

35

12 Diet therapy for patients
after joint replacement surgery
Preparation for
Hospitalization 42

Drug information for patients
after joint replacement surgery

This instruction is to provide general information about what you are
expecting and what you have to follow prior to surgery, on surgery day
and post surgery

Medical Care Team

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Specialists in Hip and Knee therapy,
Bangkok Hip and Knee Center
1. Dr.Wallob Samranvedhya
2. Dr.Sombat Rojviroj
3. Dr.Boonyarak Visutipol
4. Dr.Sarit Hongvilai
5. Dr.Phonthakorn Panichkul

Care team consists of: Nurse Coordinator
Nurse Coordinator of Joint Replacement Surgery
Attending physician program is responsible for providing information
A physician acts as a team lead for treament, about treatment, observing follow up and
surgery and entire responsibility throughout coordinating with multidisciplinary team in
your hospitalization providing appropriate cares, including providing
initial consultation in case you may have problems
Consulting physician of treatments from the pre-surgery until after
Consulting physician or physician participating discharge from the hospital
with an attending physician for treatment
such as internal medicine physician, Nurse team
rehabilitation physician or other specialists Registered nurses provide close cares to patients
being consulted by the attending physician for in compliance with professional standards
your case that may be beyond specialty of the
attending physician Instruction for Joint Replacement Patient

Anesthesiologist
Physician who is responsible for providing
anesthetics during surgery, monitoring vital
sign and perhaps participating postoperative
pain management

+ Medical Care team 03

Rehabilitation physician and Nutritionist
Physiotherapist Professional to educate the patient about
They take responsibility since pre-operative appropriate foods or to be avoided foods
preparation to ensure a patient has fully physi-
cal readiness. Post-surgery, a rehabilitation team Pharmacist
assists the patient with physical rehabilitation Professional to take care and provide the
in several aspects to resume daily activities by information about medicine related to
his/herself or being supported correctly by treatment and personal underlying diseases
family or care taker, including continuation of for use of medication as appropriate
rehabilitation for the patient to return to close-
ly previous physical condition or better than
pre-surgery

Instruction for Joint Replacement Patient +Medical Care team 04

Roles and
Responsibilities of Patient

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• Receive information • Give information to Care
from Care team team
Ask Care team about Give information about
symptoms and the disease currently used medicine,
you have, and treatment including vitamins, supplement
plan including searching or medicine from traditional
additional information medicine practitioner or
from trusted sources, self-bought medicine;
if you have any concerns, information of drug or
promptly ask questions allergen causing allergy;
to a health care provider and information of
• Well follow the underlying diseases and
received recommendation treatments to physician and
Participate in treatment nurse
plan with Care team and If other examination or
follow all received treatments from other
recommendation from health providers (not
pre-surgery, post-surgery Bangkok hospital), please
until after discharge from bring along the results of
the hospital such examination and
treatments

• Thoroughly study this
instruction

+ Roles and Responsibilities of patient 05 Instruction for Joint Replacement Patient

Frequent Questions ||||||||||||||||||||||||||||||||||||| What are recreation activities

?How long is hospitalization ? Do I need to do physical ?I can do after surgery

Answer: In general, a patient stays therapy after discharge Answer: You can do any activities
in the hospital approximately 3 - 5 Answer: It depends on individual impacting to joints such as
days with a goal that the patient progress if your rehabilitation walking, dancing, golfing,
can follow the instructions prior matches with the set plan. swimming, bowling, gardening
to being allowed for discharge. In some cases, you may need a and etc. You should avoid any
What if I stay home alone physiotherapist to help you at activities heavily impacts to
home or make an appointment joints such as running, jumping,
?Answer: Please try to find a basket ball and etc.
?for physical therapy at OPD
family or care taker to be with When can I drive ? What are any noticeable
you at least for the first week Answer: About 4 weeks
after discharge. after the surgery; however, abnormalities I may have after
please obtain the discretion joint replacement surgery
?How long does from your doctor Answer: As for knee replacement
surgery, you may feel numbness
surgery take ?When can I resume working around tiny areas, outside of
Answer: General joint surgical wound that is not harmful.
replacement surgery Answer: Please consult with You may feel discomfort when
takes about 1 - 2 hours your physician as it depends on kneeing but this depends on
difference of each individual, physical therapy after surgery.
Is any special equipment type of work and recovery after Some patients may feel or hear
surgery. a slight “click” when moving knee
?required after discharge that is caused by moving of knee
?When do I need a follow up implant surface. This is also not
Answer: Walking aids such as harmful
walker used for the first 2 - 4 Answer: the first follow up is
weeks then the walker can be about 1-2 weeks after surgery As for hip replacement surgery, you may
replaced with crutches but it then frequency of follow ups feel length of each leg is not equal by
also depends on individual needs. depends on your progress and comparing to pre surgery. It depends on
Some patients may need a seat postoperative rehabilitation, pathological condition and the disease
supporter when using a toilet normally 6 weeks, 12 weeks, prior to surgery. In some cases, a physician
where the toilet is too low or 6 months after the surgery may recommend insole to balance the leg
a chair when bathing. then yearly. length. Some patients may feel pain or
sore of surgical leg when put the weight
on the leg around first 2-3 months after
surgery. Also if it is hip replacement
surgery with anterior approach, you may
feel numbness around the front of tight,
it is not harmful.

Instruction for Joint Replacement Patient +Roles and Responsibilities of patient 06

Pre-operative Preparation

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A patient will undergo physical examination prior DO not shave a surgical area
to surgery and receive the surgical information Using razor may cause infection because
from nurse and physiotherapist. The appointment shaving may cause skin abrasion. If shaving
for this is scheduled around a week prior to surgical area is required, nurse or nurse
surgery. This step takes approximately 4 hours assistant is taking care of it prior to surgery.
in the hospital. The step includes the followings: Visit by Anesthesiologist prior to surgery
• Blood drawn and urine collection (chest X-ray A patient will meet with an anesthesiologist
and EKG may be required) prior to surgery for evaluation and receive
• Visit with internal medicine for evaluation of information about pain management
and physical examination during surgery and post surgery
• Physical assessment, muscle exercise and use of
walking aids demonstration by physiotherapist
• Nurse will give information about what would
happen prior to and after surgery, including
essential self-care practice

Stop using anti-coagulant drug Exercise/ Activities
If a patient is taking anticoagulant A physician may suggest you to start
drugs, please consult with a an exercise program from pre-surgery
physician prescribing the drugs until post surgery because the exercise
to stop using them at minimum can prevent thrombosis (blood clot) in
of 5 - 7 days prior to surgery. veins and increase your strength and
A nurse who taking care of the motion after surgery. This is very essential
patient for pre-surgery will also for function of respiratory system,
advise the recommendation blood circulation, and urinating and
about other drugs that should excretory system; however, if you feel
be stopped prior to surgery. more joint pain during exercise or activities,
please notify your physician, nurse or
physiotherapist. (After exercise, you may
experience muscle aches that is normal.)

+ Pre-operative preparation 07 Instruction for Joint Replacement Patient

Dieting inflammation, including refraining from
supplement or vitamin. All regularly used
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||| medicine must be reviewed prior to surgery and
the physician will advise which ones should be
You should have enough foods containing all 5 stopped prior to surgery, when to stop, and
food groups and control your weight within an which ones can be continued taking.
appropriate range because overweight may impact Prevent Infection
to a surgical joint. You should avoid high calorie
foods such as high sugary foods, sweets, high ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
fat deep fried foods, meat with fat and etc.
You should also choose cooking methods like Infection can be routed from skin and oral
boiling, steaming and grill for calorie reduction cavity, please follow the following instructions
and weight control. to reduce the infection
In addition, it is very important for patient with • Do oral examination prior to surgery as infection
joint replacement, you should receive optimum can pass though blood circulation if you have
vitamins or minerals from intake foods such as decayed tooth or during dental procedure
vitamin C, vitamin D, iron, calcium, phosphorus, • Notify your dentist that you have joint
magnesium and etc. The sources of such vitamin replacement surgery prior to undergoing dental
and mineral are fruits, meats, eggs, milk and procedure every time
low fat dairy products, fish and meats included
bones that can be eaten as a whole, and green +Pre-operative preparation 08
vegetables like kale, spinach, broccoli, nuts and
whole grains.
Stop Smoking

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You are recommended to stop smoking at least
4 weeks prior to surgery. Smoking causes high
postoperative risks, especially, breathing and it
also delays surgical wound healing.
Medicine

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Some medicine must be stopped taking at least
5 - 7 days prior to surgery to reduce blood loss
during surgery. Examples of this medicine group
are aspirin and medicine composed with aspirin,
anti-inflammatory drug, thrombolytic drugs or
anticoagulants or platelet and drugs for joint

Instruction for Joint Replacement Patient

• Bath, shampoo and clean your body prior to Walking aids/ daily activity aids
surgery
• Avoid environment that may cause skin ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
irritation such as sun bathing, scratches from
animal or bites from bugs. If you have any A patient needs walking aids some times after
wounds or scratches around the leg of surgical surgery. The patient many need other aids to
site, please notify your doctor. help do some daily activities depending on a
surgery type. Your attending physician and team
Transportation will assess environment, suggest some adjustment
at home and assist with selection of walking aids.
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Equipment you may need
You are required to have either family or • Four legged walking aids or
friends to take you home when your attending
physician allows discharge. Please do not drive crutches
home but travel by vehicle that has enough • Other equipment supporting
space for you to flex or extend your knee.
daily activities
• Bathing chair

+ Pre-operative preparation 09 Instruction for Joint Replacement Patient

Physical therapy program for Total Hip Replacement and
Total Knee Replacement surgery

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Important reminder prior to any exercise, DO NOT hold your breath while exercising

Sitting exercise (Sit on a chair with back rest, both heels on the floor)
Pose 1: Ankle exercise: flex both ankles upward together for 10 repetitions
with both heels on the floor at all times
Pose 2: Upper arm muscle exercise: sit on the chair with both hands beside
your body on the crouch seat, put your hands on the armrest with a little
flexed elbows, then extend both elbows together until arms are straight for
10 repetitions (a patient with shoulder pain should avoid this exercise)
Pose 3: Thigh exercise: Sit with your back leaning against back rest. On an exercise leg, put
the heel on the floor with almost fully straight knee then tighten the knee fully straight
then release for 10 repetitions
Pose 4: Breathing exercise slowly inhale through your nose until the stomach is inflated
together with both arms upright then slowly exhale through your mouth until the stomach is
deflated with both arms down for 5 repetitions

Lying exercise (lie back down on bed)
Pose 1: Ankle exercise, lie on the back with straight knees then slowly flex
both ankles together for 10 repetitions
Pose 2: Exercise for knee and hip muscle, lie on the back, flex both knee
and hip by drag your foot upward to your hip, do one side at the time for
10 repetitions
Pose 3: Thigh exercise: lie on the back with the pillow under your knees, then
tighten both knees down against the pillow without lifting your hip for 10 repetitions
Pose 4: Hip muscle exercise: lie on the back with both legs straight, tighten your hip by pressing
both heels down against the bed for 10 repetitions (do it like you almost lift your hip upward)
Pose 5: Abdominal muscle exercise: lie on the back both knees up but heels on the floor, tighten
your abdomen as if you lift your body and hold it by counting 1-2-3 for 10 repetitions (while
counting, do not hold your breath)
Pose 6: Knee muscle exercise: lie on the back and put tip of your feet against the wall or bed
edge with slightly flexed knees then fully straighten your knees for 10 repetitions, you can
put a pillow between your soles and bed edge

Instruction for Joint Replacement Patient +Pre-operative preparation 10

Home Preparation for patient after joint replacement surgery

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Recommendation • Keep all carpets away and fix damaged floors,
• If your chair is too low to get up easily, ensure no tripped points

you can put pillow or blanket to make • Remove all cables and obstacles on walk ways
the level higher • Install lighting during night at walk way,

• If your bed is too high, change a thinner toilet and bedroom
mattress or bedding • In some cases, your pet should be taken care

by others
• If your bedroom is upstairs with stair access,

you are recommended to move to downstairs
to avoid using stairs for the first two weeks
• Ensure stair rails installed tightly
• Manage equipment, items and utensils for
ease of use and not obstruct walk way
• Keep equipment and cloth at the level to
easily reach. The level should be between
shoulder and waist
• Keep communicating devices closely to yourself,
including important contact numbers. In case
of emergency, that is reachable
• Adjust appropriately level of bed: not too high
or too low
• Prepare a chair with back rest and armrest,
not too soft cushion, non-movable and no
wheeled, avoid using a low chair because it is
difficult to get up
• Prepare a house helper until you can do it
yourself

+ Pre-operative preparation 11 Instruction for Joint Replacement Patient

Preparation for Hospitalization A night before
Surgery day
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||| • Refrain from water and foods
after midnight, including gum
Things to bring along Prior to an appointment and candies to empty your
• This instruction date, you will receive a stomach (the exact time to top
• Personal identified card such call from the hospital to eating and drinking will be
as ID card confirm your time and informed
• Continuous Positive Airway • Bath and shampoo to reduce
Pressure (CPAP) if you are using date for admission. infection
• List of used medication with Once you arrive at the • Do not shave surgical area. If
dosing, including supplement hospital, please contact required, nurse or nurse assistant
and self-bought medicine and Pre-Operative Preparation will do prior to surgery
list of allergic drugs and foods • Take medicine only recommended
• Shoes that are easily put on Department. by physician for pre-surgery
and off • Remove nail polish
• Walking aids (if any) • Remove all jewelry
• Case of glasses, contact lens, • If you are not feeling well,
hearing aids or others (if any) please contact your attending
physician for advice

Instruction for Joint Replacement Patient +Preparation for admission 12

Post

Operative
Care

Patient’s room post surgery Dieting

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When surgery is complete, you will be transferred You will be encouraged to start
to Semi ICU for safety and will be closely observed eating promptly after you
by physician and nurse about 1 day. Nurse and become conscious after surgery
care team check your vital signs, pain score and by starting with a tiny ice cube
overall condition. You will be encouraged to start and small amount of water for
breathing exercise and moving your foot and 2 - 3 hours after surgery.
ankles to prevent postoperative complications A care team starts increasing amount and type
and promote rehabilitation. After a day in Semi or foods that you can have without nausea and
ICU, if your condition is acceptable, a physician vomiting until you can have a regular diet.
considers transferring you back to a regular ward. At the beginning of post surgery, you may lose
your appetite that is normal but please keep
Fluid and antibiotic through veins trying having food as much as you can.
It promotes your recovery. In case you lose your
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or medical diet with high nutrition and nutrients
To ensure you receive sufficient fluid, you will will be recommended for you to receive sufficient
receive IV fluid and antibiotics at least for a day calories and nutrients.
after surgery. Both fluid and antibiotics through However; it will be recommended by physician
IV is started from pre-surgery until post surgery. and nutritionist for appropriate dieting.

Instruction for Joint Replacement Patient +Post-operative care 14

Surgical Wound Care recovery. The catheter will be removed a day
after surgery to prevent urinary tract infection.
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Your surgical wound is dressed with gauze at ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
the beginning. Afterwards, a physician will
change a wound dressing with waterproof Some patients may get oxygen therapy to reduce
dressing before discharge. exhaustion or help with breathing. In general,
they will get oxygen on the first day after surgery
Surgical drains by oxygen canular through nose or oxygen mask
covering both nose and mouth. A nurse team
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||| monitors your level of oxygen in blood system by
attaching your tip of finger with a monitoring
You may or may not have a drain after surgery. device.
The drain removes fluid and blood under the Anticoagulant drug
wound so it can reduce swelling and pain. The
drain will be removed a day after surgery ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||

Intermittent pneumatic compressive device to Your attending physician considers prescribing
prevent thrombosis you anticoagulants to prevent deep vein
thrombosis. Pharmacist closely manages the use
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Intermittent pneumatic compressive device looks Instruction for Joint Replacement Patient
like a bandage to cover your calf and it is
connected with air pump that will inflate and
deflate regularly to stimulate blood flow in
your leg. It prevents thrombosis in your vessels.
You should wear tourniquet during lying or
sitting on bed until you can walk well.
Cold Compression

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You should use cold compression at all times
during staying in bed or sitting on a chair to
reduce swelling as well as pain. When discharge,
you will receive a cold pack for cold compression
as recommended by a care team
Urine Catheter

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You may have a urine catheter after surgery
to measure your urine output and provide
you comfort of urination during the first day

+ Post-operative care 15

Breathing exercise device however, if you feel nausea and vomiting, please
call a nurse team for a physician to prescribe these
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Constipation
You may receive this device after surgery. The
device is small and able to be held by one hand. ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The device helps you deeply inhale and exhale
to fully expand your lungs. The exercise prevents Constipation after surgery is common because
postoperative complications. You should use the the pain relief medication may decrease the
device for breathing exercise at least 10 repetitions bowel movement and change of dieting and
every 2 hours while you are awake. The common types of foods that impacts bowel movement.
cause of post surgery fever is the inadequate lung You may receive laxative daily but if you have
expansion; therefore, you should do breathing a problem of using laxatives such as not passing
exercise often. stool or passing stool too often, please notify a
Anti nausea and vomiting medication care team to adjust medication.
Blood transfusion
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Some patients may experience nausea and vomiting
after surgery. That results from pain relief If your laboratory result shows low blood
medication or some medicine. These symptoms count, you may feel dizzy or faint. A physician
can go away by itself after the first day of surgery; may consider giving you blood transfusion.

Instruction for Joint Replacement Patient +Post-operative care 16

Pain relief medicine and Pain management Local injection around the joint
after surgery
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During surgery, surgeon will put
Pain Scale injection around the knee or hip
During your hospitalization after joint replacement joint. That injection is combination
surgery, a nurse team keeps observing and of pain relief medicine,
asking your pain according to pain scale from anti-inflammatory drug and local
0 to 10 to adjust dosing of pain relief medication anesthetic that helps reduce pain
for you. Pain scale is shown as the picture above. after surgery.
10 means you are in pain the most that you Oral tablets
have ever experienced and 0 you have no pain
at all. You should be cooperative in telling ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
your pain scale to a team of physician and nurse
in order for the team to manage your pain best. A care team will bring you tablets after the
completion of surgery. Tablets controlling pain
0 1-2 3-4 after joint replacement surgery are divided into
No hurt Hurts little Hurts little two main groups: anti-inflammatory drugs and
analgesic acting through nervous system.
bit more A team adjusts dosing of each type of medicine
based on pain and side effects such as drowsiness
5-6 7-8 9 - 10 in order you to undergo physical therapy best.
Hurts even Hurts whole Hurts
worst Instruction for Joint Replacement Patient
more lot

+ Post-operative care 17

Instruction for Joint Replacement Patient Intravenous / Intramuscular Injection

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The team may use injection for controlling your
pain in the first 24 hours after surgery.
The injection will reduce the pain fast but its
effect may not stay long depends on the type
of injection.
Peripheral nerve block

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For patients with knee replacement surgery,
Adductor Canal Block will be used for pain relief,
anesthetic is injected around the nerves above
the knee and the catheter is left there for
automatic continuous infusion to add anesthetic
slowly with this adductor canal block. The patient
will not feel pain but muscle still functions, so
the patient can start exercise of standing and
walking within 24 hours after surgery.
For patients with hip replacement surgery,
anesthesiologist uses a method to relieve pain
by blocking peripheral nerve that is a primary
cause of pain and around surgical site with
anesthetic. This method well controls pain and
perhaps reduces amount of pain medicine the
patient requiring during first 6 - 12 hours after
surgery. However, this method may cause thigh
muscle weaken temporarily, especially when
walking exercise our team will take care of you
until your muscle recover from anesthesia.

+Post-operative care 18

Activities and Exercise after Surgery

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Coughing and Breathing exercise Ankle pump

It is very important to prevent lung disease After surgery, if you become conscious,
and infection. Coughing: start with deeply flex your ankles up and down slowly to
inhale and effectively cough out by using increase blood flow in your legs
your abdominal force. Breathing: slowly
inhale through your nose until your stomach Smtorevnegmtehnrtehabilitation and
inflated then slowly exhale through your
mouth until your stomach deflated, repeat Physiotherapist and nurse team assist you
5 repetitions. Sometimes, you may use with rehabilitation and movement of your
breathing aid when exercising. new joint. In general, a physiotherapist
assists you with standing up and walking
Your cooperation in physical therapy within the first 24 hours after surgery.
is essential for your rehabilitation You may feel pain when the first move
Changing postures on bed after surgery; however, you need to make
the move as soon as possible.
To prevent bed sores and thrombosis, Your physician team prescribes medicine
a nurse team will assist you with changing controlling your pain during physical therapy.
the posture, the best posture depends on Physiotherapist educates you about safe
a type of surgery you have. movement while on bed, get in and out of
the bed, stand up from sitting and sit from
+ Post-operative care 19 standing. You will also practice walking with
walking aids such as 4 legged walking
equipment or crutches, walking up or down
stairs, getting in and out of the car and other
daily activities such as bathing, dressing
and etc.

Instruction for Joint Replacement Patient

Sitting Walking up and down stairs

You can sit on bed the first day after surgery Physiotherapist teaches you to walk up
then you are recommended to start sitting and down stairs. When walking up stairs,
on a chair for about 1 hour then increasing walk the leg without surgery up first then
timing each day. follow with the surgical leg to the same
step. When walking down stairs, walk the
Walking surgical leg down first then follow with
the leg without surgery to the same step.
You can start walking exercise within the At the beginning, do not walk up and
first 24 hours after surgery when you are down with legs switched
assessed by either physician team or nurse
team with conclusion that you can start Bathing and Dressing
walking exercise. You will receive instructions
of weighing on when walking that how much After surgery, nurse team assists and
weigh you can put on the surgical leg and recommends you with sponge bathing or
instruction of leg movement. Your duration bathing. Keep your surgical wound away
of walking will be increased each day. In some from wetness until you are allowed by your
cases, after joint replacement surgery, you physician team. You may use a bathing chair
may limit weighing on the surgical leg. It also while bathing. In addition, you may use any
depends on discretion of your attending aids to wear your socks or shoes for safety.
physician team. In general, the patient will
walk with a walker at the beginning, then Transportation
selection of walking aids depend on weighing
on walking, appearance, and ability of After surgery, during your rehabilitation, it is
movement. Physiotherapist gives you recommended for you to travel by a standard
recommendation about types of walking aids. car. If a vehicle is too high or too low from
the floor, you may difficultly get on and off.

Instruction for Joint Replacement Patient +Post-operative care 20

Physical rehabilitation after surgery

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Surgical Day

• Move your ankles up and down to prevent vein
thrombosis

• Move and change sides on bed with helper
• Breathing exercise
• Deeply inhale and exhale, coughing exercise
• Drink water and eat foods
• Pain relief medication
• Cold compression at surgical site
• Undergo assessment by physiotherapist
• Start moving out of bed

First day post surgery

• Move your ankles up and down to prevent vein
thrombosis

• Breathing exercise
• Undergo assessment by physiotherapist, start moving

out of bed
• Walk to a chair then sit for about an hour
• Exercise walking to toilet
• Have foods as much as you can
• Pain relief medication
• Cold compression at surgical site
• Remove urine catheter and drain

+ Post-operative care 21 Instrucคt่มูioือnสfำoหr บัJรoผinปู้ tว่ Rยeผpา่ lตaัดceเปmลeี่ยnนtขP้อaเทtiียeมnt



























EAT GOOD DEiAgeSstIiLbYle
Clean
Food FOOD,
GOOD
LOW HEALTH

Salt CalHcIiuGmH
Protein
Soft drink

Alcohol

Cigarette

Diet Therapy for patients after Risks and Side Effects
Joint replacement surgery
Fatigue from duration of
The importance of nutrition after surgery is surgery, loss of blood and
to promote surgical wound healing process. body fluids
The sufficient nutrients is essential because Nausea and vomiting after
the body will absorb chemical components surgery from medication
from foods to repair tissues and cells producing
natural would healing, decrease infection, Loss of appetite or inadequate
and reduce fatigue. According to that, diet food intake for body needs,
is very important for patients to recover and especially the elderly
resume their normal condition faster as well Underlying diseases such as
as weight control after surgery to reduce poorly controlling of DM may
impacts to the surgical joint not to bear over cause slow wound healing
weight, reduce pain and promote well Patients with overweight or
treatment plan. obesity may have a heavy
At the beginning after surgery, the patient impact to the joint
may receive blood transfusion, IV fluid and
antibiotics. Also, the patient may feel nausea
and not fully conscious, IV fluid may be
required until the patient can have sufficient
diets and continue staying in the hospital for
approximately 5 - 7 days.

Constipation

Instruction for Joint Replacement Patient +Diet Therapy for patients after Joint replacement surgery 36

Instructions to choose diets for patients
after Joint replacement surgery

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1. Nutrition to promote wound healing 1.2. Carbohydrate and Fat: To help produce
energies to cells and promote functions of white
1.1. Protein: A role of protein to the body is to blood cells so the wound is healing quickly.
build up and repair tissues. Lack of protein Sugar is essential to produce energies to cells
highly causes low production of new tissues and aggregation of white blood cells. Fat is a
therefore if the condition of having wounds source of energy and a component of cell walls.
or surgical wounds, the body requires more Lack of Carbohydrate and fat will break up
protein than normal. Essential sources of protein Protein to energy. Sources of Carbohydrate from
containing amino acids from foods are such as foods are rice, bread, biscuits, grains, taro, potato,
lean meat, egg, milk, cheese, yogurt, peanuts, etc. Sources of fat from foods: animals are fish,
beans etc. yogurt, ice-cream, cheese, milk, etc; from plants:
olive oil, rice bran oil, soybean oil, avocado,
almond, walnut, etc.

+ Diet Therapy for patients after Joint replacement surgery 37 Instruction for Joint Replacement Patient

1.3. Minerals consist of Sodium, Potassium, 2. Diet Therapy for reducing weight and
Chloride, Calcium, and Phosphorus that are controlling weight within acceptable range
chemical components to maintain normal
functions of cell and balancing between Good weight control is not necessary to reduce
water in/out of cells. Balance of minerals and weight to standard or normal weight. Currently,
water is essential to maintain blood flows in the evidence shows reducing weight around
tissues. If skin receives inadequate water, 5 - 10% of current body weight can reduce
nutrients could not be carried to cells. health problems and impacts to knees. Diet
1.4. Zinc is an essential mineral to produce selection and modification are ones of factors
cell tissues. When the body has a wound, to lose weight. Principles of weight control are
high amount of zinc is required. Sources of listed below:
Zinc from foods are oyster, mussels, sunflower • 2.1 To reduce energy (calories) about 500 - 1,000
seeds, liver, red meats, fish, eggs, etc. kilo calories of the normal diet can lose weight
1.5. Vitamin is also essential for wound healing approximately 0.5 - 1.0 kilogram. Having all food
as it is to synthesize Collagen that functions groups is recommended for full nutrients,
against infection such as: consult with physician or nutritionist for suita-
• Vitamin C from foods: oranges, grapes, ble amount intake
lemons, strawberries, cantaloupe • 2.2 Eat all meals but reduce amount of each
• Vitamin E from foods: vegetables, rice bran meal for example, reduce about 1 - 2 scoops of
oil rice a meal, take more vegetables for more
• Vitamin A from foods: liver, carrots, orange fiber and prolong full stomach, take amount of
colored vegetables and fruits, leafy greens rice as set only once without taking addition.

Instruction for Joint Replacement Patient +Diet Therapy for patients after Joint replacement surgery 38

Also skipping any meals causes eating more in • 2.11 Reduce/ avoid adding fish sauce, salt, soy
the next meal than normal and decreases the sauce or salty seasonings before eating
energy burning (the use of energy). As a result, • 2.12 Add artificial sugar or sweetener in foods/
eating the same amount but use less of energy drinking instead of sugar
could cause gaining more weight. • 2.13 If feeling hungry between meals, choose
• 2.3 Eating punctually and each meal interval foods with high fiber such as fresh/quick
should not be long. If interval of each meal is boiled/boiled vegetables, lean meat without skin
too long, it causes eating more each meal and or no sugar drinks
high limitation of suitable food selection. • 2.14 Avoid eating all the times, foods or snacks
• 2.4 Do not skip breakfast, you will eat more with high calories. This eating habit more often
next meal could cause receipt of over calories as unnecessary
• 2.5 Choose foods with low calories and fat • 2.15 Choose suitable amount of fresh fruits
such as egg white, tofu, fish meat, lean meat instead of canned fruits, sweets and avoid
without skin, and leafy vegetables more often. drinking fruit juice
Avoid high fat foods such as fat meat, processed
foods, sausages, bacon, deep fried foods, curry,
bakery, margarine, gravy, salad dressing, etc.
It is recommended because fat 1 gram provide
9 kilocalories that is about twice of its provided
by Carbohydrate or Protein.
• 2.6 Choose foods cooked by boiling, steaming,
grilling, baking and mixing instead of deep
frying. Limit amount of oil when cooking and
use not over 1 teaspoon a meal
• 2.7 Choose low or no fat milk or yogurt instead
of full cream milk or dairy products due to high
fat and cholesterol and avoid condensed milk
and all types of flavored milk
• 2.8 Avoid sweets, snacks, candies, honey,
soft drink and soda
• 2.9 Avoid beverages with alcohol because
alcohol provides almost same amount of calories
as fat does
• 2.10 Slowly eating and chewing could reduce
amount of food to intake

+ Diet Therapy for patients after Joint replacement surgery 39 Instruction for Joint Replacement Patient

3. Diet Therapy for patients with fatigue, such as custard, ice-cream, jelly, tapioca pearl in
nausea, vomiting and less eating coconut milk, etc. Milk and soy milk are sources
of high calcium. Fresh fruit juices are also
Postoperative patients may be fatigue, tired, recommended but tea and coffee are voided.
intermittent sleeping, having wound pain or If needed, decaffeinated tea and coffee are
nausea, dizzy or vomiting due to loss of blood recommended. Alcohol beverages are fully banned.
and body fluids or anesthetics effect. Physicians Soft diet provides adequate calories and nutrients
recommend patients to have full resting so the to patient’s needs if the patient can finish the
patients may lose appetite or eat small foods; diet. It is a key that how to make patients eat
therefore, it does not meet a body need. Diet is the foods. Taste of the food is challenge even
an essential part to help patients with quick soft tasted food if it can be made tasty, the
recovery and returning to normal faster. patient can enjoy having foods like spicy foods.
Decoration and color of the foods can stimulate
Dieting after surgery should be started with light, patient’s appetite and forget their illness.
soft, easy to digest, soft smell, and non spicy foods. If patients lose their appetite, having meals more
An important food is protein that promotes often by dividing into 5 - 6 meals could receive
produce and repair damaged tissues, a quick more calories.
wound healing process. All animal meats can be Once patients can have foods better, high
cooked foods for patients after surgery but they calories foods should be served. If patients sill
must be cooked to soft and well boiled. Easy to lose their appetites and eat less so food intake
digest meats such as fish and egg are not sticky is not met the body needs, supplement or
but well sources to be used for patient’s foods. medical diet which is high and full nutrient will
Boiling and steams of vegetable until they are soft be considered for patients to have sufficient
and well boiled for patients. Fruits: select soft fruits, calories and nutrients.
fruits without hard peels and high fibers such as
ripe bananas, ripe papayas, ripe mangoes, etc.
Sweets: they should be not too sweet and soft

Instruction for Joint Replacement Patient +Diet Therapy for patients after Joint replacement surgery 40

4. Diet Therapy for DM patients to control 5. Diet Therapy for patients with
their blood sugar at acceptable level after constipation
surgery
Constipation means condition of less often passing
4.1 Eat variety of foods and all food groups: stool than normal. A normal person passes stool
rice/starch/grains, vegetables, fruits, meats/beans, 3 times daily or 3 times a week, if a number of
milk and fat to ensure receipt of all needed passing stool less than 3 times a week deems
nutrients. abnormal. Having enough foods, all meals and
4.2 Select high fiber foods such as brown rice, sufficient fluid intake keeps maintaining a normal
whole grains, vegetables and fruits excretion system. Especially, fiber foods from
4.3 Eat amount of foods according to nutritionist vegetables, fruits, grains, and other seeds which
recommends by eating similar amount of each cannot be digested in human stomach and bowels
food group daily will be excreted with stools. Mentioned fibers
4.4 Eat each meal about 4 - 5 hours interval benefits stimulation of bowl movements then
4.5 Do not skip any meal stools become large and soft for ease of passing.
4.6 Eat meal at similar time daily
4.7 Avoid high fat and sugar foods Normal intake of fiber is least 25 - 30 gram daily,
4.8 Avoid sweets, snacks and added sugar drinks if more than 50 - 60 gram, it may cause flatulence
4.9 Keep your weight within the appropriate and excessive gas or blocks absorption of some
range. For overweight patients, keeping your vitamins or minerals. Sources of fibers are as
weight down about 5 - 10 % of previous weight follows:
can help control your blood sugar better. • Vegetables such as cooked ivy gourd, cooked
kale, water mimosa, Chinese cabbage. Suggest-
ing having at least 1 - 2 scoops of these a meal
• Fruits such as cultivated banana, ripe papaya,
guava, mango, apple. Suggesting have a whole
each of fresh fruits, 8 - 10 cut pieces a meal
• Whole grains such as brown rice, coarse rice,
sesame seeds and corn
• Dry beans such as cooked red bean, cooked
green bean, pumpkin seeds, sunflower seeds
• Other sources: soluble fibers with Inulin found
in onion, garlic, cabbage, asparagus

+ Diet Therapy for patients after Joint replacement surgery 41 Instruction for Joint Replacement Patient

Drug
information

Drug information for Patients with osteoarthritis of the knee or hip
and undergo the joint replacement surgery
patients with Surgical will receive medication for 3 major purposes:
to reduce surgical infection, to relieve pain
Implant and to reduce thrombosis. The detailed drugs
you may receive are listed below
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1. Antibiotics If a patient with history of drug allergy or severe
adverse event of antibiotics used, the patient
Physician considers prescribing antibiotics to should inform the history to attending physician,
prevent surgical infection for patients undergoing pharmacist or medical staffs prior to surgery so
Joint Replacement Surgery such as Cefazolin, the physician can choose appropriate and safe
Vancomycin, Clindamycin, etc. Administration antibiotics, In addition, if some abnormal signs
of such antibiotics starts within 1 - 2 hours prior are noted during the patient receives antibiotics
to surgery based on type of choosing antibiotics, such as itching rashes on body, face swelling,
additional dose may be given during surgery if swelling mouth, tight chest, difficulty breathing
prolong surgery or excessive blood loss. or other symptoms deemed like adverse event
The physician will consider stopping using such from antibiotics, notify physician, nurse or
antibiotics within 24 hours after surgery if signs pharmacist promptly,
of surgical infection are not noted such as
surgical wound shows oozing or pus or persistent
high fever after surgery.

+ Drug information 43 Instruction for Joint Replacement Patient

2. Analgesics a day because it may cause risk for hepatitis and
avoid having alcohol during taking Paracetamol.
Patients with osteoarthritis of knee or hip Common Adverse Events
commonly have pain around knee or hip, Some Some patients may experience side effects such
cases may have additional back pain if they walk as nausea, vomiting or itchy rashes by using this
abnormally; therefore, it causes limitation of medicine. If you experience aforementioned
working, daily activities or physical therapy. side effects, please contact physician or pharmacist.
The use of analgesics is to relieve pain so the 2.2 Non steroidal anti-inflammatory drugs; NSAIDs
patients will move better, be able to resume daily Mechanism of action of NSAID inhibits enzymes:
activities as normal or be able to follow a physical Cyclooxygenase reducing production of
therapy program as set. There are several groups Prostaglandin which causes fever, pain and
of analgesics which have different mechanism of inflammation; therefore, this medicine group is
action and patterns. Selection of analgesics widely used as a single drug for mild to moderate
depends upon individual patient as appropriate pain or combined medicine with other analgesic
as listed below: for severe pain with inflammation or swelling
2.1 Paracetamol and redness. This group consists of several drugs
Paracetamol is commonly the first choice which are different in properties, dosing,
recommended to be used in patients with administration methods, side effects and cautions
osteoarthritis because it is safe and significantly of use. As a result, this group must be prescribed
effective for mild to moderate pain. by only physician or pharmacist for efficacy and
Dose of Paracetamol for adults as recommended safety to patients.
is oral 500 – 1,000 milligrams at a time and Common Adverse Events
repeated dose can be taken every 4 - 6 hours if 1. Stomach irritation: Patients may have stomach
pain still exists. Do not take over 3,000 milligrams burning, discomfort or ulcer in digestive tract.
Some patients may have severe side effects like
Instruction for Joint Replacement Patient vomiting with blood or stool with blood or
black stools, so they should take the medicine
promptly after meal and drink a lot of water
to reduce stomach irritation and consult with
physician or pharmacist promptly for treatment
or change of new analgesics with side effects
of mild stomach irritation or prescription of
antacids in combination of such NSAIDs.

+Drug information 44

2. Drug allergy: If patients have this medicine 2.3 Tramadol
then any of body rashes, swollen face, swollen Tramadol could be used for moderate to severe
mouth, tight chest or difficulty breathing is noted, pain without fever or inflammation. Nowadays,
please consult with physician or pharmacist there are a variety of products in the market in
promptly several forms, dosages and administration based
3. Retention of salt and water in the body and on physician’s or pharmacist’s recommendation.
possibly rising high blood pressure; therefore Do not take overdose or exceed 300 - 400
patients with DM, hypertension, kidney failure, milligrams a day.
heart or vessel diseases must consult with Common Adverse Events
physician or pharmacist before using this • Nausea, vomiting and constipation: if you
medicine experience aforementioned symptoms, please
4. Reducing kidney function: patients must consult with physician or pharmacist because
use this medicine at recommended dosing and these symptoms can be managed by reducing
avoid overdosing. If long term use of this dosage
medicine is necessary, you must use it under • Dizziness, blurry vision or drowsiness: Driving
the close supervision of physician for regular or work requiring high concentration should be
kidney function check avoided.
5. Prolong blood coagulation: you must be • This medicine group may cause risks to falls
caution for having wounds or excessive bleeding Other groups of analgesics are not mentioned
as well as you must always notify physician or herein as less common use or using for severe
pharmacist if you are taking any medicine or specific conditions as follows:
impacting to blood coagulation such as Warfarin,
Dabigatran, Rivaroxaban, Apixaban, etc.

+ Drug information 45 Instruction for Joint Replacement Patient

2.4 Opioids / Narcotic analgesics 2.5 Antidepressants and anticonvulsants
This medicine can be used for moderate and This group is used for Neuropathic pain such as
severe pain but not for reducing fever or numbness or burning of legs or tip of the foot
inflammation. A physician considers prescribing Common Adverse Events
this medicine only for patients with postoperative • Drowsiness, confusion or blurry vision: Driving
pain because this medicine causes a lot of side or work requiring high concentration should be
effects and drug addiction. Using of this group avoided.
must be under the close supervision of physician. • Drug allergy: if patient takes the medicine
Common Adverse Events then experiencing body rashes, swollen face,
• Constipation, nausea, vomiting and drowsiness: swollen mouth, tight chest, difficulty breathing,
If taking high dosage, it may cause severe consult with physician or pharmacist promptly
drowsiness, low blood pressure, slow breathing; • This medicine group may increase risks of falls
therefore, a physician closely follows up and
prescribes for a very short term use Muscle relaxants
• Body itchy rashes, swollen eyes, swollen lips, This medicine does not directly act to reduce pain
difficulty breathing: if these symptoms are notices, but act to central nervous system to relax muscles;
it may be caused by drug allergy, please notify therefore, it relieves tightness and tiredness.
physician or pharmacist promptly Common Adverse Events
• This group may increase risks of falls • Drowsiness, dizziness, dry mouth, dry throat,
and constipation; therefore, driving or work
requiring high concentration should be avoided.
• This medicine group may increase risks of falls

Additional Recommendation
• If a patient takes pain relief tablets but cannot control pain, the patient is
recommended to consult with physician to assess the progress of disease or the
medicine received
• Always notify physician and pharmacist if a patient is taking other medicine for
other diseases or supplement or herbs for the physician assess the use of medicine
as suitable to the patient’s condition

Instruction for Joint Replacement Patient +Drug information 46

3. Anticoagulants Prevention of Vein Thrombosis
Prevention of vein thrombosis includes use of
Patients post knee and hip replacement surgery anticoagulants, use of massaging equipment
are at risk to blood clot within vein (deep vein and leg exercise of which provides difference in
thrombosis:DVT) because of restrictions of effectiveness, convenience, side effects and
motion and vessel injury from surgery; therefore, expenses. Herewith, this topic focuses using
the patients need anticoagulants at minimum anticoagulants to prevent vein thrombosis.
of 10 - 14 days for knee replacement surgery Anticoagulants act to inhibit function of blood
and 28 days for hip replacement surgery. coagulation then blood is slowly coagulated;
If patients have blood clot in vien, the patients therefore, it can reduce risk of blood clot.
may experience any of the following symptoms:
symptoms: There are several types of anticoagulants
that provide different pros and cons.
• Blood clot in leg’s vessel: Physician considers choosing a type of
swollen, red, hot and pain leg anticoagulants upon patient’s condition
as appropriate as follows:

• Blood clot in lung’s vessel:
headache, confusion, palpitation,
tight chest pain, coughing up blood
and possible death

• Blood clot in brain’s vessel: Instruction for Joint Replacement Patient
hemiplegia (one side of body is weak),
crooked mouth, difficulty speaking

+ Drug information 47

3.1 Injected anticoagulants as well as the patient must notify physician or
Type of currently well known anticoagulant is medical staff of your abnormal bleeding.
Heparin group because it can act to inhibit blood
coagulation immediately. This group is mostly • 3.2.2 New Oral Anticoagulants: Dabigatran,
used for patients at the beginning when the Rivaroxaban and Apixaban
patients cannot take tablets or waiting Warfarin
to act. This group includes several medicine such This group can act to inhibit specific coagulation
as Heparin, Enoxaparin, Fondaparinux, etc. factor and prevent blood clotting rapidly. This
This medicine is injected through subcutaneous group is unnecessary to be co-used with injected
1 - 3 times a day based on type of medicine anticoagulant. Selection of type and dose depends
and patient’s kidney function. Common adverse on a patient’s condition, co-medicine or herb and
events are such as abnormal bleeding, blood kidney function of individual patient. (regular dose
blister at injection site. If the aforementioned is 1 - 2 times a day). Significant adverse event is
symptoms are noted, please notify physician, bleeding that is divided into two groups: non severe
pharmacist or nurse. bleeding and severe bleeding as explained below.
3.2 Oral anticoagulants The patients and family should regularly observe
signs of bleeding.
• 3.2.1 Warfarin • Non severe bleeding: bleeding gums, nosebleeds,
Warfarin has been used for a long time. It acts to skin blood blister, etc.
inhibit functions of vitamin K which is an essential • Severe bleeding: urine and stool with blood,
component for production of blood coagulation dark stool or bleeding in brain, etc.
then it delays clotting process. The medicine takes If a patient has non-severe bleeding that can stop
approximately 3 - 5 days to each the effective level. within a few minutes, the patient reports to
It may be a good choice for blood anticoagulation physician at the next appointment. If a patient
in long-term treatment and it must be combined has severe bleeding or continuing bleeding that
with injected anticoagulant at the beginning of cannot stop within 10 - 15 minutes, please urgently
treatment. meet with physician for stopping bleeding and
There are a number of factors affecting to action symptomatic treatment. Other adverse events can
of Warfarin such as amount intake of vegetables, include nausea, vomiting, stomach discomfort,
combination of using other medicine or herbs itchy rashes, etc. If these aforementioned symptoms
or supplements, underlying diseases, liver function, happen at the beginning of taking this medicine,
etc. With those factors, a patient must have the symptoms will get better on their own. If the
regular follow up visits with physician during symptoms become worse or the patient cannot
taking this medicine to check function of blood tolerate the medicine, please notify physician or
system or International Normalised Ratio (INR) medical staff to adjust the medicine.

Instruction for Joint Replacement Patient +Drug information 48