The Improved Clinical Pathway Service program tries to get you back to full health as quickly as possible. Research has shown that the earlier a person gets out of bed and starts walking, eating and drinking after having an operation:

the lower the risk of complications from surgery,
the shorter their recovery time, and
the better the outcomes of surgery.

During your hospital stay there will be daily rehabilitation goals for overnight cases (major surgery). Longer term rehabilitation goals are also set. You will be encouraged to achieve these by a team of doctors, nurses, physiotherapists and other healthcare professionals where necessary and your progress will be monitored. You will be supported in reaching your goals. You will be involved in planning your care and recovery from the time you are seen by your surgeon until safe discharge from hospital. In the case of major surgery (spinal, hip or knee replacement) you will be referred to an anaesthetist who will perform an anaesthetic assessment and advise you about a clinical optimisation programme depending on your medical history. Your GP or a physician may do the pre operative assessment if an anaesthetist is not available. You will be advised about how to get into the best possible shape prior to surgery. They also will identify and stabilise any medical conditions you have that may affect the operation. This is an opportunity for you to tell us about your individual needs and circumstances. If you have any problems with home care after discharge, you need to plan to manage these with your GP or surgeon before coming to hospital for your operation.

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Depending on your operation, you may be able to go home sooner than expected. Patients on this program have had an average hospital stay of two days for joint replacements, four days for spinal procedures.

It is essential that you have someone to take care of you, that you are able to contact your surgeon or hospital and that you have the necessary equipment and support to aid mobility e.g a toilet riser for joints and spines. It is important that the discharge process is planned or a referral to a step down facility is put into place before the operation.

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It is essential that you are in the best possible health to get the most benefit from surgery. For spinal or joint replacement surgery, a pre-operative assessment of your general health state, blood tests and X-rays will be undertaken one to six weeks before the operation by an anaesthetist, GP or Physician. This is to ensure that you are fit enough to withstand the stress of the anaesthetic and that you have the best possible outcome from the surgery. If your health is not optimum, you will be referred back to a GP or other specialist for management of these conditions and the operation may be postponed until you are fit for surgery and the risk which have been identified are reduced or eliminated.

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You will have access to physiotherapy 'pre-habilitation' for joint replacement and spinal surgery. A physiotherapist will work closely with you to ensure that you are made stronger and properly prepared for the surgery. This will improve the experience, result in a quicker and easier recovery. The physiotherapist will assess your muscle strength, range of motion and functional capacity. A Pain, Stiffness and Functional questionaire will be completed. This information will be assessed again 3 to 6 months after the surgery as a measurement of your progress. 

A unique strengthening program will be designed for you and you will be encouraged to follow this program on your own. The physiotherapist will work intensively with you in hospital to assist you in getting up and mobilising. This will help speed up recovery and enable a earlier and safe discharge home so that you can return to a normal life with reduced pain, improved mobility and overall function.

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Surgeons perfom 'minimally invasive' surgery where there is less cutting of the muscles and ligaments in the case of joint surgery. The skin incision is shorter, muscle function returns more quickly and ambulatory aids (cane, walker or crutches) can be discarded sooner.

Blood conservation techniques are employed resulting in less blood loss and a drier wound, which decreases the need for blood transfusions during the surgery.

The surgeon also infiltrates the incision area with medication that results in prolonged pain relief.

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You will meet your anaesthetist either in a pre-assessment clinic in the case of major surgery or on the day of the actual surgery. The anaesthetist will get most of your relevant history from the GP, surgeon or a physician who did the pre-assessment. Some relevant questions will still be asked to enable the anaesthetist to prepare a specific anaesthetic most suited for you. You will be given medication to take which will reduce your anxiety and the intensity of postoperative pain. The anaesthetist will discuss the type of anaesthetic to be used with you.

The most commonly used anaesthetic for hip and knee replacement surgery is a spinal anaesthetic. This has been shown to have the best outcomes. This may sound scary, however all it entails is an injection in the small of your back in which 2 to 3 milliliters of local anaesthetic is injected into the fluid that surrounds the spinal cord. The needle does not go near your spinal cord or your nerves. You will be awake but numbed from the waist down. If you are having a spinal anaesthetic and are anxious about your operation or being awake during it, you may also be offered sedation during the operation. This will keep you calm, take away your anxiety and in most cases allows you to become so relaxed that you fall asleep naturally for the duration of the surgery. During joint replacement surgery, the surgeon will inject a mixture of local anaesthetic and anti inflammatory directly onto your joint just before closing your skin. This has been shown to be very effective in reducing the amount and intensity of pain after the operation. A spinal anaesthetic has been shown to reduce the incidence of blood clots in your calves (DVTs) and is excellent for providing pain relief for up to 4 to 6 hours after surgery (when the most severe pain is usually experienced). Thereafter the 'spinal' block will slowly wear off and when you begin to experience discomfort, it will be at levels that oral pain kllers can more easily address.

To control your pain post operatively, the anaesthetist will prescribe a combination of common oral medication shown to have an enhanced effect when used in combination, without the severe side effects of other pain medication (like nausea, confusion and poor co-ordination). You will be given this pain medication regularly, which usually keeps you comfortable enough to sleep. The anaesthetist will administer an anti-nausea agent to keep the nausea, normally experienced with surgery, at bay. Careful fluid balance will be maintained and this will eliminate the need for urinary catheters and will therefore enable quicker mobilization.

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You will meet your anaesthetist either in a pre-assessment clinic in the case of major surgery or on the day of the actual surgery. The anaesthetist will get most of your relevant history from the GP, surgeon or a physician who did the pre-assessment. Some relevant questions will still be asked to enable the anaesthetist to prepare a specific anaesthetic most suited for you. You will be given medication to take which will reduce your anxiety and the intensity of postoperative pain. The anaesthetist will discuss the type of anaesthetic to be used with you.

The most commonly used anaesthetic for spinal surgery is a general anaesthetic. The anaethetist will administer the anaesthetic agent in a cannular placed in your vein. You will be kept asleep for the duration of the operation either with anaesthetic gasses or intravenous anaesthetic agents. At the end of the procedure the general anaesthetic will be reversed and you will wake up to be in control of all your senses.



To control your pain post operatively, the anaesthetist will prescribe a combination of common oral medication shown to have an enhanced effect when used in combination, without the severe side effects of other pain medication (like nausea, confusion and poor co-ordination). You will be given this pain medication regularly, which usually keeps you comfortable enough to sleep. The anaesthetist will administer an anti-nausea agent to keep the nausea, normally experienced with surgery, at bay. Careful fluid balance will be maintained and this will eliminate the need for urinary catheters and will therefore enable quicker mobilization.

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On the morning of the operation you should not eat anything 6 hrs before your surgery. You are allowed and encouraged to drink clear fluids such as water, black tea, and apple juice (no milk) up until two hours before the surgery. Follow your doctor’s instructions regarding the use of medication in the days leading up to surgery.

For spine and joint surgery you will need closed slippers and pyjamas or tracksuit that you can exercise in.

You will start mobilising on the day of joint surgery as soon as the spinal block has worn off. The physiotherapist will get you going up and down stairs the next day in preparation for discharge.

In spinal surgery, mobilisation may only take place a day after surgery.

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Your post-operative instructions should detail exactly what types of activities you can continue to engage in. These activity restrictions will differ, depending on the location of the surgery. In general, after spinal surgery you should:

• Avoid bending or twisting motions at the level of the surgery.
• Avoid lifting and carrying objects that exceed the weight limitation issued by your surgeon.
• Avoid sexual activity until cleared by your doctor.
• Avoid strenuous activities of any kind (golfing, tennis, home improvement tasks, etc.).
• Walk frequently, to the limit prescribed by your surgeon.
• Wear your brace as instructed.

If you follow all your surgeon’s instructions, you can expect a smooth spinal surgery recovery that relieves your back pain and any previous numbness or tingling. Many people find that spinal surgery restores their quality of life and allows them to resume their previously active lifestyle, once the surgery has healed.

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In general, patients do very well after discharge. However, it’s important that you contact the surgeon if any of these occur:

• You have increasing pain in the operative site.
• There is new or increased redness or warmth since discharge.
• There is new or increased drainage from your incision.
• The operative site is increasingly swollen.
• Your calf becomes swollen, tender, warm or reddened.
• You have a raised temperature for more than 24 hours.
• For total knee replacement, your ability to flex (bend your knee) has decreased or remains the same as when you were discharged from the hospital.

After a joint replacement, swelling is expected. Swelling can cause increased pain and limit your range of motion, so taking steps to reduce the swelling is important. Continue using ice packs or some form of cold therapy to help reduce swelling
Hip. Generally, it is safe to resume sexual activity six weeks after surgery as long as there is not significant pain.
Knee. Sexual activity may resume when you are comfortable

Incision care

Your incision will be covered with a dressing. Before you go home, your surgeon or nurse will explain how to take care of your wound and when to remove your dressing. Make sure you understand these instructions before you leave the hospital and who to contact if you need assistance

Do:

Use your assistive devices for balance as instructed by your surgeon or therapist
Continue your exercise program and increase activity gradually; your goal is to regain strength and function.

Do not:

Sit for longer than 30 to 45 minutes at a time.
Drive before your first post-op visit. The decision to resume driving your vehicle is made by your surgeon.
Lift anything heavy after surgery. Avoid lifting objects in a position where you need to squat or bend. Avoid climbing ladders. Your surgeon will let you know when it is OK to lift heavy objects.

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