in San Francisco. Today I'm recording an Anna Toolkit lecture for hip arthroscopy, especially in relations to post-op instructions and restrictions. In terms of hip arthroscopy, it is very important for the patients to understand the surgery and compliance with post-operative restrictions in order for the surgery to be successful. I think it's very important to communicate instructions and restrictions to the patients before the actual surgery. And then also to review it after the surgery as well. So even though this lecture has to do with post-operative instructions, I'm gonna really talk about why it's important to give this information to patients even before the actual surgery. So in my practice, we'll send a patient instruction packet to patients on information about pre-surgery preparation, including their medications, physical therapy, MPO status, what to do on the day of the surgery, and then also post-op surgery instructions such as restrictions, post-op exercises, and how to find us if there's any emergencies. So this is what we send out to patients. We'll email this out to them about two weeks before surgery, ideally, so they have some time to look over it. But it's three pages, really two pages. The third one is just showing them some diagrams of how to do their exercises. But we'll have a section on what to do prior to surgery, what to do on the day of the surgery, and then expectations and what to do post-operatively. So we'll go through each of these sections in detail. In terms of the pre-surgery instructions, I talk about the medications. So I discussed this in a separate and a toolkit lecture specifically about what medications I prescribe and how to use those. But I will send the medications to the patient's pharmacy before the surgery so that they'll actually have a chance to pick it up before the surgery itself versus finishing the surgery and then trying to go to the pharmacy afterwards and picking that up. And so it's a lot easier for them to get it beforehand. And I'll also give them their physical therapy referral before the surgery itself as well. So we'll send this to the patients at least a week before the surgery so they can have some time to start setting up their post-operative PT appointments. Around here, those can be kind of hard to get into. So a lot of patients need to set up their post-operative PT well in advance. If they're trying to find a PT appointment after they've already had the surgery, it's gonna be hard for them to get in within seven days of their surgery, which is what we prefer. We'll also talk about MPO. So definitely no food after midnight the night before. But if a patient has a surgery later on in the afternoon, we'll allow them to have some sips of clear liquid up to four hours before surgery. So check with your anesthesia team and your surgery center on specific protocols for that. But typically, very minor sips of clear liquid is okay. In terms of the surgery day instructions, we'll tell the patients when to arrive in terms of their scheduled time. But we'll also ask them to arrive at least two hours early before the surgery for preparation. And we'll give them instructions on wearing loose-fitting clothing. They kind of ask about that. Any piercings and jewelry that are in specific areas that may need to be removed, we'll tell them to take those out ahead of time. Use glasses instead of contacts. So these are kind of little things, but they do help with the surgery day preparation and making sure all of our cases are moving along quickly if the patients are on top of all of these tasks before they get here. And of course, you wanna make sure the patients have a ride home after the surgery. We tell patients we can't just let them get into a taxi or an Uber afterwards. They need to have somebody take them home. Post-surgery instructions, there's some things to consider here. One is what you wanna do with the surgical dressing. So some surgeons will allow patients to take off their surgical dressings after three days. Usually, there'll be steri-strips. Depends on how you wanna close the hip portals. I tend to use buried monocle sutures so we don't have to take any stitches out and then steri-strips over it. You could also just use like simple nylon sutures on the skin and take those out a week later. But if they're steri-strips, sometimes we'll let the patients take the outer dressing off but keep the steri-strip on. After three days, the dermal layer should be closed so it should be less risk for bleeding and infection. But sometimes to be safe, we'll actually just tell the patients not to mess with their dressings. Don't take it off until the post-operative visit. Now, I see my patients about one week after the surgery. So that's not a big issue because then we could just take it off one week later. But some practices, if you're not seeing the patient for two weeks or maybe not until their four-week check or something, then you probably want them to take the dressings off themselves earlier on. In terms of bathing, I ask the patients to keep the dressings dry for that first week. So if they shower, sometimes they can put like an extra layer of protective covering like saran wrap over the hip area just to make sure water doesn't get in there. But I do use Tegaderm dressing as shown here. You can get these out on Amazon. This is where I found that picture. So patients can get that and reinforce their dressings as needed. Or technically it should be waterproof but you wanna make sure just to be safe, water doesn't kind of get underneath like an edge or something. So I usually tell them to kind of reinforce it or cover it with saran wrap if they wanna shower. But then once the dressings come off, they can get the incision wet, whether that's at seven days or a little bit earlier. So some physicians are okay with them getting the dressings wet as soon as three days afterwards. But definitely don't submerge the incision in like a swimming pool or bathtub for at least four weeks until it's fully healed. Okay. Other instructions that are important to consider are a weight bearing status and crutch use. So there's quite a wide variation of protocols for this based on the surgeon. I've seen some surgeons let their patients be weight bearing as tolerated post-op day one. And then other surgeons have their patients be non-weight bearing for four weeks for a regular hip scope, labral repair, osteoplasty. So all things considered for a regular or routine hip arthroscopy, not like a labral reconstruction or anything that may have slower healing, there's still a wide variation in the weight bearing status. I tend to recommend foot flat touchdown weight bearing for my patients, especially if you're considering that over toe touch weight bearing. Toe touch weight bearing, if they're just putting their toe down and their heel is up, it tends to actually stress the hip flexor and that can actually cause more pain anteriorly. So if the patient is able to put their heel down and foot flat, it kind of offloads the hip flexor a little bit more. So if you wanna restrict their weight bearing a little bit, I do recommend foot flat touchdown weight bearing, like the weight of the foot, weight of the leg on it at most. But if you wanna protect them from full weight bearing, that's what I would recommend. You can also determine if you wanna use a post-operative hip brace or no brace. This is a surgeon preference and it can also be related to what you do with the hip capsule. If you're making a big capsulotomy and then closing that up, you wanna likely immobilize them in a hip brace so they don't stretch out or rupture the capsule repair. If you're doing more conservative capsule preservation techniques or capsulotomy techniques without cutting much of the capsule or cutting the iliofemoral ligament, then you may not need a hip brace for that. And then in terms of crutch use and brace use, that can be anywhere from one week and I've seen up to three weeks or four weeks for some surgeons. Okay, in terms of range of motion, most surgeons will limit hip extension to less than 10 degrees because you don't wanna stretch out the anterior capsule and also irritate the hip flexor if you do too much hip extension. Similarly, you don't wanna do too much hip flexion right off the bat because there's gonna be a lot of post-operative effusion and hip flexion can cause pain and that'll also put some stress on your labral repair if you're doing a maximum flexion. So some surgeons will limit hip flexion to less than 90 degrees. I tell them less than 100 now, I've kind of stretched out to less than 110 just so they can sit comfortably on the toilet or any other couch. You can probably let them go up to 100, 110 without too much issue. In terms of the range of motion exercises, you can consider using a CPM machine which some surgeons use. Some surgeons will have patients on an upright stationary bike post-op day one or post-op day zero. I've seen some literature on that to be safe as well. And then you can also just have them do heel slides if you wanna be a little bit more conservative with their protocol. So here, these are the exercises we have our patients do starting post-op day one. We'll have them do quad sets just to activate the quads, heel slides for range of motion and have them do this up to 90 degrees as tolerated, knee extension just so they're not developing any type of contractures. And then of course, calf pumps just for DVT prophylaxis so they're distally moving their muscles. In terms of driving, though, patients also typically ask you about that. So I tell them you have to be fully off opioids and you really shouldn't drive when you're on, if you're using crutches still, especially if it's your right leg, that's gonna be a little bit harder operating the pedals. So usually they can start driving once they're off the crutches, which for me is about two weeks after surgery. And then you wanna make sure they know how to contact you or your office or whoever's on call if there's any red flags like fevers, chills, drainage, like uncontrolled pain or any falls after the surgery. So in my practice, we'll send all these instructions out two weeks before the surgery so the patient can review it. I like to do a video appointment for a pre-op session with my patients about a one week before the surgery. This is sometimes like a very quick five minute check-in. Sometimes they have a lot of questions and it could take a little bit longer, but I think it's very helpful for the patients to have that quick check-in at least before the surgery, just to kind of go over some of these details. So if you have time in your practice, you can carve that out. You can also have your PA do a pre-op appointment with your patients as well, because these are pretty routine things usually that they ask. But during the session, I'll prescribe them their medications and send that to their pharmacy. I'll put in their PT referral and send that to them so they could pick that, get that ready before the surgery itself. And this is where I also go through a surgical consent. You should ideally go through a surgical consent before the surgery instead of on the morning of the surgery. So we'll do all that during the pre-op video appointment. And then before the patients go home, we'll also review their post-op instructions in the recovery room with the patient and their caretaker, whoever's taking them home before their discharge. And those post-op instructions should match the pre-op ones. You want to make sure you don't have conflicting things unless you had to change something during the surgery, but it's good to just kind of bring that home and reiterate the same things after the actual surgery itself too. So here are my personal post-op instructions for the patients. I have my patients foot flat, touchdown weight bearing for two weeks with crutches. If the patients are doing well at their one week post-op check, I'll let them start to weight bear without crutches for short distances indoors. And then at two weeks, they can fully come off crutches even when outdoors at that point. And then I don't use a brace or a CPM machine. I use the Periportal Capsulotomy for my hip arthroscopy so we're not cutting the iliofemoral ligaments. So it's been very safe without using a brace with that surgical technique. I have them start post-op exercises on post-op day one. I have them start PT within five to 10 days after surgery so they can start working on some of the other exercises with their physical therapists. I see them one week after the surgery and then I have them keep the dressings on until that first post-op check. All right, that's it for this lecture. Thanks everybody.

hip arthroscopy

pre-operative instructions

post-operative care

weight-bearing protocols

patient communication