Advanced Surgical Techniques

• Hip replacement is one of the most successful surgeries in modern times, often dubbed the "operation of the century"
• Anterior (direct anterior) approach is the only truly intermuscular (muscle-sparing) and internervous approach
• CCO surgeons are pioneers in this approach with a combined 50+ years of experience
• By preserving all muscles and tendons: quick recovery, rapid return of normal gait, much lower dislocation rate (no precautions necessary), low blood loss, no permanent muscle or tendon damage
• Excellent component positioning with live intra-operative fluoroscopy (X-ray)
• Primarily performed in an outpatient setting with same-day discharge
• Most often done under spinal anesthetic with sedation; surgery time approximately one hour
• Patients bear weight as tolerated and are often off walking aids within a week
• Small 3–4-inch incision over the front of the hip — vertical or horizontal (Bikini incision)
• Used for all primary hip replacements and the vast majority of revision hip replacements
• Patients who previously had traditional posterior/lateral approaches universally report the anterior approach provides an easier, less painful, and quicker recovery

• Aims to restore a patient's pre-arthritic (native) alignment, joint lines, and knee kinematics
• Accounts for three functional axes of the knee: flexion-extension, internal-external rotation, and varus-valgus
• Recreates the patient's natural knee motion and soft tissue balance for a more "forgotten" feel
• Bone resections resurface the femur and tibia while maintaining constitutional varus or valgus
• Tibial cut follows native slope; femoral cuts parallel the natural joint line obliquity
• Emphasizes ligament sparing — balance achieved through precise bone cuts, not soft tissue releases
• Patient-specific guides, navigation, or robotic-assisted systems often used for increased accuracy
• Advantages: improved range of motion, less pain, higher patient satisfaction, fewer soft tissue releases, better restoration of native joint line
• Limitations: less long-term survivorship data vs. mechanical alignment; technically demanding, often requires advanced instrumentation or robotics

• Advances include implantation techniques, implant design, alignment principles, bearing surface longevity, and pain management/anesthesia
• Uses preoperative CT imaging and advanced 3-D computer planning to custom size and position implants
• Restores pre-arthritic anatomy and alignment using kinematic alignment principles
• Custom models and cutting guides created using 3-D printing technology
• CCO surgeons have extensive robotic-assisted experience but prefer PSI as a more accurate and less invasive approach
• May include: MyKnee or Prophecy personalized knee solutions, medial stabilized implant design, kinematic alignment, vitamin E–infused highly cross-linked polyethylene bearings
• Surgery performed in an outpatient setting
• CCO surgeons currently serve on the design team for an augmented reality application for total knee replacement and are members of an International Advisory Team for robotic Total Knee Arthroplasty and future development

• Also called "medial stabilized" — designed to replicate how a healthy knee naturally moves
• In a normal knee, the medial (inner) side acts as a stable pivot while the lateral (outer) side allows more motion
• Patients report a more stable, "natural-feeling" knee during walking, climbing stairs, and standing from seated
• Enhanced medial stability reduces the sensation of the knee shifting or giving way
• Guided, controlled motion pattern may reduce implant wear and support long-term durability
• Promotes consistent motion early in rehabilitation — physical therapy exercises feel more intuitive
• Supports a wide range of activities from daily tasks to recreational pursuits such as cycling or golf
• Goal: reliable stability, smooth motion, and lasting comfort so patients can focus on an active, independent lifestyle

• Combines the surgeon's expertise with computer-guided technology for improved precision and personalization
• Detailed pre-operative imaging and planning software map the patient's unique bone structure and joint alignment
• Robotic system provides real-time feedback and guidance while the surgeon maintains full control
• More accurate implant alignment and sizing — may improve knee mechanics and overall comfort
• Enhanced precision assists with ligament balancing for a more stable, natural-feeling knee
• Limits unnecessary bone removal and reduces soft tissue disruption — less pain, decreased swelling, more predictable recovery
• Real-time data allows fine adjustments during surgery rather than relying solely on visual estimation
• Especially helpful in knees with complex anatomy or significant deformity
• Goal: enhance accuracy, protect healthy tissue, and deliver reliable results for long-term comfort and mobility

• Pain, nausea, and recovery protocol questions are the most anxiety-producing parts of joint replacement for most patients
• All CCO surgeons use the most advanced techniques for pain/nausea control before, during, and after your procedure
• Minimizing swelling is paramount — our advanced techniques and combined experience help at every step
• This outline describes an evidence-based rapid recovery protocol incorporating nerve blocks, limb elevation, reduced initial activity, cooling/compression, and anti-swelling medications

Rapid Recovery Protocol

• Aims to reduce inflammation, complications, and accelerate return to function while managing pain and swelling
• Individual plans customized by your CCO provider based on age, comorbidities, and surgical specifics
• Hip and knee recovery share many similarities; Total Knee Arthroplasty recovery is typically more involved
• Any specific guidance from your surgeon always takes precedence

Pre-Operative Preparation (1–2 Weeks Before Surgery)

• Patient education: expectations, pain management, home setup; emphasis on multimodal strategies to reduce opioid reliance
• Maintain light activity to optimize pre-op ROM; focus on quad strengthening; avoid high-impact exercises
• In preparation for your surgery, it is important to eat well, stay hydrated and get appropriate rest. There are many peri-operative nutritional programs that CCO surgeons have used and helped formulate. If you are interested please discuss with your surgical team

Pre-Operative/Intra-operative (Day of Surgery)

• Pre-emptive nerve blocks (e.g., adductor canal, femoral nerve, IPACK) administered by CCO anesthesia partners
• Anti-swelling medications started (e.g., Celebrex, Diosmin) — tailored to your medical history
• Spinal anesthesia is the gold standard — safer, more effective and efficient than general anesthesia; sedation added so you are not aware during surgery
• Intra-articular injections placed directly into the joint during surgery — all modalities work synergistically for the most comfortable recovery

Immediate Post-Operative Phase (Day 0–1)

• Regional anesthesia provides relief for up to 48 hours; transition to multimodal oral/IV meds to minimize opioid use
• Limb Elevation: Try to keep your limb elevated through the day when you are not ambulating. For Total Knee Arthroplasty patients, do not place pillows behind your knee in the recovery period
• Reduced Activity: In the early phase of recovery we want to allow your joint time to rest and to keep inflammation as low as possible. To do so, we recommend using assistive devices as directed by your team and PT, limiting steps to <700/day and reasonable distances per walk. Weight bearing as tolerated is typical unless otherwise directed
• Cooling and compression: continuous cryotherapy (Game Ready or ice packs) for 72 hours or 15–20 minutes every 2–3 hours; compression wraps/stockings should be worn as much as you can
• Anti-swelling medications: IV NSAIDs (e.g., ketorolac) or continue pre-op meds; monitor for GI side effects
• Key goals: pain <3/10, initial ROM 0–80° flexion, quad activation, independent transfers for potential same-day discharge

Early Recovery Phase (Days 2–7: Home or Rehab)

• Remove continuous nerve block catheters by Day 3–4 if used; continue multimodal regimen, tapering opioids
• Limb elevation: 40 minutes hourly while awake, or 4–6 hours daily
• Reduced activity: essential mobility only; avoid prolonged standing/sitting (>30 min); progress from walker to cane; rest breaks every 30 minutes
• Cooling and compression: ice packs 40 minutes hourly (protect skin); compression wraps during non-elevated periods
• Anti-swelling meds: continue NSAIDs or Diosmin for 6–8 weeks; combine with TXA if given intra-operatively
• PT 1–2×/week: ROM exercises (heel slides, quad sets), gait training, edema massage; neuromuscular electrical stimulation if needed
• Key goals: reduce swelling, ROM 0–100° flexion, independent ambulation 100–800 feet, wean assistive device

Intermediate Recovery Phase (Weeks 2–6)

• Fully transition to non-opioid meds; as-needed analgesics only
• Limb elevation: 40 minutes hourly or as needed, reducing frequency as edema improves
• Gradually increase low-impact activities (e.g., stationary bike by Week 2–4); avoid twisting/pivoting/high-impact until Week 12
• Ice 1–3 times daily post-activity or PT (20 min on/off); compression during ambulation
• Continue NSAIDs or Diosmin; monitor for swelling resolution
• PT 2–3×/week: closed-chain exercises (step-ups, lunges), balance training, pool therapy (if incisions healed by Week 4), soft tissue mobilization
• Key goals: ROM 0–120° flexion, walk without limp, return to light ADLs (driving by Week 4–6 if off opioids)

Advanced Recovery Phase (Weeks 7–12 and Beyond)

• Minimal meds; focus on activity-based relief
• Limb elevation as needed for flare-ups
• Transition to moderate activity; avoid high-impact until 3–6 months; build endurance (walking, cycling)
• Cooling/compression post-exercise if swelling recurs
• Taper anti-swelling meds by Week 8 unless chronic issues
• PT as needed: advance to resistance training, sport-specific drills; return to work/recreation by Week 6–12
• Key goals: full ROM (0–115°+), no swelling, return to normal activities with 90–95% function by 3 months

Monitoring and Precautions

• Track swelling, pain, and ROM daily; contact provider for signs of infection, DVT, or excessive swelling
• High-protein diet with vitamins (C, D) to support healing
• Expected outcomes: reduced hospital stays, faster ROM gains, high satisfaction with proper adherence

You will likely be prescribed medication post-operatively. These meds are utilized to reduce inflammation/swelling, control pain, minimize bleeding and lower risk of DVT after surgery. Medications that are prescribed or recommended by your surgeon, will have dosing and duration tailored to your health profile (e.g., kidney function, stomach history, bleeding risk). The recommendations below are based on common orthopedic practices and ERAS (Enhanced Recovery After Surgery) guidelines, which all CCO surgeons employ. Consult your surgeon or orthopedic team for a personalized regimen, as protocols vary by institution and patient factors. Non-medication measures (ice, elevation, compression) remain essential alongside drugs. Always follow your doctor's specific instructions. We are here to answer any questions.

Reduce Inflammation and Swelling

These primarily target prostaglandin-mediated inflammation and are a cornerstone of rapid recovery protocols

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) — Most common and effective for post-op inflammation and swelling

Celecoxib (Celebrex) — COX-2 selective; often preferred (e.g., 200 mg daily for 30 days) due to lower GI bleeding risk

Meloxicam (Mobic) — 7.5–15 mg daily for 4–6 weeks; widely used for swelling and pain

Ibuprofen (Advil, Motrin) — OTC or prescription; 400–600 mg every 6–8 hours as needed

Naproxen (Aleve) — Longer-acting OTC option

Diclofenac (Voltaren) — Oral or topical

Ketorolac (Toradol) — Short-term IV or oral for early post-op

Note: NSAIDs reduce swelling at the source but may increase bleeding risk or cause stomach upset; often combined with a stomach protector (e.g., omeprazole) and avoided if on strong blood thinners

Reduce Bleeding and Blood Loss

These minimize intraoperative/postoperative blood loss, hematoma formation, and transfusion needs

Tranexamic Acid (TXA, Lysteda, Cyklokapron) — Antifibrinolytic; highly effective in ERAS protocols

IV — Given intraoperatively (1–2 g) to reduce bleeding. This is administered by anesthesia during your procedure

Oral — Extended postoperative use (e.g., 1 g multiple times daily for days) reduces swelling, pain, and blood loss; emerging evidence supports multi-dose regimens

Blood Thinners

There are many options used by CCO to minimize your risk for blood clotting. Please follow directions as prescribed

Low-Dose Aspirin — Often used for VTE prophylaxis; at 81 mg twice daily, it has mild anti-inflammatory effects but primarily prevents clots without significant side effects

Blood Thinners for VTE Prevention (e.g., rivaroxaban/Xarelto, apixaban/Eliquis, enoxaparin/Lovenox) — Prevent clots but do not directly reduce surgical bleeding. These are used in select patients

Supportive or Complementary Medications

Acetaminophen (Tylenol) — Not anti-inflammatory but reduces pain and is safe with NSAIDs for multimodal control (up to 3–4 g/day)

Bowel regime to minimize constipation issues. This not only includes meds but also hydration and dietary selection

Important Notes

Combination Therapy — NSAIDs + acetaminophen + non-medication strategies (elevation, ice/compression, early mobility) work best for swelling and inflammation

Bleeding Risk — NSAIDs and TXA are generally safe in modern protocols, but avoid extra NSAIDs if on full-dose anticoagulants

Contraindications — NSAIDs may be avoided in kidney disease, GI ulcer history, or heart issues; TXA is contraindicated in active clot or certain thrombotic conditions

Duration — Anti-inflammatories often used for 2–6 weeks; TXA for days to weeks in some protocols

If at any time you have questions or concerns or are unclear about your discharge medications, please contact your CCO surgical team directly.