Recovering at home after hip or knee replacement

Most people go home within one to three days of a knee replacement, and some go home the same day (AAOS OrthoInfo). That means much of the early recovery happens in the living room, the bathroom and on the stairs, not in a hospital.

The American Academy of Orthopaedic Surgeons puts it plainly for hip replacement: the success of surgery depends largely on how well the patient follows the surgeon's instructions at home during the first few weeks (AAOS OrthoInfo). Three things carry most of that weight: moving safely without a fall, doing the prescribed exercises every day, and catching a problem early.

A little preparation before the patient arrives home removes most of the daily risk. Surgeon-reviewed guidance from AAOS recommends (knee; hip):

• Live on one floor for now. If the bedroom is upstairs, set up a temporary bedroom on the main level to limit stair use.
• Make a recovery station. Keep the phone, medications, water, glasses and the TV remote within easy reach of one firm chair.
• Choose the right chair. Use a stable chair with a firm seat, a firm back and two arms. After a hip replacement, the seat should keep the knees lower than the hips.
• Clear the walking paths. Remove throw rugs and run electrical cords along the walls so the walker has a clear route.
• Equip the bathroom. A raised toilet seat, a shower chair or bench, grab bars and a handheld shower hose make bathing safer.
• Add reaching tools. A reacher, a sock aid, a long-handled shoehorn and a long-handled sponge help avoid deep bending.
• Line up help. Expect to need help with cooking, shopping, bathing and laundry for several days to several weeks.

Ask the hospital team which equipment Medicare or the patient's plan will cover and who will deliver it before discharge day.

A fall in the first weeks can damage a new hip and may lead to another surgery. Stairs are the biggest hazard until strength and balance return (AAOS OrthoInfo). Use the walker, cane or crutches the therapist recommends, hold the handrail, and have someone nearby until balance improves. The surgeon and therapist decide when the device can be put away, not the calendar.

The CDC's Check for Safety checklist is a useful room-by-room walk-through for families:

• Stairs: keep them clear, fix loose steps, and have lights and handrails on both sides.
• Floors: move furniture out of walking paths and pick up shoes, papers and cords.
• Kitchen: keep everyday items about waist high so there is no reaching or step stool.
• Bedroom: put a lamp within reach of the bed and a nightlight on the path to the bathroom.
• Bathroom: use a non-slip mat in the tub or shower and grab bars by the tub and toilet.

When home hazards are likely, CDC's STEADI program suggests an occupational therapist evaluate the home (CDC STEADI coordinated care plan).

Exercise is the core of recovery. For knee replacement, AAOS advises continuing the exercises prescribed by the physical therapist for at least two months after surgery, and notes that walking does not replace them (AAOS OrthoInfo). For hip replacement, most people can resume light daily activities within three to six weeks, and some discomfort with activity and at night is common for several weeks (AAOS OrthoInfo).

A typical home program includes a graduated walking plan that starts indoors, practice with sitting, standing and stairs, and specific exercises several times a day. Some patients who have had a hip replacement are given precautions for sitting, bending and sleeping, usually for about six weeks. These differ by surgical approach, so follow the surgeon's and therapist's instructions rather than general lists found online.

Keep the wound clean and dry. Change the dressing only the way the surgeon instructed, and ask before leaving the hospital how and when to change it and when showering is allowed (AAOS OrthoInfo). After hip replacement, stitches or staples are usually removed about two weeks after surgery, and the wound should stay dry until it has fully sealed (AAOS OrthoInfo).

Some patients with certain risk factors may need antibiotics before dental work after a joint replacement. The surgeon will say whether this applies.

Keep this list on the refrigerator. AAOS advises telling the doctor right away about any of these (knee; hip):

Possible infection

• Fever higher than 100°F that does not go away, or shaking chills
• Increasing redness, tenderness or swelling around the wound
• Drainage from the wound
• Increasing pain both with activity and at rest

Possible blood clot in the leg

• Calf or leg pain that is not related to the incision
• Tenderness or redness of the calf
• New or increasing swelling of the thigh, calf, ankle or foot

Possible clot in the lungs: call 911

• Sudden shortness of breath
• Sudden chest pain, or localized chest pain with coughing

The surgeon may prescribe blood thinners, support stockings, inflatable leg coverings, ankle pump exercises and early walking to lower clot risk. Take blood thinners exactly as prescribed and do not stop them without asking the surgeon.

In most cases it is safe to drive again once the patient is off opioid pain medication and strength and reflexes are closer to normal. The surgeon makes that call (AAOS OrthoInfo). Until then, plan rides to follow-up and therapy appointments.

Many patients recover with outpatient therapy. Others cannot leave home safely yet. Medicare covers home health when a physician or allowed practitioner certifies that the patient is homebound and needs intermittent skilled nursing or therapy under a plan of care (Medicare.gov).

Medicare's Benefit Policy Manual says a patient is homebound when they need a device such as a walker or crutches, special transportation or another person's help to leave home, and leaving home takes a considerable and taxing effort (CMS Benefit Policy Manual, chapter 7, section 30.1.1). One of its examples is a patient just home from surgery whose activity is restricted because of weakness and pain.

The same manual describes skilled services that often fit orthopedic recovery (CMS Benefit Policy Manual, chapter 7, section 40):

• Physical therapy to restore safe walking and stair climbing. Its own example is a patient after total hip replacement who cannot yet climb stairs safely.
• Occupational therapy to teach safe dressing, bathing and toileting with adaptive equipment, for example after a hip fracture.
• Skilled nursing to teach walking with prescribed devices, transfer techniques, wound care and new medications such as blood thinners, and to oversee the plan when other conditions such as diabetes raise the risk of complications.

Coverage depends on the patient's condition and documentation. Medicare Advantage plans may require prior authorization, and Texas Medicaid has its own rules.

An orthopedic referral moves faster when it includes the details the home team needs on the first visit:

• Procedure, side, surgical approach and date
• Weight-bearing status and any hip precautions
• Blood clot prevention plan, including the anticoagulant, dose and duration
• Wound and dressing instructions, and the staple or suture removal date
• Therapy orders, frequency and goals
• Equipment ordered and the supplier
• Follow-up appointment date and the surgeon's contact for questions
• The face-to-face encounter documentation required by 42 CFR 424.22

Send clinical documents by secure fax. Patients keep the right to choose their home health agency (42 CFR 482.43).