Pre-Operative Instructions

Surgery Instructions

Surgery was discussed during your visit with Dr. McCarthy. We realize that you will likely have a lot of questions. This booklet will help answer many of them and, we hope, make this a seamless process. It covers the logistics of your surgery as well as important medical information for before and after your operation. Please read it and keep it handy - it contains useful names, contact numbers, and details about your upcoming surgery. As always, if you have additional questions or concerns, please contact us at any time.

WHAT'S INSIDE

• Your timeline at a glance
• Before surgery
• Medications before surgery
• Anesthesia & equipment
• Recovery equipment
• Insurance & billing FAQ
• Day of surgery
• After surgery
• When to get help
• Your medications after surgery
• Eating & drinking before surgery
• Important phone numbers
• Benefits, alternatives & risks

YOUR TIMELINE AT A GLANCE

Use this checklist to stay on track. Details for each item are on the pages that follow.

BEFORE SURGERY

Location

Surgeries take place at either:

• HSS Main Campus – Main Hospital
  535 East 70th Street
  New York, NY 10021
• HSS ASC of Manhattan
  1233 2nd Avenue (between 64th and 65th St.)
  New York, NY 10065
• HSS Orthopaedics at Stamford Hospital
  Tully Health Center
  32 Strawberry Hill Court
  Stamford, CT 06902

THE CALL BEFORE SURGERY

• You will receive a call from the nursing staff between 2 PM and 7 PM on the day before your scheduled surgery.
• The nurse will tell you what time to arrive at the hospital and what time your surgery is scheduled.
• The nurse will review your medications with you and tell you which medications to take the morning of surgery and which not to take.
• Please see Eating & drinking before surgery for the pre-operative fasting guidelines.
• The surgery schedule is managed exclusively by HSS. We do not manage the surgical schedule and cannot prevent changes or delays. Surgical timing is sometimes unpredictable, and occasionally unforeseen emergencies cause delays. Please understand that we will do our best to streamline your surgical day with the goal of a safe and successful surgery.

MEDICAL TESTING & CLEARANCE

• Your primary care doctor must clear you for surgery by providing a note and test results.
• Medical clearance and laboratory work must be completed no more than 30 days before your scheduled surgery.
• All outside tests and medical clearance notes (labs, chest X-ray report, ECG report) must be faxed to our office at least 3 days before your scheduled surgery. Fax: 203-705-2928.
• If you have sleep apnea, you may be required to stay overnight for observation.
• HSS does not currently require pre-operative COVID-19 testing. If you feel sick before your surgery date and test positive, please contact our office, as your surgery may need to be delayed.

MEDICATIONS BEFORE SURGERY

Please contact your medical doctor before stopping any medication.

HERBAL PRODUCTS & SUPPLEMENTS

Do not take any herbal medications, natural products, or vitamin supplements for at least 10 days before surgery. This includes, but is not limited to: alfalfa, capsicum, celery seed, chamomile, chondroitin, clove, dandelion, dong quai, feverfew, fish oil, flax seed, gamma-linolenic acid, garlic, ginger, ginkgo, ginseng, glucosamine, horseradish, licorice, liver oil, melatonin, onion, papain, papaya, parsley, passionflower, policosanol, poplar, resveratrol, sweet clover, turmeric, and willow bark. Regular multivitamins are OK to continue.

BLOOD THINNERS

This includes, but is not limited to: warfarin (Coumadin), clopidogrel (Plavix), aspirin, heparin, Aggrenox, enoxaparin (Lovenox), rivaroxaban (Xarelto), and the newer blood-thinning medications.

• You must have specific instructions from your prescribing physician sent to us about when to stop the medication before surgery and when to restart it afterward.
• We generally recommend stopping these medications 7 days before surgery and resuming them 2 days after surgery. However, please follow your doctor's recommendations.
• If your doctor has questions, please have them contact the anesthesia department at 212-606-1206.

ESTROGEN-CONTAINING MEDICATIONS

If you take estrogen-containing birth control (pill, patch, or vaginal ring) or oral, transdermal (patch), injectable, or ring estrogen hormone therapy:

• Stop your estrogen medication 4 weeks before surgery, if possible, for lower-extremity procedures (including ACL reconstruction and other surgeries that require limited mobility).
• If your surgery is scheduled in less than 4 weeks, stop the medication as soon as you become aware of your surgery and notify your surgical team.
• Do not stop vaginal estrogen (creams or vaginal inserts). These may be continued before and after surgery.
• You may restart estrogen 2–4 weeks after surgery, depending on your mobility and your surgeon's recommendations.
• If you are unable to stop estrogen before surgery, or must stop it only shortly before surgery, your surgeon may recommend a blood thinner for approximately 1 month after surgery to help reduce the risk of blood clots.
• If you are having a knee arthroscopy (such as a meniscus procedure), the decision to stop estrogen will be made jointly by you and your surgeon based on your individual risk factors.
• If you have questions about stopping your medication or need guidance on alternative contraception while off estrogen-containing birth control, please contact your surgeon or the provider who prescribes your medication.

BIOLOGICS & DMARDS

If you take a DMARD (disease-modifying antirheumatic drug) or a biologic medication, please discuss the timing of your surgery, and when to stop and restart your medication, with both your prescribing provider and our surgical team. The recommendations vary depending on the specific medication and your medical condition.

GLP-1 MEDICATIONS

If you take a GLP-1 medication (such as Ozempic, Wegovy, Mounjaro, or Zepbound), different eating and drinking rules apply - see Eating & drinking before surgery.

ANESTHESIA & EQUIPMENT

ANESTHESIA

• Most surgeries are done with regional anesthesia. This includes a nerve block and some medication to help you relax. You also have the option of general anesthesia. You will meet your anesthesiologist on the day of the operation and will discuss all the possible options.
• You may schedule a meeting with an anesthesiologist before your operation. This is not required. If you would like one, please contact our office and we will help arrange it.

MEDICAL EQUIPMENT

• I may order a brace or sling and an ice machine for you to take home after surgery. The company may call you in the days before the operation to discuss this with you.
• Brace / sling: Coverage depends on your insurance plan and DME (durable medical equipment) coverage. Your brace will be provided by Dr. McCarthy's office or through an outside equipment supplier - Eschen for New York surgeries or Biodynamics for Stamford surgeries - depending on your insurance plan. Depending on your coverage, you may have to pay up front for your brace before surgery.
• Ice machine: Insurance companies do not cover the ice machine. There is a rental or purchase fee depending on the type of machine you choose. We highly recommend the ice machine, as it helps with post-operative pain and swelling. See Recovery equipment on the next page for how to order.
• Home electrical stimulation (NMES) device: If you have been provided with one, see After surgery for how to use it.

PRESCRIPTIONS & INSTRUCTIONS

• I will give you your post-operative instructions on the day of your surgery. Sample post-operative instructions are on my website, moiramccarthy.com.
• I will provide prescriptions for pain medication based on the needs of your specific surgery. See Your medications after surgery.
• If appropriate for your surgery, I will give you a physical therapy prescription on the day of surgery.

RECOVERY EQUIPMENT

Get your recovery equipment before surgery - an ice machine helps reduce pain and swelling after your operation.

At minimum, an ice machine is highly recommended (purchase or rental option). A knee or shoulder bundle is recommended.

• Chosen for you
  Products reviewed by Dr. McCarthy for your recovery

• 1–3 days
  Delivery in 1–3 business days

• Use your HSA
  Not covered by insurance; pay with an HSA account or other method

• Order early
  So you have them right after surgery

HOW TO ORDER FROM THE RECOVERY SHOP

Or scan to order

• Visit the website or scan the QR code
• Review recommended products
• Select products (purchase or rent)
• Check out and pay
• Receive in 1–3 business days

Disclosure: Dr. McCarthy has a financial relationship with The Recovery Shop. Patients may select an alternative vendor. For information, ask the office staff.

INSURANCE & BILLING FAQ

How much is my surgery going to cost?

Your out-of-pocket costs depend on the procedure, your insurance plan and deductible, and whether the provider is in-network with your insurance.

How can I find out the cost of my procedure?

1. Ask our office for your surgical procedure codes.
2. Call the Member Services number on the back of your insurance card and follow the prompts for benefit questions.
3. Give them the specific codes to find out your coverage for the procedure and the anesthesia.
4. Ask if they can provide a cost estimate based on your coverage, and how much of your deductible you must meet for your surgery to be covered.

For estimated hospital costs, you can also call the Insurance Advisory line.

Is there anything else I will be billed for?

After your surgery, you will receive separate bills from:

1. Dr. Moira McCarthy (surgical procedure)
2. Hospital for Special Surgery or Stamford Hospital (operating room time and supplies)
3. Anesthesia (East River Medical Anesthesiology at HSS; Harbor Point Anesthesia at Stamford)
4. The brace company

Do I have to get my own insurance authorization?

No. Authorization for your surgery is obtained by our office staff and billing company.

Will I need a brace, sling, or other DME?

Most surgical cases require a brace or sling at the time of surgery/discharge. This is billed through the DME part of your insurance.

What if I receive a bill I have a question about?

Find out who the bill is from (Dr. McCarthy, the hospital, anesthesia, or the brace company) and follow up with that billing company. Usually the phone number on the bill is the best one to call.

Billing questions about Dr. McCarthy's charges: IV Medical Services · 877-893-5790 or 631-998-3495

DAY OF SURGERY

WHAT TO EXPECT

1. Before your operation: I will meet you in the pre-operative holding area. We will review the procedure, I will answer any remaining questions, and you and I will sign a consent form.
2. In the operating room: Your brace or sling will be applied. It is essential - you must wear it unless I tell you otherwise.
3. After the operation: I will speak to your family members or friends in the waiting area. They will be able to see you once you are settled in the recovery room.
4. In the recovery room: A nurse will care for you, and I will speak with you. You will also meet a physical therapist, who will show you the exercises you are allowed to do and may give you a sheet to take home as a reminder.
5. A few days later: My PA will call you to see how you are doing and answer any questions.

You must have an escort
Please arrange for someone to take you home after surgery. You will not be allowed to leave the hospital alone. You will also need private transportation (car, taxi, etc.) - you will not be allowed to take public transportation home.

ELEVATION

Keep your operated arm or leg elevated as much as possible.

• Knee surgery: place a pillow under your ankle/lower leg to keep the leg straight. Do not put a pillow behind your knee.
• Shoulder surgery: you may want to sleep in a reclined position with your head and shoulder raised to decrease pain and swelling over the first few days.

AFTER SURGERY

ICE MACHINE (COLD THERAPY)

• The ice machine helps decrease pain and swelling. Use it for 20–30 minutes, at least 4 to 6 times a day for the first few days. After that, use it at least 2 to 3 times a day. Use it more often if you continue to have pain and swelling.
• Always place a thin layer of clothing or a towel between your skin and the cooling pad to prevent frostbite or skin injury.
• NICE® machine: this machine provides cold therapy and compression. You may begin using the compression setting 1 week after surgery, unless your surgeon directs otherwise.
• Follow the manufacturer's instructions for proper use and wear time.
• Check your skin regularly. If you notice excessive redness, numbness, blistering, or skin irritation, stop using the device and contact our office.

HOME ELECTRICAL STIMULATION (NMES) DEVICE

If you were given a home neuromuscular electrical stimulation (NMES) device, begin using it after surgery as directed. Its goal is to help activate your quadriceps muscle, reduce muscle weakness, and support your recovery.

• Use it for about 20 minutes per session, 2–3 sessions per day, or as instructed by your surgeon or physical therapist.
• If you have questions about how to use it, please contact our office or your physical therapist.

WOUND CARE

• If you have a large bandage such as an ACE wrap, remove it after 48 hours. There will be smaller bandages over all your incisions. If these are clean and dry, you may leave them on until your first post-operative appointment. If they become soiled or wet, remove them and pat the area dry.
• Leave the Steri-Strips (small white tapes) on all incisions - even if they are wet or bloody.
• Do not apply any cream or ointment (including bacitracin, Neosporin, Mederma, or anything else) to the incisions at this time.
• Keep the incisions clean and dry until 2 days after the stitches are removed in my office.
• Some bleeding or fluid leakage from the incisions is normal after this type of surgery and may continue for 24–48 hours. You may change and/or reinforce the bandages as needed.

SHOWERING

• You may shower after 48 hours, as long as the incisions stay clean and dry and you are steady enough to get in and out of the shower. Place water proof dressings over all incisions to keep them dry.
• Shoulder surgery: you may remove the sling to shower.
• Knee surgery: wrap your knee in plastic wrap and secure it with tape around your thigh. Then put the brace on and cover it with a cast bag (available at your local drug store) or a garbage bag with a hole cut in the bottom for your foot. Secure it with tape around the thigh and ankle. If you had knee surgery that requires a brace, you must wear the brace when showering for at least the first 2 weeks.
• If the stitches get wet, pat them dry.

BRACES, SLINGS & EXERCISES

• Use any assistive devices (sling, brace, crutches) as instructed. Do not decide on your own to remove a brace or sling - this may negatively affect the outcome of your surgery. If you have questions, please call the office.
• Do your post-operative exercises. If you were given a physical therapy prescription, set up your appointment and begin therapy. If not, do only the exercises taught to you by the therapist.

WHAT'S NORMAL

RETURNING TO WORK OR SCHOOL

• You may return to work or school in the next few days after surgery, when you feel up to it. Surgery often makes you tired for days to weeks, and everyone is different. You may need to start slowly and gradually build up your time away from home.
• At school you may need extra time, an elevator pass, room to elevate your leg or arm, and additional help. I can provide a note for work or school if you need one.

Follow-up: Make sure you have an appointment to see me 10–14 days after surgery. Call the office with any questions: 646-714-6360 (New York) or 203-705-0900 (Stamford).

CONSTIPATION

Pain medication may make you constipated. Try the following, in this order:

A. Take Colace (stool softener).

B. Decrease the amount of narcotic pain medication you are taking.

C. Stay well hydrated. Drink decaffeinated fluids.

D. Drink prune juice.

E. Take Senokot (over-the-counter laxative).

F. Take MiraLAX (stronger over-the-counter laxative).

G. If none of these has helped, or if you have significant abdominal pain and/or uncontrolled nausea or vomiting, call the office.

WHEN TO GET HELP

BLOOD CLOTS

• Orthopaedic surgery patients are at risk for blood clots, especially after lower-extremity surgery. Please tell me, your medical doctor, or anesthesia if you or someone in your family has a history of blood clots anywhere in the body, or any type of clotting or bleeding disorder.
• Obesity and use of oral contraceptives can increase the risk of blood clots. Women should not take oral contraceptives while immobile after surgery (see Estrogen-containing medications).
• Travel after surgery, such as long flights or car trips, may also increase the risk. If you are traveling within 3 months of your surgery, please notify my office for advice about aspirin or other medication.
• Signs of a blood clot may include calf pain or cramping, swelling throughout the leg and foot, chest pain, coughing, or shortness of breath. Call the office immediately if you notice any of these. If the symptoms are severe, call 911 and go to the nearest emergency room.

YOUR MEDICATIONS AFTER SURGERY

You will be given prescriptions for a narcotic pain medication, Tylenol, an anti-inflammatory (naproxen or meloxicam), and an anti-nausea medication. We suggest taking the pain medication the first night before bed, to ease pain when the nerve block wears off. Avoid taking pain medication on an empty stomach, as it can make you nauseous. Otherwise, use the narcotic pain medication only as needed. Take the anti-inflammatory daily, as prescribed, to reduce swelling and pain.

Do not drink alcohol or take illicit drugs while taking pain medication, especially narcotics. This may cause serious or possibly fatal side effects.

PAIN MEDICATION

Usually this will be oxycodone, Tylenol, or Norco. Oxycodone and Norco contain narcotics, which are powerful pain medications. You will need them in the days after surgery, and you will find you can take fewer pills after the first few days. Narcotic pain medications cause constipation, so stay well hydrated and take a stool softener.

Norco also contains Tylenol. There is a maximum daily limit of 3 g (3,000 mg) of Tylenol per day, so take only the prescribed amount of these pills. Do not take regular Tylenol while you are taking Norco.

ANTI-INFLAMMATORY

You will be prescribed either naproxen or meloxicam - not both. Follow the instructions for the one on your prescription label, and never take them together.

This medication is essential to help with pain, swelling, and inflammation from surgery. Take it as prescribed. It can affect your stomach, so take it with food, and stop taking it if you develop stomach pain or any concerning GI issues.

BABY ASPIRIN (TO PREVENT BLOOD CLOTS)

Aspirin is an anticoagulant that helps prevent blood clots (DVT). If you have significant symptoms concerning for a blood clot (increased swelling, pain, fever), please call the office. Like naproxen, aspirin can cause stomach problems. If you develop stomach issues, stop taking it and call the office.

Aspirin 81 mg tablet Take 1 tablet with food once a day.

ANTI-NAUSEA MEDICATION

Take this only if you are nauseous after surgery, and only as directed.

Zofran 4 mg
orally dissolving tablet Take 1 tablet every 6 hours as needed for nausea/vomiting.

STOOL SOFTENER

Take this to prevent constipation, for as long as you are taking narcotic pain medication or if you need it, and stay well hydrated. If you are still constipated, see Constipation in the After Surgery section.

Colace 100 mg tablet Take 1 tablet three times a day.

EATING & DRINKING BEFORE SURGERY

These guidelines are for general purposes only. Your physician or surgeon may require you to follow a different plan - if so, follow your physician's instructions. Your medical clearance provider may also adjust your fasting guidelines for the day of surgery.

Do you take a GLP-1 medication? This includes, but is not limited to: Trulicity (dulaglutide); Byetta, Bydureon (exenatide); Saxenda, Victoza (liraglutide); Adlyxin (lixisenatide); Ozempic, Wegovy, Rybelsus (semaglutide); Mounjaro, Zepbound (tirzepatide); Xultophy (insulin degludec and liraglutide); and Soliqua (insulin glargine and lixisenatide). If so, follow the right-hand column. If you take Xultophy or Soliqua, contact your endocrinologist or provider in case your insulin needs to be adjusted.

CLEAR FLUIDS

IMPORTANT PHONE NUMBERS

HSS – HOSPITAL FOR SPECIAL SURGERY

STAMFORD HOSPITAL (TULLY CENTER)

BENEFITS, ALTERNATIVES & RISKS OF SURGERY

POTENTIAL BENEFITS

While every person is different, and every person responds to surgery differently, the surgery you agreed to is intended to improve your pre-operative symptoms and/or limitation in function.

ALTERNATIVES TO SURGERY

This surgery is elective. The alternatives include, but are not limited to: pain management; anti-inflammatory medications; injection therapy; physical therapy; acupuncture; and other non-surgical treatments.

SURGICAL RISKS

Infection: Infection can occur after any surgery despite the highest level of precaution. Superficial infections (on the skin) or deep infections (within the joint) may occur. A skin infection is generally treated with oral antibiotics. If you develop a deep infection, you may need additional surgery and prolonged oral and/or IV antibiotics.

Blood clot: Deep vein thrombosis (blood clot) is unusual but can occur in some patients after this type of surgery.

Ligament injury: To allow visualization under anesthesia, the ligaments may be released to allow better visualization and to prevent cartilage damage. If necessary, this generally heals uneventfully and does not require additional surgery or treatment.

Nerve injury: Injury to nerves can occur during surgery. Some skin nerves will be cut just by making an incision in the skin. Small patches of numbness around the incisions are generally tolerated well by most patients, but some develop pain in addition to numbness. Some nerves can get stretched or injured during the surgery. Most neurapraxias (nerve injuries) are temporary and resolve, although permanent injury to the nerve can occur. Because nerves involve sensation as well as muscle power, nerve injury can produce numbness in the treated limb as well as weakness or paralysis.

Pain: Pain is often improved from pre-operative levels. However, pain can persist and may continue for many months.

CRPS (complex regional pain syndrome): In rare instances, patients may develop severe burning pain with changes in the skin without an obvious cause that would explain the pain. This is classified as a pain syndrome and is thought to be an abnormal response to the trauma of surgery. The incidence of CRPS is unpredictable, and it can result from any trauma, including surgery. Patients subsequently require pain management services by a pain management physician.

Opioid management: While we do our best to control pain while minimizing exposure to opioid pain medications, your surgery may require their use. Even at low doses, these medicines have risks, including the risk of addiction.

Swelling: Prolonged swelling can persist for a period of time following surgery.

Stiffness: Stiffness can persist due to scarring from the injury or the surgery.

Hardware/graft failure: If your surgeon has used plate(s), screw(s), or other implants, you may later require surgical removal of the hardware due to factors including pain, loosening, and/or wearing away of the hardware.

Recurrence / need for re-operation: The condition for which you had surgery may return. There is always a chance of failure with any type of surgery.