Surgical Services at Cayuga Medical Center. Patient Name: Surgery Date: 101 Dates Drive 10 Arrowood Drive. Ithaca, NY Ithaca, NY 14850

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1 Surgical Services at Cayuga Medical Center Patient Name: Surgery Date: Locations: Cayuga Medical Center Surgical Services Department Surgicare Convenient Care Center 101 Dates Drive 10 Arrowood Drive Ithaca, NY Ithaca, NY (607) (607) Pre Admission Interview Your surgeon has scheduled you for surgery at Cayuga Medical Center. You have also been scheduled for a Pre Admission testing interview. Some patients will be required to come in for this appointment while other patients may be able to have their interview over the phone. If you are required to come in for the interview, please complete the Anesthesia Questionnaire, Latex questionnaire, and medication list at the back of this booklet prior to your interview. Plan to spend approximately minutes reviewing the information with the Pre Admission nurse. You may also have blood work or additional studies, as ordered by your surgeon at this time. If you have any questions or concerns, please call the Pre Admission Department at (607)

2 Preoperative Instructions You will receive a telephone call from a pre operative nurse the afternoon prior to surgery with pre operative instructions from your anesthesiologist (Monday surgery will receive telephone call on Friday). Follow ALL eating, drinking, medication and arrival time instructions provided. Please follow these instructions or your surgery may be delayed or cancelled. Arrival Time: Your arrival time will be given to you the day prior to surgery. You will be advised to arrive approximately 1&1/2 hours prior to your scheduled surgery time. Diet: Specific times to stop eating and drinking will be given to you the day prior to surgery. NOTE: Clear liquids include water, clear juices, broth, plain popsicles, Gatorade, plain Jell-O. This does NOT include dairy products or juices with pulp. Please avoid red colored fluids and popsicles when possible. It is recommended that consumption of alcohol be avoided 24 hours prior to and following surgery. Do NOT chew gum or eat hard candy/mints. Medications: Please bring a list of your current medications, including herbals and supplements, with date and time last taken. If you use an inhaler, bring it with you the day of surgery. The nurse will review with you which medications you should and should not take prior to surgery. General Instructions: You may NOT drive yourself home after surgery. Please make arrangements for a responsible adult to drive you home after surgery. Notify your surgeon if there is a change in your physical condition. Leave all jewelry, money and valuables at home. (remove ALL jewelry and body piercings) Take a bath /shower and brush your teeth prior to arrival. Wear loose comfortable clothing. Do not wear makeup or nail polish the day of surgery.

3 Remove contact lenses prior to arrival. Bring glasses and case. Wear your dentures and hearing aids. Bring your CPAP machine if you use one. No smoking or use of tobacco products 24 hours prior to surgery. Use of tobacco products is prohibited on all Cayuga Medical Center properties. Bring photo identification and insurance cards. Bring a copy of your Health Care Proxy or MOLST form if you have one. Day of Surgery General Instructions: It is important that you arrive on time. If there is a delay with your procedure time we will call you at home to minimize the time you will need to wait. We ask that no more than 2 people stay with you before and after surgery. You will be asked by multiple people to verify your name, birth date and procedure that you are having. This is an important safety measure. You will be required to sign multiple consents, including surgery and anesthesia consents. Pre Operative Phase You may be asked to change into a hospital gown. The gown may be a warming gown meant to keep you more comfortable during your stay. Your pre operative nurse will instruct you how to control the temperature. Your pre operative nurse will perform a physical assessment, including height, weight and vital signs. He/she will review your medications and health status. He/she will start an IV to provide a means of administering fluids and medications throughout your surgical stay. Your surgeon will review your procedure with you. He/she will review your recent health status. Depending on the type of surgery he/she may place his/her initials on the operative site or you may be given a bracelet to wear indicating the procedure.

4 Your anesthesiologist will review your chart and meet with you. He/she will review the anesthetic options and have you sign the anesthesia consent. Depending on the type of anesthesia agreed upon, the anesthesiologist may also initial the anesthetic site. Types of Anesthesia General anesthesia: You will be asleep during the entire procedure. Spinal: is an injection given in the back that numbs the lower have of the body. This wears off a couple of hours after surgery. Local: numbs just your knee Regional: numbs below your hip Your surgical nurse will review your chart and verify your procedure and the type of anesthesia you will be having. He/she will also verify any initials that your surgeon or anesthesiologist may have placed. Preparing for ACL Surgery Initial Goals, Before Surgery: Reduce Swelling in the knee Get back the normal range of motion of the knee Walk normally. This may take anywhere from one week to as long as two months depending on how the knee responds to the initial injury. Before Your Surgery How the ACL is repaired You may need to have specific tests arranged before your surgery, like blood tests, urine tests, chest x-ray, and/or EKG. Leg measurements may be taken to order a knee brace. There are a number of different techniques available to repair a torn ACL. Each surgeon has his own preference for each particular situation. ACL reconstruction is essentially an arthroscopic procedure. An arthroscope is a pen-shaped instrument to which a tiny video camera is attached. The camera is attached to

5 the end of the arthroscope and sends images to a video screen. Your surgeon looks at the screen and is able to get a clear view of the inside of the joint. Most ACL reconstructions are performed as outpatient procedures. Typically, reconstruction takes two to two and a half hours. There are different choices available to the surgeon in determining how best to reconstruct the torn ACL. They all involve a graft using something to substitute the torn ACL. Graft Options Patellar tendon Hamstring Allograft Post-Operative Instruction for ACL Repair Diet Please follow discharge instructions from your anesthesiologist regarding progression of your diet. When instructed, begin with clear liquids and light foods (jello, soups, etc.). You may progress to your normal diet if you are not feeling nauseated. Wound Care Maintain your operative dressing until your post-operative visit with your surgeon. Loosen bandage if swelling of the foot an ankle occurs. Keep steri-strips in place until they fall off or they are removed at your first post-operative visit. To avoid infection keep surgical incisions clean and dry. After stitches are removed, you may shower, but no immersion of operative leg (i.e. bath, hot tub, or swimming pool) for two weeks. ASK SURGEON Ice Ice wrap/cryo Cuff is recommended. You should ice the knee as often as possible reduce swelling and discomfort. Do not ice the knee more than 20 minutes at a time. Let the knee warm up before reapplication. Avoid getting your wound wet.

6 Medications Take your pain medication as needed. Do not wait until you are in a lot of pain before taking the medication. Strong oral narcotic pain medications have been prescribed for the first few days. Use only as directed. It is not uncommon to have an upset stomach with use of narcotic medication. For this reason, take your medication with food. If your symptoms are severe, or the medication does not treat your symptoms, please call the office and we will prescribe a different medication. Physical Therapy Ask SURGEONS Physical therapy is typically ordered at your first post-operative appointment. Early post surgical exercises should be started after the effects of anesthesia have subsided, usually within the first few days. Cayuga Medical Center has two outpatient physical therapy offices.

7 Island Health Center 310 Taughannock Blvd Ithaca, NY (607) Brentwood Physical Therapy 10 Brentwood Drive, Suite A Ithaca, NY (607)

8 Post-Operative Home Exercises Ankle Pumps With each foot separately or at the same time, point and flex the toes as if pumping the gas pedal of a car repeatedly, times every five to 10 minutes. Ankle Circles With each ankle separately or at the same time, rotate the ankles in a large circle about 10 times each direction, times every five to 10 minutes.

9 Heel Slides (Knee Flexion) This exercise will promote muscle activity of the hamstrings as well as help increase the amount of knee flexion. Lie on the bed on your back, with legs straight and together and arms at the side. Bring the heel of the operated leg toward your buttock to a point where a mild stretch is felt. This position is held to a count of ten. Slowly return to the starting position. This is repeated five to 10 times, two-three sets (one set described as when the exercise has been performed five-10 times) twice daily.

10 Quadriceps Setting This is a good beginning exercise, as it not only initiates the needed muscle contraction, but is also helpful in increasing extension of the knee. Lie on the bed on your back, with legs straight and together and arms at the side. Push the back of the knee downward onto a flat surface. Hold for five to 10 seconds, followed by relaxing for a short period of time. Repeat five to 10 times, two-three sets (one set described as when the exercise has been performed five-10 times) twice daily. (The amount of discomfort will determine how many each individual can perform.)

11 Straight Leg Raises This is another excellent exercise to promote strength to the quadriceps and the flexor muscles important in walking. Keeping the operated leg as straight as tolerated, raise it approximately six to ten inches upward. Hold for five-10 seconds, and then lower slowly to the start position. Repeat five to 10 times progressing to 20 times, two-three sets twice daily (one set described as when the exercise has been performed five-10 times). Once this exercise can be done without any difficulty, gradual resistance at the ankle (such as the use of ankle weights) can be used to further strengthen the muscles. The amount of weight used should be increased in no more than onepound increments. The individual bends the uninvolved leg by raising the knee and keeping the foot flat on a flat surface. This will help decrease or avoid unwanted strain on the lower back region.

12 Follow-Up Care Follow-up appointment You should have an appointment scheduled post-operatively for 5-10 days after surgery. The purpose of this appointment is to remove your dressings, remove the sutures or staples, and review the operative findings. Please call the office if you need to change this appointment, or if you do not have an appointment Driving Do not drive until approved by your doctor. Do not drive if you are taking narcotics or muscle relaxants as they can make you drowsy and slow your reaction time. Returning to Work Return to work will depend on your type of employment and can be discussed at you first post-op appointment When To Call the Office: ASK SURGEONS Call your surgeons office if any of the following occurs: Increase swelling in the thigh or calf Pain in the thigh or calf Numbness in the operative leg Change of color or temperature in the operative leg Pain in the operative leg, progressively worsening despite proper use of medication Fever greater than degrees Excessive nausea/vomiting from the use of pain medication Continuous draining or bleeding from the dressing Frequently Asked Questions: Q: How long will it take to return to sports? A: Everyone recovers at a different rate. The most standard answer that you will hear from the doctor is six months. It s possible to return sooner than six months, but the risks for re-injury are higher. It takes about months for your new ACL to be in peak condition. Q: How long until I can drive?

13 A: If you have ACL surgery on your left knee, you could be driving within a week or two depending on medications that you are taking. If you have surgery on the right knee, it will be a little longer. Q: How long will it take after surgery to have a bowel movement? A: Pain medications may cause constipation after surgery. Make sure you drinking plenty of water and eating a fiber rich diet. Talk to your doctor about stool softeners if necessary. Q: What are the potential complications of ACL surgery? A: Complications are rare, but they do include graft loosening, hardware failure, over-constraint and stiffness, as well as typical surgical complications including nerve or vascular problems. Talk to your doctors about potential complications prior to your surgery. Q: How long will I be out from work or school? A: The time spent out of work or school can vary from a week to two depending on graft choice, transportation, and type of occupation Q: Is physical therapy necessary? A: Physical therapy is necessary from about 1-6 weeks post-op. The therapy goal is to reduce the pain and swelling, regain range of motion, and increase the strength of the muscles. Therapy may have to be modified based on the individual progress through the weeks of rehab. Q: Is it possible that there is more injured than just the ACL? A: After the initial injury, there is a 50% chance of damage to the meniscus. In the acute situation, the meniscus tear may be repaired. In the chronic situation, the incidence of meniscal tear is 75%, and the torn portion of the meniscus usually has to be removed After Discharge You will be provided with instructions on how to care for yourself upon discharge from your surgeon and anesthesiologist. Please follow these instructions carefully.

14 You will receive a follow up phone call from a surgical services nurse the day after surgery. He/she will be calling to check on your status and answer any questions that you may have at this time. You may receive a survey in the mail following your surgical experience. We would appreciate it if you would take a few minutes to complete the survey and return. We appreciate any feedback that you can provide about your surgical experience. The Orthopedic Patient Navigator is a health care professional who acts as a patient liaison to better coordinate your care. She is available to answer questions you may have. Please feel free to contact the Orthopedic Patient Navigator if you have any questions or concerns Elyse Putorti, ATC, Orthopedic Patient Navigator Telephone: orthopedicservices@cayugamed.org Thank you for choosing Surgical Services at Cayuga Medical Center

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16 ANESTHESIA QUESTIONNAIRE - PAGE TWO

17 Please list any additional medical problems that were not addressed by the survey on the opposite side of this questionnaire. Have you been exposed to Chickenpox in the past 3 weeks? Yes No Drug Allergies: Current Medications: Please list drug name, dosage, and frequency below. Also list alternative medicines & Dietary substances. Previous Operations: Please list operation, year of surgery & hospital: Anesthesia Complications: Has anyone in your family had Malignant Hyperthermia? Other Anesthesia complications: Menstruating Females: Date of last period Are you pregnant or could you possibly be pregnant? Yes No Adults: Check the number of flights of stairs that you can climb without getting short of breath: Can t Climb Stairs Less than 1 Flight 1 Flight 2 Flights More than 2 Flights Personal Habits: Smoking Yes Packs per Day: Number of years smoked: Smoking No When Quit: When Smoking Packs Per Day: Alcohol: Amount: Other Substances: ALL PATIENTS HAVING SURGERY TODAY: When did you last have anything to eat or drink? Give date & approximate time Do you have any health proxy issues that you would like to make known to your surgeon or anesthesiologist? Signature: Date / Time: Witness: Date / Time: PAGE 2 OF