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Contents Page

Enhanced Recovery .......................................................................................4

Pre-Admission Discharge Planning ..............................................................5

Pre-operative Assessment ............................................................................6

What is a Knee Replacement? .....................................................................7

Alternative Treatments..................................................................................7

Benefits of Surgery .......................................................................................7

Risks and Complications of Surgery and Knee Replacement .....................8

Pre-op Exercises 9 The Day of Surgery .......................................................11

The Operation .............................................................................................11

After the Operation ....................................................................................12

Pain Relief ....................................................................................................12

Post Op Exercises ..........................................................................................13

Mobility .........................................................................................................16

Stairs ..............................................................................................................17

Daily Expected Post Op Goals and Achievements ......................................18

Getting Ready for Home ..............................................................................19

Medication ....................................................................................................19

Wound Care ..................................................................................................19

Once at Home ...............................................................................................20

Out Patient Appointments ...........................................................................21

Patient Agreement to Treatment ................................................................25

Further Information .....................................................................................27

Contact Information .....................................................................................27

Enhanced Recovery;

At Blackpool Teaching Hospitals NHS Foundation Trust we aim to provide high standards of care based on current recommendations and protocols. Enhanced Recovery After Surgery (ERAS) is part of this and ensures that all members of the hospital and primary care staff work together to improve the patient experience throughout their stay in hospital. Recent research has recognized that patients who are maintaining a healthy lifestyle before surgery recover much better after surgery.

By identifying any problems after surgery early such as pain control or post operative nausea and vomiting we can ensure that patients are able to move around early after surgery, take on the necessary calories needed to recover and therefore ensure a timely discharge from hospital.

What Enhanced Recovery Means for You

  • Taking an active role in your recovery – following the advice of the clinical team. • Being positive about your recovery.
  • Starting normal activities eg, eating, drinking, toileting, walking (with supervision initially), as soon as possible after surgery.
  • Making sure that before you come into hospital for your surgery, that you have organised any help that you will need at home after you are discharged home.
  • Being aware of your discharge date prior to coming in for surgery.
  • Knowing your estimated length of stay. This will be two days following your surgery, in some cases patients can go home the following day if they manage to move around the ward independently on crutches.

Patients who actively participate in their recovery;

• Feel better, sooner.

• Leave hospital sooner.

• Return to normal living sooner.

• Ensure you have help in place ready for discharge and relatives / friends are aware of the estimated date of discharge.

• Ensure that you follow a healthy diet on the weeks prior to your surgery in order to prepare your body for surgery and aid with recovery.

• Bring loose fitting clothes, you will be encouraged to move around the ward within 24 hours, often on the day of your surgery. You will also be encouraged to walk on the first day after your surgery (depending on your consultants advice).

• It is important to look after yourself before coming in for surgery. This includes keeping your skin clean and dry and reporting any rashes or breaks in your skin a week prior to coming in for surgery to the Orthopaedic Nurse Practitioner (the telephone number can be found in the contact information at the end of this booklet).

• You need to complete your exercise programme as recommended.

We would expect you to stay in hospital for 2 days following your surgery. Prior to coming into hospital you need to think carefully about any adaptations to your lifestyle or possible assistance that you may require when you return home. These could be such things as;

• Preparing meals in advance, to keep ready in the freezer.

• Using microwaveable pre prepared meals.

• Having plenty of supplies in store including long life milk for emergencies.

• Internet shopping.

• Recruiting friends and family to help with shopping/housework/looking after pets.

• Removal of any clutter that may impede you walking with walking aids.

• Removing any loose rugs, that you could catch with your walking aids.

• Plan your transport to and from the hospital. It is important to eat and drink before surgery.

Please make sure you eat a good meal the evening before surgery and have a light supper at 10pm before you go to bed. If you are on the afternoon list you will be able to eat breakfast on the day of surgery. You will be told if you are able to eat breakfast. You will be able to drink water on the day of surgery up until the time you are admitted. Once at the hospital the preadmission nurses will tell you when you need to stop drinking

To ensure a safe and timely discharge home, we will ensure that:

• Your blood count (HB) is checked to see that it is at an acceptable level.

• You can walk independently with walking aids.

• You are able to walk up and down steps (where applicable).

• Your pain relief is sufficient.

• A routine check x-ray of your knee has been performed.

Pre-operative Assessment

In preparation for surgery, you will be asked to attend a pre-operative assessment clinic where blood tests, x-rays, infection screening and a check of your general health may be performed by the health care team. If you have a long term illness, heart, lung or a metabolic (diabetes, thyroid) condition, a consultant anaesthetist may see you in an anaesthetic clinic to make sure you are medically fit for an anaesthetic.

The anaesthetist will discuss with you the different types of anaesthesia and pain management methods available to you. It may be necessary for you to be seen by a specialist if you have a more serious health problem. If you are not considered fit for anaesthetic and surgery your operation will be cancelled. You will receive an out-patient department appointment with your consultant surgeon who will discuss alternative treatment options.

This may include the following:

  • medication.
  • injection.
  • physiotherapy.
  • an appliance.
  • arthroscopy (key hole surgery)

It is important that you inform the nursing staff if you take any form of medication. If you are on blood thinning tablets e.g. aspirin, warfarin, clopidogrel or dipyridamole please inform the nursing staff as you may have to stop taking this medication before the operation. This would only be under the direction of a doctor or nurse practitioner.

It is also important to let the staff know if you have ever experienced any problems such as allergies or stomach upsets, when you have previously taken pain relief. You should also advise the pre op staff if you are already taking regular pain relief. In some cases, you will need to have some investigations repeated 1-2 days prior to your surgery. The pre op nurses will provide you with the necessary completed forms if this is the case.

If you need to have a repeat blood test, you will need to attend the Pathology Lab with your completed blood test form. The Pathology Lab is open between the hours of 8.30am and 4.30 pm Monday to Friday and is located at the far end of the main hospital corridor in the older part of the hospital.

If you need to have a repeat X ray, you will need to attend X ray North with your completed X ray card. X ray North is open between the hours of 8.30am and 4.30 pm Monday to Friday. X ray North is located near to Orange Reception, where you will have been on another occasion to visit the Orthopaedic doctors.

Following your x ray, you may be given a blue slip. Please discard this and DO NOT attend the Outpatient Department as stated on the blue slip. The blue slip is routinely handed out to all patients after their X ray to advise the clinic staff that they have had their X ray, however you are NOT attending clinic that day, therefore please discard the blue slip.

What is a Knee Replacement?

A knee replacement is an operation to replace a worn or damaged knee joint. Knee replacements are performed usually because you are suffering pain and movement difficulties.

A knee prosthesis (artificial joint) is made from metal, plastic, ceramic or a combination of these materials, and can last 10 to 15 years. However, over time the prosthesis may become worn and loose and a replacement (revision) of the knee may be required.

The operation is advised for the relief of knee pain, caused by arthritis. It is a major operation with risks attached, it should only be undertaken if your tablets are not controlling your pain and severely affecting your lifestyle.

Initially your doctor may suggest changes to improve symptoms e.g. weight loss if necessary, physiotherapy and exercise to reduce stiffness, and the use of walking aids. If these treatment options do not improve pain and imobility, a partial (unicondylar) or a knee replacement operation may be advised. Your doctor will discuss treatment options with you. If you are unsure of your treatment please discuss this with a member of the health care team.

Provided that you work hard with your exercise programme before and after your operation, you can expect to improve significantly the quality of your life, reduce your pain, improve your mobility and benefit from your new knee replacement.

Risks/complications of surgery and total knee replacement

All surgery and anaesthetics carry some risks, particularly if you have other medical problems or are overweight. The healthcare team looking after you have been trained to make sure that these are minimised and your treatment is carried out safely. There are, however, some specific risks relating to knee surgery that you need to be aware of:

  1. Infection – sometimes despite the strictest precautions, infections can occur. Superficial infection may occur at your wound site.
  2. Deep infections – may occur early after the operation or much later. For this reason we recommend any infection that you develop in any part of your body is treated promptly and that you tell your Dentist when you see them that you have had a knee replacement.
  3. Deep vein thrombosis (DVT) – despite taking precautions to try and prevent a blood clot (a thrombosis) forming in the veins of your leg after surgery, this still remains one of the commonest risks after knee replacements. Occasionally these clots can dislodge and travel through the heart to the lungs. This is known as a pulmonary embolism.
  4. Very rarely even death can occur.
  5. Loosening of the prosthesis (new joint) – this is a risk of all artificial joints and is caused by a weakening of the bond between the new joint and your bone. It is hoped that your new knee will last at least 10-15 years, but it may loosen before this time, particularly if you are overweight or damage the joint by falling on it or return to heavy employment. If it does loosen then it is usually possible to remove it and replace it with another one although this is a more complicated operation with greater risks.
  6. Persistent pain – the operation may not relieve all of your pain and you may continue to experience some mild discomfort. Complex regional pain syndrome, while uncommon, may be the cause of pain, swelling, stiffness and skin changes.
  7. Nerve damage – very occasionally nerves can be damaged or stretched during your operation. This usually recovers over a period of time.
  8. Persistent knee stiffness – sometimes despite your exercises your knee joint may become very stiff. This seems to be due to excessive scar tissue forming around and within your joint. Sometimes this is helped by a further operation to manipulate your joint. It is very important that you do your exercises regularly after your operation.
  9. Other recognised risks of knee surgery include bone fracture, bruising, urinary retention and the risks associated with anaesthesia and blood transfusion

Pre Op Exercises;

In the weeks before your operation, it is important that you maintain the mobility of your knee joint and the soft tissues around it. You also need to strengthen the muscles around the knee. By strengthening the muscles around the knee, you will help to support your new joint, improve your posture and walking pattern, as well as greatly aiding your progress after your operation.

A member of the Pre Op Physiotherapy, ‘Homeward’ team will arrange to visit you at home prior to your surgery to assess your mobility and to give you some pre op exercises to start doing. Start these exercises as soon as you have been given this booklet. You should not feel too much pain or discomfort with them.

Please do all of the exercises on BOTH legs

Exercise 1

Lie on your back or sit up with your legs out straight in front of you on your bed. Bend your ankle up and push your knee down firmly against the bed. Hold for 5 seconds. Repeat 6 times, 3 times a day

Pre-op exercise 1

Please do all exercises on BOTH legs

Exercise 2

Lie on your back, or sit up with your legs out straight on your bed. Exercise your knee by pulling your toes up, straighten your knee and lift your leg 10cm off the bed. Hold for approx 5 seconds, then slowly relax. Repeat 6 times, 3 times a day. Increase to more than 10 repetitions each time if you are able.

Pre-op exercise 2

Please do all exercises on BOTH legs

Exercise 3

Sit or lie as shown. Put a rolled up towel or block under your knee. Exercise your knee by pulling your foot up, tightening your thigh muscle and straightening your knee. (Keep the back of of your knee on the towel or block). To make the exercise harder put a small weight on your ankle. Hold for 5 seconds. Slowly release. Repeat 6 times, 3 times a day. Increase to 10 or more repetitions, as it feels easier.

Pre-op exercise 3

Please do all exercises on BOTH legs

Exercise 4

Sit on a chair. Pull your toes up, tighten the front of your thigh muscle and straighten your knee slowly. Hold for approx 5 seconds. Slowly release. To make the exercise harder put a small weight on your ankle. Repeat 6 times, 3 times a day. Increase to 10 repetitions each time if you are able.

Pre-op exercise 4

Please do all exercises on BOTH legs

Exercise 5

Sit on a chair with your feet flat on the floor. Slowly bend your knee as much as possible. Hold for 5 seconds. Then straighten your knee as fully as you can. Repeat 6 times, 3 times a day. Increase to 10 repetitions each time if you are able.

Pre-op exercise 5

Please do all exercises on BOTH legs

Exercise 6

Lie on your back or sit semi reclined on your bed with a plastic board/bag under your leg. Bend and straighten your hip and knee, as much as you can, by sliding your foot up and down the board. Repeat 6 times, 3 times a day. Increase to 10 repetitions each time if you are able. If you wear a sock, your foot will slide easier and the sock will help to protect your heel from any soreness.

Pre-op exercise 6

The Day of Surgery

It is usual for you to be admitted, to the surgical admissions unit on the day of your surgery. You will be sent further information regarding the time to come into hospital and which unit to attend nearer to the time. Most people get out of bed on the day of surgery and sit in a chair. The first day after surgery we would expect you to be up and mobilising on the ward.

The orthopaedic ward has both male and female patients, in order to protect patient dignity we encourage everyone to dress in day clothes rather than night wear. You will need to bring some loose fitting clothes that you feel comfortable to mobilise in. The nurses will need to see your wound so trousers need to be loose fitting to enable access.

Please ensure you bring suitable footwear to wear after your operation. This needs to be:

  • Flat.
  • Supportive.
  • With a back/heel strap to it. Not backless.
  • A reasonable fit even if there is some swelling in your foot.

Please DO NOT bring in new slippers, if your foot is swollen you will not be able to wear these.

You also need to remember to bring into hospital;

  • This booklet – as you will need it in order to be able to follow your post op exercises and advice.
  • Your green bag with your medications - the pre op nurses will have given you this.
  • Your completed PROMS form, which the pre op nurses will have given you too.

See also the supplementary booklet, ‘Coming into Hospital for an Operation’.

On the morning of your operation please take a shower/bath before coming in to hospital. When you are admitted to hospital, members of the health care team will prepare you for theatre. The limb to be operated on will be marked before the operation. A member of the health care team will escort you to the operating theatre.

You will spend a short time in the recovery area of the operating theatres before you are taken to the ward. You will be offered drinks in the recovery area and you should be able to eat and drink normally when you go to the ward. You will have a cannula in your hand which will be used to give you some antibiotics after the operation which help to reduce the risk of post operative infections. Some discomfort will be experienced following the operation so pain relief medication will be given to help ease the discomfort. You may have an intravenous drip in your hand to give you fluids and antibiotics after the operation. An antibiotic is given before the operation and sometimes for 24 hours after the operation to help reduce the risk of post-operative infection. The drip will be removed 24 to 48 hours after surgery.

All operations which involve cutting the skin or muscle result in some pain. We work very hard to reduce the amount of discomfort that you will feel after any procedure. It is rare to be able to completely remove all postoperative pain but we strive to reduce it to a level that is easily bearable. We have a number of methods of achieving this, together with a team of specialist staff whose role it is to help in the management of acute pain should it be needed. An operation will inevitably result in some pain, however, pain can be a very different experience in every person and the best way to treat it can be different as well. What you experience may not be the same as your family or friends.

The different types of pain relief include:

  • Tablets or syrup/liquid You will need to be able to drink and not feel sick before taking these pain relief medicines. They may take 30-45 minutes to work and it is important that you take the medication before the pain becomes too bad.
  • Injections These can be used if you are not eating and drinking properly. They are given either into your drip or through a small needle just under the skin in your arm or thigh. These usually take 20 minutes to work.
  • Local anaesthesia A one off dose of local anaesthetic medicine as an injection may be given in the anaesthetic room before the operation starts, it may be done whilst you are awake or asleep. This will be discussed with you by the anaesthetist prior to the operation. It will numb the area which is being operated on and will stay numb for a few hours after the operation ends. Other forms of pain relief described above will be used in addition to the local anaesthetic medication

Post-operative exercises ;

It is essential that you commence the following exercises as soon as you can after your operation. These exercises replace the previous exercises that you were doing before your operation.

Exercise 1

Post-op exercise 1

After your operation it is very important that whilst you are not as mobile as usual, that you do deep breathing exercises, to try to prevent the occurrence of any chest infections. You can start this exercise yourself after your operation.

Sit upright in bed or your chair. Take a normal breath in through your nose, allowing the air to flow to the bottom of your lungs, so that your abdomen rises slightly on inhalation. Breathe out through your mouth. Repeat 5 times.

Follow this with 3 deep breaths, allowing your lungs to fully expand to their maximum capacity. If you hear any secretions in your chest or throat, when doing your deep breaths then try to cough them up. Repeat another 2 times. Do for 10 seconds every hour. Continue this exercise daily until you are up and about as normal and your chest is normal ‘for you’.

Please do this exercise on BOTH legs

Exercise 2