The enhanced recovery programme is composed of a number of factors designed to help speed
up your recovery after your operation. This class is the first stage of the process in
encouraging you to be an active participant in your own care and recovery from your joint
replacement. By explaining the journey you are all about
to embark on, we aim to better prepare you for your operation and post operative recovery
and to help you understand what as a healthcare team we are trying to achieve.
We hope you will have a better understanding of the goals we are all aiming for you to
achieve so that you are able to return home sooner than would otherwise have been expected.
In a healthy knee joint the surfaces of the bones are covered in a smooth, slippery material
called articular cartilage, enabling smooth, pain free movement.
In an arthritic joint, the cartilage becomes worn, exposing the bone underneath and making
the joint surfaces roughened and deformed. This can make movement and walking painful.
Often the joint will stiffen and thigh muscles can become weak.
The pain can become severe enough to disrupt sleep and significantly reduce quality of
life.
A knee replacement involves the damaged bone surfaces being substituted with metal and
plastic components. The most common type is a total knee replacement.
This involves replacing the end of the thigh and top of the shin bone with metal components.
A plastic insert is then attached to the shin bone component and sometimes the back of the
knee cap is resurfaced with a small plastic button.
The components are cemented in place giving immediate solid fixation.
Your knee is always likely to feel somewhat artificial. Your function will improve for
a year to 18 months post surgery.
Occasionally arthritis is confined to one part of the knee.
In this situation your consultant may discuss the possibility of a unicompartmental (otherwise
known as partial) knee replacement. This just replaces the damaged part.
You will be able to weight bear immediately post operation. You will have a scar on the
front of your knee closed by clips which will be covered with a film dressing and a bandage.
An ice pack will be wrapped around your knee called a cryocuff to help reduce the swelling.
You will be asked to attend a pre-operative assessment appointment approximately two weeks
before your operation to assess your general health, well being and fitness for surgery.
Routine blood tests, an ECG (heart tracing) and a urine sample will be taken.
You will be seen by the surgical team and the risks and the benefits of the operation
will be explained and you will be asked to sign a consent form. If you take any medication
please bring your prescription with you to this appointment. We also need to know if
you are likely to need some help when you leave hospital, if you already receive support
from social services, a district nurse visits or you are struggling with any daily activities.
This enables us to make the necessary arrangements to support you on discharge.
You will be given two cartons of a carbohydrate drink which is designed to minimise the effect
of starving you before your operation. Please take one the night before your operation and
the second drink before 6am on the day of your operation.
You should have a shower at home before you come into hospital with the antibacterial
wash which will be provided to you by the nurses at pre-op assessment. Please bring
the bottle into hospital with you on admission as it will be used during your stay in hospital.
On the day of your operation you will be admitted to the ward by the nursing staff and prepared
to go to theatre. Nursing staff will record your observations, a doctor will draw an arrow
on the limb you are having operated on and your consent form will be checked. A theatre
gown and paper pants will be given for you to wear. You will be able to speak to an anaesthetist
before the operation if you have any concerns about the anaesthetic. You will be given some
pain killers designed to be working in your system for pain control after your operation.
The operating theatres either run for half a day or a full day. If your operation is
planned for an afternoon list you will be encouraged to have a light breakfast before
7am so that you are not starved all day. A porter will escort you to theatre reception
on a trolley about twenty minutes before your operation here you will wait before being
taken into the anaesthetic room.
In the anaesthetic room you will be attached to some routine monitors by the theatre staff
and a drip will be placed in the back of your hand by the anaesthetist. You will be sat
upright to allow a spinal anaesthetic to be injected into your lower back. This will numb
your legs for the duration of the operation and for a short time after. We will then lie
you down and you will be given an injection to make you feel sedated or asleep.
After your operation you are moved to the recovery room where the recovery nurses continue
to check your observations. Your leg numbness wears off quite quickly once in recovery and
once that occurs you may start to move your new joint to reduce early stiffness setting
in. You may need extra pain killers or treatment for feeling sick whilst in there and once
fully recovered a ward nurse will collect you and escort you back to the ward.
Once on the ward your observations will be taken regularly and the sensation, circulation
and movement to your feet will be checked. You will have a pair of boots on your feet
which will pulsate every thirty seconds and possibly elastic stockings. These reduce the
risk of developing a deep vein thrombosis. The boots are removed once you are walking
however the stockings are to be worn at all times for six weeks post operatively.
You will be given a second pair on discharge so you have one to wear and one to launder.
You will need assistance to get these on and off at home so please have a think about friends
or relatives that can assist you with them. If you don't have any one to support you with
this on discharge please let us know. The nurse will monitor your pain and nausea
and vomiting score and give you pain relief and anti-sickness medication as required.
You will be given pain relief regularly, if you need further pain relief let the nurses
know.
The bandage to your knee will be reduced after four hours of returning to the ward to expose
a film dressing. The cold ice pack called a cryocuff will be reapplied. The knee cuff
is applied around the knee joint and filled with iced cold water by decanting it from
a thermos flask. The water in the cuff will stay cold for approximately 30 minutes initially
staff will exchange the water for you and then you will be shown how to do this so that
you can apply the ice pack regularly to help to control the swelling that naturally develops
post operatively.
The nurses will encourage you to eat and drink as soon as possible and drips will be taken
down when your blood pressure is stable. After surgery it is advisable to drink a mixture
of drinks tea, coffee and juices rather than just water. Drinking too much water at this
stage can affect your recovery.
The numbness in your legs will be short acting so that you are able to mobilise within four
to six hours of returning to the ward. Early movement of the new joint is important in
reducing stiffness and swelling which helps the function of your new joint to return to
normal once at home.
Urinary catheters are avoided if possible after surgery and you will be encouraged to
mobilise onto a commode the same day. This is a good way of starting early movement in
your new joint. Some patients with mainly heart or kidney problems may need production
of urine closely monitored and will have a catheter placed during their anaesthetic.
On occasions patients struggle to pass urine once on the ward and a urinary catheter may
also need to be placed.
We also know early mobilisation reduces the risk of deep vein thrombosis, chest infections
and pressure sores. Providing that you feel well and your blood pressure is stable, a
physiotherapist or member of the nursing team will assist you out of bed to stand up and
take a few steps and sit back on your bed. If you feel ok you can sit out in your chair
or take a short walk. You will be given a zimmer frame at this point but as soon as
you are able we will progress you onto elbow crutches for use at home and when you feel
confident we will teach you how to do stairs or a step as appropriate.
The physiotherapists will encourage you with your exercises until you can achieve a 90
degree bend at the knee, straighten your knee fully and you can lift your leg off the floor
unaided.
The qualified physiotherapist or the assistant physiotherapist will see you every day until
you are able to mobilise independently and manage a step or a flight of stairs as well
as independently get yourself out of a chair or bed.
The exercises will need to be continued for several weeks after you have left the hospital.
You will be able to progress to walking unaided over a six week period. You will find you
can progress to walking unaided indoors within a few weeks but may require a stick or a crutch
for outdoor walking. As soon as you feel confident to manage with sticks instead of crutches
or only one stick you are encouraged to progress yourself. It is advised to use a single stick
or crutch in the opposite hand to your operated leg.
It is vital that you take pain killers regularly, as when you are working very hard performing
the exercises your leg may become sore, bruised and swollen. If you experience pain which
is not relieved with your regular medication please tell one of the nursing staff.
All the leg exercises will:
Minimize the risk of blood clot formation
Strengthen the muscles
Regain knee joint flexibility
Prepare your operated leg for an improved walking technique.
The initial aim is to perform a minimum of 5 to 10 repetitions 3 to 5 times a day- increasing
the number or repetitions as you are able. Generally frequent short bursts of exercises
are best. It is important to find a happy balance- performing too many exercises may
aggravate swelling and pain, performing too few will cause stiffness and loss of movement.
A member of the physiotherapy team will check your progress whilst you are in hospital.
Regaining strength and movement is hard work and takes determination and dedication. You
will need to keep motivated about performing the exercises yourself to achieve a good outcome.
It is normal to experience swelling that can make the operated leg feel quite solid. Once
mobile you will find the swelling tracks down the leg with gravity too causing the calf
and or ankle to swell. It is important to keep varying the position of your leg to avoid
stiffness and excessive swelling, alternating between spending an hour with it down to practise
bending and an hour with it straight and elevated.
Some people can hear the movement of the components moving against each other, some people feel
the movement and others experience both. Unless it causes significant pain or feelings of
instability in the knee, this is nothing to worry about.
A sensation of the knee stiffening up can occur if you have been sitting or standing
in one position for a few minutes. It will resolve quite quickly if you start to move.
A knee replacement only replaces the worn parts of bone, so it is still very common
to experience muscular ache, particularly if you have been very active. Keeping your
thigh and bottom muscles strong is the best way of reducing muscular ache.
Following discharge home we advise that you continue to elevate your leg and use ice.
You will be given the cryocuff filled with water to take home and chill in the fridge
to use regularly through out the day. If you are using ice directly on the knee, always
place a clean damp layer of towel between the ice and your skin to prevent an ice burn.
All total knee replacement patients attend outpatient physiotherapy sessions after discharge
from hospital. You can choose from a number of venues and the ward physiotherapist will
organise this for you. The hospital that you choose will contact you directly with an appointment.
Depending on your choice of venue the sessions usually start 1-2 weeks after you leave hospital.
The sessions are usually once or twice a week. To bridge the gap between inpatient and outpatient
physiotherapy we operate an early discharge scheme.
You will be contacted at home by telephone within a few days by one of the team. They
can talk through any concerns you may have about your progress or exercises. If appropriate
they can also visit you at home to review your movement or mobility.
When you get home it is very important to take your pain relief regularly as directed
by the nursing staff. If you don't manage your pain relief properly, things like going
to the kitchen to make a cup of tea could be difficult and painful. Its important to
gradually increase the number of exercises you are doing throughout the day, but please
make sure you pace your activities- don't do all your jobs at once. We advise that you
do exercises at least three times a day. It is better to do short but frequent bursts
of exercises. In preparing you for your discharge home an
occupational therapist will assess your ability to manage day to day tasks. You should have
been provided with a home information sheet to complete and bring with you today. This
gathers information on your home environment and asks about equipment you may have already
in place. If any concerns are high-lighted on this form
by the occupational therapist you will be contacted by telephone to discuss these further
prior to your admission. The occupational therapist may suggest different ways of doing
things or suggest help from other people for example social services and provide any equipment
you may need.
It would be helpful to plan for your discharge by doing things like organising your kitchen
so that frequently used items are to hand ensure rooms will be easily accessible while
using a walking aid by taking up any loose rugs and moving bulky furniture. Ensure you
have support for shopping or have stocked up your freezer and cupboards prior to coming
in. Occupational therapists will also see you
on the ward after your operation to ensure you can do everything that you need to do
in order to manage at home. They will assess if you are able to get into and out of bed
independently, manage to get on and off the toilet and chair and manage your own personal
care including bathing or showering.
Discharge arrangements are commenced early on in your care and this will be discussed
with you. We aim to get you as independent and as mobile as possible before you leave
the hospital so that you feel confident to manage your own care.
Your discharge home is led by the nurses on the ward working closely with the physiotherapist
and occupational therapist. You will be given an estimated date of discharge of two to three
days after your operation. This gives you and your relatives a date to aim for so that
preparations can be made. This date is an estimate, some of our patients go home sooner
than this and some patients need a little longer.
A letter will be sent to your GP to inform him/her of your discharge and the nurse will
make arrangements for the care of your wound and the removal of clips at your practice
nurse. You will be given a supply of pain relief medication to take home. A side effect
of the pain relieving tablets is constipation so to prevent this you will also be given
some laxatives. Eating fresh fruit and vegetables and drinking water will also help. An outpatient
appointment will be provided to see your consultant or one of the team at six weeks post operatively
and you will be given the contact number for the ward if you have any concerns once at
home.
You should contact the ward you were discharged from if you experience any of the following:
Bleeding or any discharge from your wound or redness that seems to be spreading up and
down the leg. Excessive swelling of the wound area
Increasing pain and stiffness of your new joint, increasing pain, difficulty moving
the operated leg or walking if you have had a fall.
If you experience a problem with your wound healing it is very important that your consultant's
team is kept informed so that we can minimize your risk of developing a serious infection.
You will be able to go home by car and it would help if you have already arranged for
a relative or friend to be available to collect you as ambulances are not usually required.
Swelling is to be expected and can be managed by elevating your leg and regular walking.
Continue to progress your exercises, walking and build up your activities gradually. You
have had a major operation and it will take several weeks to recuperate. You will be contacted
by telephone within a few days of discharge by our physio assistant practitioner to check
on your progress and offer support and reassurance and visit you at home if needed.
In the longer term the benefits of having a total knee replacement are less pain, a
functional range of movement, a better walking pattern, improved ability to carry out daily
activities, being able to return to work if appropriate for you and to return to those
leisure and social activities you've not been able to do because of your arthritis.
We hope this DVD has been informative and wish you well for your operation.