Please keep this booklet and bring it with you to all your appointments, your inpatient stay and your follow up appointment. The blank pages are provided for you to
Important Dates
Pre Assessment Clinic ______
Notes
Operation Date______
Admission Time______
Notes
Expected discharge Date______
6-10 week Follow up Appointment______
Notes
1 Year Assessment______
Joint deterioration can affect every aspect of a person’s life. In its early stages, it is common for people to ignore the symptoms of osteoarthritis, but as the disease progresses, activities like walking, driving and standing become challenging andmay become difficult. This brochure will help you understand some of the basics of the normal knee, arthritis and knee replacement surgery. This brochure is for educational purposes only and is not intended to replace the expert guidance of your orthopaedic surgeon. Any questions or concerns you may have should be directed towards your orthopaedic surgeon.The first knee replacement procedure was performed in 1968. Since then,millions of people have received knee replacements. In the UK about 70,000 Total Knee Replacements are done each year and here at The Great Western Hospital we carry out 500 every year. Knee replacement surgery is afairly routineprocedure and is usually an extremely successful surgical procedure. The term “replacement” leads one to believe that surgeons remove the entire knee. In truth, your surgeon removes thin sections of bone, cartilages and the thickened joint lining and worn/ damaged cartilage found at the ends of thebones in your joints.
The Knee
The knee is a complicated rotating hinge joint formed by the tibia (shinbone), femur (thighbone) andpatella (kneecap). The ends of the bones in the joint are covered with cartilage, atough, perfectly smooth lubricating tissue that helps cushion the bones during movement. Arthritis isany condition that affects joint cartilage and itusually develops over years of constant motionand pressure in the joints. As the cartilage continues to wear away, the joint becomesincreasingly painful and difficult to move. There are many different kinds of arthriticconditions that can affect the human body and there are millions of people who areaffected with arthritis each year. The commonest is osteoarthritis.
Osteoarthritis
Osteoarthritis, often referred to as OA, is the most common reason for joint replacement surgery. Osteoarthritis is a degenerative disease that destroys the joint cartilage, often leading to painful bone on bone contact. It can cause pain, stiffness, swelling and loss of motion in the joint, which may vary in duration and severity from person to person. Some doctors, textbooks and literature have different names for osteoarthritis, such as osteoarthrosis, degenerative arthritis, and wear and tear arthritis.
Treatments such as the relief of pain, physiotherapy exercise, support braces, walking aids and weight reduction can help control the symptoms of osteoarthritis for a time. When these treatments fail to provide adequate relief from pain, total joint replacement may be recommended. Your surgeon will assess your individual condition and prescribe a treatment that will give you the best results.It is known that younger patients (under 55) do tend to continue to suffer from residual pain and instability in their knee following knee replacement surgery. In fact, research has shown that 20% of younger patients are dissatisfied with the functional outcome of their knee replacement. This is compared to 5% dissatisfaction in the older age group.Surgical alternatives to total knee replacements are keyhole operations or partial knee replacements; though these are only effective in patients with very specific patterns of wear.
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune syndrome, meaning the body’s immune system attacks and destroys healthy joint cartilage. Rheumatoid arthritis can occur at any age, even in children, and it is considered a systemic disease that affects multiple organs.
In the joints, rheumatoid arthritis causes inflammation of the joint lining, called the synovium. Inflammation of the synovium can cause pain, stiffness, swelling, warmth and redness, and can eventually lead to cartilage loss.
Rheumatoid arthritis often affects many joints such as the hips, knees, and hands. This disease can have periods of flare-ups followed by a quick remission of symptoms. Rheumatoid arthritis is a chronic condition that may last a lifetime. However, treatment is available to help reduce pain, swelling, and slow joint destruction.
Total Knee Replacement
A total knee replacement replaces your diseased knee joint and eliminates the damaged bearing surfaces that are causing you pain. The design of the implant offers you renewed stability and minimizes the wear process.Total knee replacement offers the greatest quality of life improvement of all operations. It has one of the highest success rates and one of the best outcomes. Once your new joint has healed completely which can take up to18 months, you should experience the following benefits from the surgery.
- Reduced or no joint pain
- Increased movement and mobility
- Correction of angular leg deformity
- Increased leg strength (if you exercise)
- Improved quality of life
- The ability to return to most normal activities.
Total knee replacement is performed while you are under spinal anaesthesia with an injection to control the pain in your leg, which your surgeon will explain to you before surgery. Your surgery will last approximately 1 ½ hours. Care before your surgery and time spent in the recovery room can add an additional 1-2 hours before you are back in your hospital room.
The lower part of the replacement knee joint is comprised of a flat metal plate and stem that your surgeon will implant in the tibial bone. This tibial tray can be either cobalt chrome alloy or titanium alloy. It can be fixed by either cement or bone “ingrowth”. Next, a polyethylene (hard plastic) insert is clipped into the tibial tray to serve as the new knee bearing surface. The upper part of the replacement knee joint consists of a contoured metal shield that fits around the lower end of the thigh bone (femur). The inner surface is fixed to the cut bone surfaces by the surgeon’s choice of bone ingrowth or bone cement. The outer surface of the contoured metal shield is shaped to allow the knee cap (patella) to slide up and down in its groove. The surgeon may choose to retain the natural knee cap or re-surface it. In this case a polyethylene button will be cemented in place.
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Preparing for surgery
We aim to see and treat all patients within 18 weeks from referral from the GP; however there will be exceptions depending on any other investigations and treatments which may be required. During this time you will attend several appointments. You will meet one of the orthopaedic surgeons and have x-rays to decide that you really do need a knee replacement.
You will also need to attend a pre-assessment clinic to make sure that you are fit enough to have the surgery. During this visit you will attend a pre-operative education class during which you will be told a lot more about the operation. You will also have to undergo further tests, depending on your specific problems to ascertain your suitability for surgery. Some patients may need review by an anaesthetist at this stage, depending on your medical history.
At this appointment, you may be asked to sign a consent form and the complications associated with surgery will be explained to you before you give your consent. This form is very important and you need to listen carefully to the information given to you. Sometimes this form is completed on the day you come into hospital.
Physical Conditioning – It is important to be as fit as possible before undergoing joint replacement. Participating in a doctor-prescribed exercise program before surgery can help patients make a more rapid recovery. Moderate exercise is an integral part of treating arthritis. Activities such as walking, swimming, riding a bike or gardening can assist in keeping your bones strong and your joints supple, which may help relieve stiffness. Low-impact exercise will not wear out your joints. Although exercise may sometimes cause discomfort, proper exercise will help nourish the cartilage, strengthen the muscles, and prolong the life of your joints. Your knee may be so painful and stiff that exercise is not possible, in which case try to keep as active as you can. Having your muscles in good condition prior to surgery will help you in the recovery phase after the operation.
Nutrition
Proper nutrition is a concern for joint replacement patients. Orthopaedic surgeons
recognise that many joint replacement candidates may not be in peak nutritional
health. Try to eat a well balanced diet; more information is available from Pre- operative assessment clinic. Proper nutrition can assist in your recovery by assisting in wound healing and energy levels.A high intake of Vitamin C the day before your operation is recommended, fruit and vegetables are a good source of this.
Stopping Smoking
Before surgery it is absolutely essential to stop smoking. It is necessary to stop smoking at least two to four weeks before the planned procedure. Smoking impairs the transfer of oxygen to the healing tissues, which may increase healing time and the possibility of other complications. The hospital is a non-smoking site so you will not be able to smoke during your hospital stay. There are lots of national initiatives available to help you stop smoking. Patches may help you during your hospital stay.
High Blood Pressure
High blood pressure can result in your operation being postponed. If, at pre- operative assessment clinic or on admission to the ward, your blood pressure is high, you will be asked to go home and seek advice from your GP. This would obviously be a great disappointment to you and your family as it could delay your surgery until your blood pressure is better controlled.
Feet
Your feet are very important and need to be well looked after prior to joint surgery.
You may have found difficulty in bending due to pain and have been unable to treat your feet, resulting in corns, in growing toe nails etc.
If you have any of these problems then a chiropodist can help you. Getting problems sorted out before your admission will help you to regain your mobility quicker. It is probably best to talk to your GP or practice nurse about getting referred to a chiropodist.
Healthy Skin
For your operation to go ahead your skin needs to be healthy and free from sores or open areas. People who suffer from eczema, psoriasis, leg ulcers or any other skin conditions need to be extra careful. In the weeks leading up to your operation you must ensure that any open areas on your skin are healed and there is no infection present.
For advice and treatment of any skin complaint you must consult your GP or practice nurse.
There is a possibility that your operation could be cancelled if your skin is not healthy.
A swab from your nose and possibly your groin will be taken at pre-operative assessment clinic to ensure you are not carrying the bug Methicillin Resistant Staphylococcus Aureus (MRSA). If this swab is positive you will receive treatment through your GP and re-screening. You will not be able to have your operation until the swabs are negative.
Urinary Problems
This is a problem that nobody likes to talk about. Up to three million people in the UK suffer from stress incontinence (leaking when laughing or coughing). It can be very embarrassing having to rush to the toilet because of dribbling. Incontinence can cause urinary infection and complications following surgery including wound infection.
Help is available. You can have a professional assessment with your own GP, community nurse or continence advisor. Getting help with this problem will reduce the risk of infection. A urine sample will be taken at pre- assessment. If positive, you will need antibiotic treatment before your operation. It may possibly delay your surgery date. If you are experiencing any symptoms of a urine infection it is a good idea to visit your GP before your pre-assessment date.
Support on discharge
You will need further assistance on discharge as you may not be able to manage some housework and fitting special compression stockings used to prevent thrombosis (see risks and complications section). Please ensure that you have somebody to help you with these tasks on discharge for a temporary period of time. There is some help available in the community but this will need to be paid for.
Before Surgery
You will be admitted to the theatre admissions lounge (TAL). This is a dedicated area within the operating theatres where patients can be assessed and prepared for Orthopaedic surgery.
When you arrive the nurse will assess you, take a blood sample and prepare you for theatre. You will also be seen by the anaesthetist who will discuss the type of anaesthetic you are going to have for your operation.
The surgeon will see you and mark the leg that is to be operated upon. The surgeon will also check your consent formed is correct and signed. This will be completed if not already done at the pre-assessment clinic.
Your belongings and medications will be taken up to the ward while you are in theatre. Please do not bring any valuables. The only items needed are sensible footwear, not new as your feet may be swollen, washing items, a set of day clothes which are easy to put on, and nightwear/dressing gown. You must also bring your current medications with you. A small amount of change may be needed for newspaper magazines during your stay.
The Anaesthetic
While you are in the Theatre Admissions Lounge The Anaesthetist will come to see you to talk about your anaesthetic.
Generally the type of anaesthetic used for knee surgery is:
Regional anaesthesia with sedation.
This is a spinal anaesthetic which is injected into your spine and makes you numb from the waist down. You will be given sedation to feel fully asleep and you will not be aware of the operation. There is a lesser risk of blood clots and chest infection and less sickness associated with this type of anaesthetic. This will be supplemented with nerve blocks to numb your leg. You may need a urinary catheter and will not be able to feel your legs for 4-6 hours after surgery.
If you are unable to have a spinal anaesthetic then a general anaesthetic will be used. This anaesthetic can make you quite sleepy and nauseas after surgery. The nausea can be controlled with medication.
The Anaesthetist will discuss with you which procedure is best for you.
After Surgery
You will be collected from the recovery unit by a nurse from the ward. You will be wheeled back up to the ward in your bed.
You will have an Intravenous Infusion (IVI) in a needle in the back of your hand or arm when you return to the ward; this will continue for a short while until you are drinking. There may also be drain coming out from your knee to drain away any blood which might otherwise accumulate in the operation site. A urinary catheter may also have been inserted.
The anaesthetist will advise you before the operation as to the best method of pain relief for your operation. Your pain will be controlled by a local anaesthetic which is injected into your knee while you are in theatre. The nurses will be giving you regular painkillers. If these are ineffective the please ask the nursing staff to review the painkillers that you are receiving. Keeping your pain controlled enables you to start physiotherapy as soon as possible after your operation.
The physiotherapist will start with gentle exercises and ask you to bend your knee and try to straighten and lift your leg. The large padding around the knee should not stop you from bending your knee.It is also important to start moving as soon as possible after surgery to encourage blood flow, to regain motion and to facilitate the recovery process. Early mobility also helps to prevent complications, see page 18. The physiotherapists will come and help you to stand and maybe take a few steps as early as 2 hours after you return to the ward. If you are going to stand up on the day of your surgery the nurse looking after you will put some extra fluid into the intravenous drip in your arm just before you stand and you should eat something. A positive frame of mind is vital to your recovery and you will be encouraged to spend the day out of bed and in comfortable day clothes, returning to your night wear and bed only for sleeping.