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SOTC opened in June 2006. We specialise in day and in-patient orthopaedic surgery for patients who come from Brighton and Hove, West Sussex and East Sussex, Downs and Weald areas.
Our Centre provides the following elective orthopaedic procedures:
This book is a general guide to recovery from total knee replacement (TKR) surgery. However, not all patients have precisely the same conditions or needs. Your doctor, therapist or nurse may make recommendations, which deviate from this book; their changes take precedence. The long-term benefit of your surgery will largely depend on you continuing your rehabilitation at home. We therefore expect that you will continue to practice what the team has taught you long after you have left us.
Key contacts
Sussex Orthopaedic NHS Treatment Centre Reception 0333 200 1728.
Princess Royal Hospital Switchboard 01444 441881.
Ward 68830.
Physiotherapy / OT Extension 68834.
Pre Assessment Clinic Extension 68841.
Pre Op Unit Extension 68816.
Visiting hours At the SOTC we realise how important the support of family and friends is during the rehabilitation process. However, it is also important that patients receive optimal care and rest periods throughout the day. Therefore our ward visiting hours are:
15:00 – 17:00
19:00 – 20:30
(3 - 5pm and 7- 8:30pm)
Monday – Sunday.
You will have your operation performed by a trained specialist orthopaedic surgeon.
We would like to introduce you to the Consultants who perform total knee replacement surgery at SOTC. (Don’t worry if your surgeon isn’t pictured here, we are an expanding centre and look forward to welcoming new colleagues in the future!).
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Enhanced recovery is a new approach to the way that care can be delivered to patients having certain operations. This includes total knee and total hip replacement surgery. Enhanced recovery is a fully structured and well organised sequence of clinical care. All the staff looking after you will work from a specific programme, called a care pathway.
Enhanced recovery improves the way in which health care is organised to allow you to get better sooner after your operation. Research indicates that after surgery the earlier you get out of bed and start eating and drinking, the better. Your recovery will be quicker and complications are less likely to occur.
Benefits of ERP include:
Stages of ERP:
These are the key stages for the enhanced recovery programme:
We will tell you a little more about how we organise each of these in the next few pages.
Why have I been referred for a total knee replacement?
Your GP will have referred you to a specialist orthopaedic surgeon who will discuss with you the risks and benefits of a TKR, and whether this is the right choice for you. Most patients undergo a total knee replacement (TKR) because they are getting pain or stiffness in their knee caused by osteoarthritis (OA). The next few pages will explain a little more about the knee joint, OA and what a TKR involves.
Preparing for surgery
You are more likely to recover faster and more safely by adopting healthy living goals before your operation. In particular; stopping smoking, losing weight (if overweight), and trying to keep yourself active, will all help to improve your recovery. Also, if you are anaemic (lack of iron in your blood), or have poorly controlled diabetes, your GP may need to help you stabilise these problems before you come for your operation, as this may make the surgery safer.
Waiting lists
The waiting list time constantly changes, depending on how many referrals the surgeons receive. The waiting list may vary for different surgeons, this will depend on many factors including how many patients who the surgeon is looking after. Sometimes the surgeon you will have seen in outpatients will have a longer waiting list than another surgeon. If this is the case, and another surgeon has a free space, then the admissions staff may telephone you and ask if you would like your operation performed by another member of the total knee replacement team.
We would like to reassure you that all of our surgeons are competent, and take part in regular reviews and appraisals. All of their data is submitted to the National Joint Registry.
If you would prefer to stick with the surgeon that you have met, don’t worry, you are allowed! Please let the admissions staff know your preference when they call.
TKR surgery is considered for patients whose knee joints have been damaged by progressive arthritis, trauma or other rare destructive diseases of the joint. The most common reason for TKR is osteoarthritis (OA) of the knee. As OA progresses the cartilage is worn away and does not regenerate. The smooth joint surfaces are lost and friction develops. As this friction continues the surfaces of the joint become pitted, eroded and uneven (figure 2). Over time this can result in pain, inflammation and decreased mobility.
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Regardless of the cause of the damage to the joint, the progressively increasing pain and stiffness, and decreasing daily function, often lead the patient to consider TKR surgery.
Decisions regarding whether or when to undergo TKR surgery are not easy. Patients should understand the risks as well as the benefits and discuss with their orthopaedic surgeon before making the decision.
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In a TKR surgery a thin section of bone is taken away from the end of the femur (thigh bone) and the top of the tibia (shin bone). The bone ends are then replaced by metal surfaces. A polyethylene (plastic) spacer is placed in between the two metal surfaces to allow for smooth frictionless movement.
The back of the patella (kneecap) may also be replaced with a new plastic surface. This is called a patella button. Whether or not the patella surface is replaced depends on the amount of arthritic wear found in the patellofemoral compartment.
In some patients the arthritis affecting the knee joint may not affect all of the surfaces of the bones. In these cases a unicompartmental knee replacement may be considered. This involves replacing the joint surface only in the compartment affected by the damage.
There is no difference in the rehabilitation precautions and guidelines following unicompartmental knee replacement and TKR, but the recovery period is often a little quicker.
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Revision knee surgery involves the repair of an artificial knee joint that has been damaged or loosened over time, or as the result of infection. The majority of revision knee operations require restoration or replacement of lost bone. Bone grafting procedures may alter the post operative management. Patients may be required to use crutches and follow the knee precautions (similar to primary TKR) for longer periods. At times rehabilitation may progress more slowly than after a primary TKR.
All patients undergoing revision surgery will spend a night in the ‘Level 1’ ward bay, where patients are very closely monitored. They are usually moved onto the main ward the following day, after the doctors’ ward round.
Even though patients vary in the speed of their recovery, we find that most people are able to achieve good function and go home between 2 to 4 days after surgery. However, the outcome of the revision surgery is also dependent upon the complexity of the surgery, your age, general health, the quality of your bone, and your previous level of activity.
A knee replacement is usually a very successful operation. However, as with all surgery there can be complications. We do not want to worry you, but we are obliged to make you aware of these (even if the risk is very small) so that you can make an informed decision about having your operation, and the risks involved. Over the next few pages we have put together some information about complications which may be experienced following knee replacement. Please note that this list is not exhaustive. Make sure to discuss any concerns you may have with your surgeon, who will be able to explain in more detail.
Some people are also more at risk of developing complications due to their own past medical history. Revision surgery also may involve higher risks of complication. The surgeon will discuss with you any complications that may be more relevant to you.
The National Joint Registry reports on the outcomes of joint replacements in England and Wales. This includes the number of patients who experience postoperative complications.
Its 10th Report, published in September 2013 reports that nationally 13.4% of patients undergoing a knee replacement reported a wound problem, 7.9% experienced bleeding, 9.6% were readmitted to hospital and 3.3% required further surgery.
If you would like to find out more information about complications the reports on the National Joint Registry are free and easy to access. Please visit http://www.njrcentre.org.uk for more information.
Infection
Unfortunately, despite many special measures being undertaken to reduce the risk, an infection can occur either in the wound, or deep inside of the new joint.
Wound infections are the most common, affecting up to 5% of patients. This is an infection in or around your skin. They can settle on their own or may require antibiotics.
A Deep infection (approximately 1%) is where bacteria grow inside your new knee. This can happen slowly and not cause problems for months or even years. Deep wound infections can make you feel ill and cause you pain as the infection develops.
If an infection is diagnosed early enough, then the knee can be washed out. This can cure the infection in some cases. If this is not successful, or the infection is found too late, then the joint may have to be removed. Unfortunately, each time that you have surgery more damage is done to the muscles around your knee, resulting in a poorer outcome.
Stiffness
If you do not get your knee moving it will remain stiff forever. You must take adequate pain relief so that pain does not stop you from moving your knee and to enable you to do your physiotherapy exercises to help prevent this from happening.
Pain
As your joint starts to gain movement it can become painful. There are many things that can be done to help decrease your post-operative pain. These are explained later in this booklet.
About 1 in 5 patients report permanent pain at the front of the knee. This is more common if you had this pain before. Sometimes, having the knee replacement can make this pain worse.
There are other causes of pain around a new knee. If you are in pain after your knee, let your surgeon know.
Swelling
There is often some extra fluid around a new knee, which may make your knee feel constantly swollen.
It is common for your ankle to swell up for many months after a knee replacement.
Blood clot (Deep vein thrombosis / DVT)
This is a blood clot in one of your big veins of the leg. You can get a DVT in your leg by periods of immobility, such as a plane flight. Knee surgery is a high risk factor for getting a clot. Up to 80% of patients would get a blood clot if they didn’t have preventative treatment. The likelihood of developing post-operative DVT depends on many different factors. Your general health, medical history and post-operative mobility will all have an influence. There are also some additional risk factors such as; obesity, smoking, and previous history of DVT, which may increase this risk.
We use multiple methods to lower that risk. These are explained later in this booklet (see page 29). Despite all of the efforts to reduce the risk of DVT, it is still possible to get a blood clot in your leg. In some cases this clot can travel up to your lung (0.3% of patients). There is a very small chance that you may die if this was to happen (0.05%).
Bleeding and haematoma (Bruising)
In order to reduce your risks of DVT you will be given a drug to reduce your blood clotting. This has a side effect of increased bleeding. Usually the bleeding is just around / inside your knee. This usually clots off to form a giant clot within the soft tissues called a haematoma or bruise. (This is not a DVT as it is not inside one of your veins).
Sometimes the bleeding is more severe, and it can form a large bruise that affects your whole thigh /calf. You may notice bruising coming down around your ankle. Rarely, your surgeon will have to take you back to theatre to remove the haematoma.
Nerve or vessel damage (1 in 300 to 500)
The large nerves and blood vessels that supply your leg run close to your knee joint. These can be damaged in the operation, most commonly by either being harmed by one of the instruments, or by your nerve having its blood supply interrupted by swelling.
The damage to the nerve can vary from mild bruising, where it will not work for a few days to a few weeks, to severe and permanent damage to a nerve. Nerve damage can result in part of your leg not working. It may also result in severe pain.
To do a knee replacement, the surgeon will make a cut over the front of the knee, this damages the nerves that supply the skin. As a result of this the skin on the outside of this will always feel numb.
Wear
Modern knee replacements have come a long way even compared to 10 years ago. However, it may eventually wear out. This will result in you needing it exchanged. It is very important that you do not try to ‘save the knee’ by not walking on it. A knee that has regular activity will perform better than one that is not used.
Sometimes the knee can become loose within the bone, or the moving parts can break. This can cause damage to your bones. If you start getting more pain in your knee in the future you must seek medical advice.
Fracture
The new knee is fitted to your bone carefully. Your bone has to be specially prepared in order to accept it. Rarely, one of the bones in your leg can fracture during this process.
Usually this rare occurrence is recognised during the operation. In some cases it may not be possible to recognise the fracture during surgery, as the fractures can be small, or hidden. In these situations the fracture will normally be seen when the X-ray of your leg is taken after the operation.
The fracture may need to be fixed, and this could result in another operation. Sometimes protecting the fracture by restricting the amount of weight that you are allowed to put through the leg for a period of weeks, can be sufficient to allow the fracture to heal.
As people get older, their bones often get more fragile. If you have a knee replacement and fall over, the bone around your new knee may break. This will then need an operation to correct it.
Instability
Your own knee had ligaments to control its movement. These can not be replaced in a knee replacement. The control is now done by the shape of the knee. This may make it feel ‘unnatural’. You may also experience a clunking noise.
Blood transfusion
It is relatively rare to require a blood transfusion if you were not anaemic preoperatively. These have risks too. The medical team will discuss these with you if you need to have a transfusion.
You will attend the pre-operative assessment clinic at the hospital where you will be assessed by a nurse. You may see an anaesthetist. They will;
When you attend the pre-assessment clinic you will also be seen by the physiotherapist and occupational therapist (OT) in ‘Joint School’ (or on an individual basis where necessary). Joint school consists of an informative presentation by the therapists. You will find out more about the role of the physiotherapist and OT, including adaptations to your home environment, exercise programmes and advice on returning to your normal activities.
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Occupational Therapy (OT)
The occupational therapy team will assess your ability to manage at home and give advice about adaptive ways of completing tasks after your operation. They will also organise the provision of equipment in your home environment (such as a raised toilet seat or perching stool) where required.
Physiotherapy (PT)
The physiotherapy team will assess your mobility, advise you on exercises and walking, and discuss the phases of recovery.
You will need to make plans for going home before you even come into hospital. The time you will be in hospital is not long. This information might be useful to talk through with a friend, carer, or family member to ensure you have the practical support in place to aid your recovery. The following points will help you prepare for your surgery:
My to do list
Occupational Therapist advice
Prior to your surgery you will need to think about how you can adapt your home so that you can perform your daily tasks with minimal exertion. These adaptations are outlined below, you will also be able to discuss them with your occupational therapist before your surgery if necessary. These adaptations may include:
Assistive devices:
Depending on your essential needs at home after surgery, the occupational therapist may recommend certain other adaptations or equipment. The occupational therapist will discuss these issues with you if they arise.
Nutrition
Your nutritional status is an important component of your overall health. It provides the building blocks for your body to adequately heal and fully recover from your surgery. Therefore, it is best if your nutritional status is optimal before your surgery. Try to eat healthy, balanced meals with plenty of fruit and vegetables.
If you are overweight, your doctor may prescribe a weight loss programme prior to your surgery since excess weight on an operated joint will increase the risk of requiring further surgery. Excess weight can also cause complications during surgery. If required, you should aim to lose weight gradually at approximately 1-2 Lbs per week, losing weight rapidly can compromise your health. Your doctor or a qualified dietician/nutritionist should supervise your weight loss.
If you are on a doctor-prescribed diet before you come into hospital it is important that you tell the nursing staff and the Sussex Orthopaedic NHS Treatment Centre doctor.
Please note: Personal articles and clothing should be limited. There is very little storage space on the ward. Remember that you will require items for your trip home as well as those for your hospital stay. Things to include are:
Please do not bring to the Centre:
Although we will take all reasonable steps to ensure the safety of your personal property, the staff cannot guarantee security of your personal items.
Spiritual support through the Hospital Chaplaincy
The SOTC formally recognises the role that spiritual support can play in coping with and recovering from physical illness. To help meet your personal needs, the Centre provides chaplaincy and spiritual support services.
You will be telephoned the afternoon before your procedure to advise you of the time to attend the centre. It is essential you are available to take this call please note if we are unable to contact you your surgery may be cancelled. Patients having surgery on Monday will be rung on either Friday or Saturday.
Please telephone the Pre-operative unit if you have a cold or you are unwell, as your surgery may need to be postponed.
NIL BY MOUTH FASTING RULES FOR ERP PATIENTS
DISREGARDING THIS INFORMATION MAY RESULT IN THE CANCELLATION OF YOUR PROCEDURE.
Should you have any questions regarding the information provided please call the centre on 0333 200 1728.
Pre-Operative Instructions For The Day Of Surgery.
A waiting area is provided for individuals accompanying patients.
Please follow the instructions given at your pre-assessment appointment regarding your medications and stop all herbal medication 7 days before surgery.
Should you require a sick note please inform your nurse on admission.
The inpatient ward does not allow flowers due to the risk of infection. Please inform your visitors of this rule.
PLEASE CONTINUE TO FOLLOW THE NIL BY MOUTH RULES.
Meeting The Anaesthetist and Surgeon.
When you arrive at the hospital, you will go to the admission area and be seen by the doctors from the anaesthetic and surgical teams who will be looking after you during the operation. The anaesthetist will explain the type of anaesthetic you are having, and the way in which pain will be controlled after the operation. This is very important, as being comfortable means that you will be able to get up and about more quickly after your operation, and this will speed up your recovery.
As part of the enhanced recovery programme the anaesthetist and surgeon will work together to minimise the stress on your body during the operation. This is achieved by:
Anaesthetic Information (Modified from Royal College of Anaesthetists) www.youranaesthetic.info
Introduction
You may have heard that there are several different types of anaesthetic for TKR. These include:
For patients undergoing a TKR at SOTC, as part of the enhanced recovery programme, the most commonly used anaesthetic technique used is a combination of spinal anaesthetic with sedation, or light general anaesthetic. This means that you will be unaware of what is happening in theatre.
Your anaesthetist will explain which anaesthetic methods are suitable for you, and help you decide the best options for your surgery.
A spinal anaesthetic
This is by far the most commonly used type of anaesthetic for TKR within the enhanced recovery pathway. A measured dose of local anaesthetic is injected near to the nerves in your lower back:
Advantages, compared to a general anaesthetic
Common side effects of spinal anaesthetic
Rare complications
A general anaesthetic
For some patients, a spinal anaesthetic is not possible for medical reasons, or you may prefer a general anaesthetic.
A general anaesthetic produces a state of controlled unconsciousness during which you feel nothing. You will receive:
You may need a breathing tube in your throat whilst you are anaesthetised to make sure that oxygen and anaesthetic gases can move easily into your lungs. If you have been given drugs that relax your muscles, you will not be able to breathe for yourself and a breathing machine (ventilator) will be used. When the operation is finished the anaesthetic is stopped and you regain consciousness.
Advantages
You will be unconscious during the operation. Disadvantages of a general anaesthetic
Common
Less common
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An epidural
This is very similar in its effects and side effects to a spinal anaesthetic (see pages 15-16). However, it can be topped up post-operatively and is most likely to be used if you are having both knees done at the same time (a bilateral procedure), or are having your joint replacement re-done (revision surgery).
A nerve block
Rarely used in an enhanced recovery programme This is an injection of local anaesthetic near to the nerves that go to your leg. Part of your leg should be numb and pain-free for some hours afterwards. You may also not be able to move it properly during this time.
If you are having a general anaesthetic, this injection may be done before the anaesthetic starts, or it may be done when you are unconscious.
Advantages of a nerve block
Disadvantages of a nerve block
A combination of anaesthetics
Many patients having a spinal (or/and epidural anaesthetic in some situations), will also be either sedated or put lightly to sleep during the operation. YOU DO NOT HAVE TO BE WIDE AWAKE.
Post Anaesthetic Care Unit (PACU)
After surgery you will be moved from the operating room to the post anaesthetic care unit (PACU). In PACU you will be given oxygen, an intravenous line delivering fluids, and your pulse and breathing will be monitored until the anaesthetic wears off. Your blood pressure will also be checked regularly whilst you are in the recovery unit. The nursing staff will take the drip out of your arm as soon as possible, and you will be encouraged to eat and drink. You should also start your breathing and leg exercises (page 29-30). You will remain in PACU until you no longer require close monitoring. The anaesthetist or lead nurse will authorise your transfer to the ward when your vital signs are normal and stable.
On the SOTC Ward
Pain management
At the Sussex Orthopaedic NHS treatment Centre we provide a multidisciplinary approach to help manage any discomfort that you may experience from your surgical procedure. Following your surgery, the staff will regularly check if you have any pain and will adjust your pain medication to ensure you are as comfortable as possible.
Your pain after surgery will initially be controlled by a regional anaesthetic (usually a spinal block, but occasionally an epidural). When the effects of the spinal anaesthetic start to wear off, you must ask the nursing staff for oral pain medication.
The nursing staff are well trained on how to manage your pain. Additionally there is an acute pain team (APT) who do a ward round most week days to discuss your pain control. If the APT are not available, the nursing staff can contact the anaesthetist for advice.
The nursing staff will actively encourage you to take the medication that you are prescribed. You will have medication that will be given regularly, and medication for ‘breakthrough’ pain (‘breakthrough’ medication is for when you have pain between regular doses). Make sure you let the nursing staff know if you have pain. It is essential for your recovery that your pain is controlled; to enable you to walk, and to do your exercises.
Your pain is easier to control if you do not allow it to become severe before taking pain medication. Therefore it is very important that you tell your nurse or anaesthetist as soon as you are experiencing any discomfort, where the pain is located and if it changes in nature or intensity. For example, sometimes pain is constant and other times it comes and goes. Using ice packs can also work well for post-operative pain around the wound site. Please speak to your nurse or physiotherapist for advice about this.
Remember: please bring in and handover all of your medication to the nursing staff on the ward.
Pain scale
You will be asked to rate how much pain you have on the Pain Scale below:
0 1 2 3 4 5 6 7 8 9 10
No Pain - Moderate Pain - Extreme Pain.
Nutrition and wellbeing
On your return to the ward you will be provided with nutritional drinks 3 times a day for the first 2 days. These drinks are IN ADDITION to regular meals and snacks. This combination will keep you hydrated and promote wound healing. During your hospital stay it is important to eat balanced, nutritious meals with adequate calories and protein to maintain your health. If you have any special dietary needs please inform the catering staff upon your arrival to the ward. When selecting from your menu, choose balanced nutritious meals. Remember that your body is healing and requires extra protein to assist in the rebuilding process.
If you feel nauseated, please let the nursing staff know. They will address this. Once the nausea has subsided it is very important you try to eat and drink as normal again. DO NOT stop eating or drinking because you feel unwell, as this will affect your recovery.
Constipation
Constipation may occur after surgery either as a side effect of the pain medication or because of reduced physical activity. To solve this problem:
Physiotherapy
Exercise is an integral part of your rehabilitation following TKR surgery. The exercise regime given to you by your physiotherapist will help you to regain optimal function from your new knee, as long as you perform them regularly. Remember, you make the difference! It is extremely important that you understand that your motivation and participation in your recovery is vital in achieving the goals set out for you.
Occupational Therapy
During the course of your stay in the hospital, the occupational therapist will visit you in the ward and review your home setup with you. This is to ensure all necessary equipment is in place. They will also advise you about both your personal and domestic daily activities.
How you can help with your recovery
By actively participating in your exercise and rehabilitation programme, you will obtain the best functional recovery. We appreciate that you will have some discomfort as you participate in your rehabilitation, but it is important that you do not avoid activity. Your recovery will be faster and the results more desirable if you persist with the rehabilitation (this includes when you go home!)
NOTE: The Progress Guidelines shown below are milestones rather than events locked to a given day. Some patients may progress through several phases in one day, whereas others will take several days to progress through the phases.
On the day of surgery you can expect:
Phase 1
Phase 2
Phase 3
Below are the 2 precautions that YOU MUST FOLLOW for at least 6 weeks after your surgery to protect the new joint.
1. Avoid twisting on your operated Knee.
2. DO NOT cross your legs or ankles when lying, sitting or standing.
3. DO NOT Kneel onto your operated Knee.
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Exercises
The exercises in the following pages are a part of your individual exercise programme. The physiotherapist will advise you which exercises to perform, and when you can progress them at home. It is essential that you are an active participant in your recovery to help your body and your knee to knee regain strength. As your body heals you may feel some stiffness and mild soreness in various muscles. These feelings are normal, however, the exercises should not cause excessive pain. If a particular exercise is causing excessive pain stop performing it and contact the physiotherapist. The combination of exercise with rest, ice packs (if necessary) and pain medication will ensure that you get maximum benefit from your TKR surgery.
If you cannot manage the number of repetitions indicated in this booklet start with as many as you can manage and build on this number as you become stronger. Remember little and often is best, so try and make sure you space your exercises out throughout the day.
Preventing circulation problems
After your surgery you are at a higher risk of developing blood clots, also known as Deep Vein Thromboses (DVT). In order to minimise this risk you will be prescribed anticoagulant (blood thinning) medication and compressive tights (called TED stockings). Regular circulation exercises are also of great importance to prevent DVT. These gentle exercises improve blood flow and maintain muscle function. However, it is still important to be aware of the signs that indicate that you may have a DVT, both in hospital and when you return home.
Some signs and symptoms of DVT are:
If you notice any of these signs tell your nurse so that we can investigate and take appropriate action if required. This usually only involves a simple increase in medication or prescribing an alternative medication.
Preventing lung problems
After deep breaths are necessary to fully ventilate your lungs and help keep the airways free of mucus and infection. It is important to regularly practice the breathing exercises shown below.
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DEEP BREATHING
Repeat this every half an hour.
Early Exercises
Please start these exercises as soon as you are in the recovery unit after your operation. You should also practise the exercises on this page before your surgery to help with your knee strength and movement.
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KNEE FLEXION
Lying on your back.
Repeat 10 times, 3-5 times per day.
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STRAIGHT LEG RAISE
Lying on your back.
Repeat 10 times, 3-5 times per day.
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STATIC QUADS
Lying on your back.
Repeat 10 times every hour.
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ANKLE PUMPS
Lying or sitting.
Repeat 10 times every hour.
Early Exercises
Your Physiotherapist will guide you when to start these exercises after your operation. You should also practise the exercises on this page before your surgery to help with your knee strength and movement.
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INNER RANGE QUADS
Repeat 10 times, 3-5 times per day.
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ACTIVE KNEE EXTENSION IN SITTING
Repeat 10 times, 3-5 times per day.
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PASSIVE KNEE EXTENSION
Repeat 3-5 times per day.
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ACTIVE KNEE FLEXION IN SITTING
Repeat 10 times, 3-5 times per day.
Standing Exercises
Your physiotherapist will guide you when to start these exercises. You also need to continue with your early exercises so space them out regularly throughout the day.
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ACTIVE KNEE FLEXION
Repeat 10 times, 3-5 times per day.
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CALF RAISES
Repeat 10 times, 3-5 times per day.
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MINI SQUATS
Repeat 10 times, 3-5 times per day
START …………………………………………………..
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STEP UPS FOR STRENGTHENING
Repeat 10 times, 3-5 times per day
START……………………………………………………
Stairs Technique
Your Physiotherapist will guide you when you are ready to practise the stairs. Please do not attempt the stairs on the ward unless the physiotherapist is with you. The instructions below will help to make sure you have the correct technique.
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GOING UP THE STAIRS
Hold onto the rail with one hand and crutch in the other (or
use 2 crutches if you have no rail)
Always go one step at a time
To help you remember GOING UP
UNOPERATED LEG - OPERATED LEG - CRUTCH.
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GOING DOWN THE STAIRS Hold onto the rail with one hand and crutch in the other (or use 2 crutches if you have no rail)
Always go one step at a time
To help you remember
GOING DOWN: CRUTCH - OPERATED LEG - UNOPERATED LEG.
Walking with crutches
Your physiotherapist will teach you how to walk with crutches. Some patients will use a walking frame when they first get out of bed, but will soon progress onto crutches as directed by the physiotherapist The general principle is to place your crutches forward first (making sure they are wide enough for your feet to step through). Next, step your operated leg, and then follow with your good leg. Please ask your physiotherapist for advice on this.
CRUTCHES - OPERATED LEG - UNOPERATED LEG
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Showering / washing yourself
Dressing
When can I go home?
You should start to discuss your discharge with staff as soon as you are back on the ward. Some patients may be able to go home the day after their surgery. Most patients are discharged 1-3 days after surgery.
Goals for discharge:
The doctors, nursing staff, physiotherapist and occupational therapist will be in regular contact with you and your family throughout your hospital stay. They will assess your progress and tailor your follow up care to meet your needs. The nursing staff will constantly be planning your discharge and each individual is different. Before discharge you will be told:
Please try to get a friend to pick you up from the hospital, if they have suitable transport. Please note that Pharmacy at the hospital is very busy and you may have to wait some time before your drugs arrive on the ward.
If you decide to get patient transport please be advised there is a long wait on the day, as this is a service that is in extremely high demand.
Travelling by car
You should not drive for the first six weeks following your surgery, until your surgeon has cleared you to do so. Speak with your insurance company as they may have policies surrounding using a car after surgery. You can be a passenger but be careful that the seat is not too low. The following guidelines may help:
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Looking ahead: Advice for Home
After TKR surgery patients do not usually require ongoing physiotherapy but you will need to continue the exercises on your own at home. The Centre itself does not provide outpatient rehabilitation. However, if your therapist feels that you require ongoing therapy they will refer you to the appropriate teams.
Please bear in mind that recovering from surgery can be a very tiring process, and can feel frustrating at times. You may wish to keep visits from friends or family spread out over the first few weeks, to enable you to have time to rest and recover.
Wound care
The nurse that discharges you will run through all of the advice you need for wound care and give you a letter that explains when you should change your dressing. The senior nurse from the ward will phone you two consecutive days after you are discharged home to check you are managing well, and to answer any questions you may have. It is also important that you are able to recognise the signs and symptoms of infection:
If you have any of these symptoms ring the centre immediately and the Nurse/Dr will inform you what to do.
Scar massage
Once your wound is healed, and no longer requiring dressings, you can start to massage the scar. This will help it to flatten and be flexible. Use a non-perfumed moisturising cream and apply firm pressure in a small, circular motion. You should aim to massage it for 2-3mins, at least twice per day.
Long term protection against infection of your artificial joint
Although it is very rare an artificial joint can become infected from another infection in your body. It is important that bacterial infections such as pneumonia, urinary tract infections, or abscesses are treated promptly by your GP, as there is a small risk that it could affect your prosthesis.
How do I manage meals, snacks and drinks?
How will I manage my food shopping?
What about cleaning and laundry?
Progressing your mobility
Most patients who are discharged from hospital will be independently walking with two elbow crutches. When walking, you should use two elbow crutches until you are confident and safe to walk with one crutch. Continue to use two crutches if you have pain, or a limp when walking with one crutch. In the same way, once you feel confident with one crutch you may progress to walking independently with no crutch.
When using one crutch always use the crutch in the opposite hand to the operated leg.
As a rough guideline by the six week follow-up review with your surgeon you should be walking with one crutch outdoors and no crutch indoors. However, it is important to remember everybody is different, you should only progress your mobility if your body is comfortable with it.
The rule for progression is to only progress when you can walk without pain or a limp.
You should do a little bit more walking everyday as is comfortable for your body. Again this is different for everyone depending on your ability and pain levels. It is better to do 3 or 4 short walks a day in the first few weeks rather than 1 long one and wearing yourself out. Keep away from steep hills and slopes for 6 weeks, but gentle slopes are fine if negotiated slowly and safely.
If you are overdoing it, you will most likely be sore, swollen and tired. This is an indication you should cut back your activity levels a little, and pace yourself, so you have adequate rest between activities. Never completely stop all activity unless advised by a medical professional.
Swelling management
Swelling is a normal part of the healing process following TKR. Your knee and leg may remain swollen for several months after your surgery.
To manage the swelling we recommend that you rest for up to an hour in the bed at least once a day in the first six weeks. We also advise that you frequently elevate your legs on a footstool when sitting to help manage the swelling. You must make sure that the leg is held straight, and that you do not place a pillow underneath your knee when resting.
Ice is a natural anaesthetic that helps relieve pain and control swelling. If your knee is swollen applying ice or a bag of frozen peas can help reduce the pain and swelling. Do not leave the ice on for more than 20 minutes at a time and make sure that it is wrapped in a thin towel and plastic bag to protect your wound. You can use the ice as much as required but not more than once an hour.
When can I begin driving?
Most patients are able to resume driving about 6 weeks after surgery. This will depend on the position of your prosthesis, muscle strength and coordination and overall healing. You should not attempt driving until you feel safe to control the car, and can do an emergency stop. You MUST obtain clearance from your surgeon before driving. Failure to do so could render your car insurance invalid.
When can I return to sport?
Our duty is to educate patients regarding risks associated with higher levels of activity after TKR, which include: implant loosening, accelerated wear of the articulating surfaces and injuries. Please discuss returning to sports with your surgeon at 6 weeks post surgery follow up appointment.
When can I fly?
Most orthopaedic surgeons advise their patients not to fly for at least 6 to 12 weeks after a TKR. It is possible that sitting for a long period of time, in a confined space could greatly increase your risk of developing blood clots in the legs, Deep Vein Thrombosis (DVT).
If you have to travel by plane during the first 6 weeks after your TKR you must discuss this issue with your surgeon and GP.
Sexual relations after a total knee replacement
Will I be able to resume sexual relations, and when?
The vast majority of patients are able to resume intercourse after TKR. Patients who have had impaired sexual relations because of knee pain or stiffness usually find that after surgery their knee is pain free and has better motion. After knee surgery we recommend that you do not resume sexual relations for 4-6 weeks to allow the muscles time to heal, and also avoid positions which involve kneeling on the operated knee.
How long do I have to continue with the knee precautions?
You will need to follow knee precautions 6 weeks after your surgery. After 6 weeks you can resume these movements and activities as you feel comfortable to do so.
With your Surgeon
Follow up appointments with your surgeon are necessary regardless of how well you feel. They will want to check how you are progressing, how the wound has healed and if the scar has formed correctly. This appointment will normally be approximately 6 weeks after your operation. You will be notified by post of your appointment date and time after you have been discharged from the ward.
At the 6 week appointment you can discuss any issues with your surgeon. These may include whether you can start driving, and when you will be able to return to specific sports. Remember to write down in the back of this book any questions you may have that you would like to ask your surgeon at your follow up appointment. Your surgeon is the only person who will be able to make the ultimate decision regarding returning to specific activities, based on your progress at this point.
With Physiotherapy/Occupational Therapy
As previously stated not all patients require physiotherapy after they are discharged. . However, if you become concerned about your progress, or would like some guidance after you have gone home please contact the physiotherapy department for advice. The number can be found at the front of this booklet.
Similarly not all patients require help at home. If staff feel that these services are necessary, they will be arranged whilst you are in hospital, and you will be informed before you go home. The centre itself does not provide these services as on-going care is carried out by local community NHS teams once you are discharged.
Useful websites
Princess Royal Hospital.
This information is intended for patients receiving care in Brighton & Hove or Haywards Heath.
The information in this leaflet is for guidance purposes only and is in no way intended to replace professional clinical advice by a qualified practitioner.
