Your new knee handbook

Your new knee

If one of your knees has become so painful that it interferes with your everyday life, your doctor may recommend you for knee replacement surgery.

This involves the surgeon replacing the ends of your damaged bones with manmade materials to form a new joint that will give you better mobility and the potential to be pain free.

Fitter first means better faster

As you go through your Handbook, you will notice that one of the things we encourage is for you to be as fit and prepared for your operation as possible.

The reason for this is simple: the stronger and fitter you are before your knee replacement, the quicker you will recover after it.

It means that you will need to do the exercises on page 13 of the booklet at the bottom of this page, and carry on with as much gentle exercise (like walking or swimming) as you can manage. Of course, it’s not easy to exercise with a bad knee, but the more you can do, the better it will be. Remember, little and often works best.

Before your operation

Pre-op assessment clinic

A nurse will ask about your general health and will record your pulse and blood pressure. You will also have a short medical examination to make sure that you are fit enough for an anaesthetic and your operation.

bring along

• A record of all your usual prescription medicines (if you do not have your repeat prescription, please bring your medicines along).
• A sample of urine.

remember

• We will give you the blood test form at this clinic - keep it safe until your blood test appointment

Pre-op information school

You may be asked to attend our pre-op joint school, where a member of the therapy team will explain how to prepare for your operation, show you the exercises you need to do, and the goals you will need to achieve before discharge.

bring along

• Your new knee handbook.

remember

• Come prepared with any questions you may have.

Blood test

You will need to have a blood test one to three days before your operation. We will give you the blood test form at your pre-op assessment appointment and let you know where and when to go to have the test.

bring along

• Your new knee handbook.
• Your blood test form.

Important information

The information videos will help you to:

• understand more about the surgery
• prepare for your return home after the operation
• explain about your hospital stay and therapy
• understand what will happen when you are discharged home

To visit the Trust website, type the following into your web browser: www.gloshospitals.nhs.uk/our-services/services-we-offer/enhanced- recovery-after-surgery-eras/

This will open the Enhanced recovery after surgery (ERAS) page. At the bottom of the page, you will find the ‘Useful resources’ section. Click on the links to watch the information videos.

Be prepared

There are a number of things you can do before your operation to make life more comfortable after.

Keep fit

The fitter you are before your operation, the quicker you will recover after it.

Of course, staying fit with a knee that needs replacing is never going to be easy, but it’s important to try. In the weeks and days before the operation, make sure that you keep up with the exercises on page 13 of the booklet at the bottom of this page and try gentle exercise such as walking and swimming.

Ask for help

Ask a friend or relative to help you at home for a week or two after you come out of hospital. Don’t worry, you won’t need someone full time – it is just support with practical things like preparing meals, putting the bins out and walking the dog!

Arrange transport

Ask someone to take you to and from the hospital. It could be the same person that gives you a lift to the clinics.

Prepare your kitchen

Make sure you arrange your kitchen so you can avoid bending unnecessarily. Organise your fridge and shelves so things are within reach.

Stock your freezer with your favourite meals and your cupboards with food that is easier to prepare so you can avoid long periods standing in the kitchen.

Once home after surgery you need to avoid using low ovens, instead cooking with the hob or microwave.

You may want to organise a place to eat in the kitchen to avoid carrying your dinner whilst still using walking aids.

Check your medicines

In the weeks before your operation, follow advice from your doctor or the pre-op assessment clinic on your routine medications especially if you are taking Aspirin, Warfarin or Clopidogrel. Stop taking herbal medications two weeks before your operation.

If you feel unwell

Get in touch straight away if you become unwell between your pre-op assessment appointment and your admission date, for example if you have:

• A cough, cold or chest infection.
• A urinary infection.
• A skin infection (or broken or sore skin).

By letting us know, we can make sure that you are fit for your surgery and that your operation is not cancelled on the day.

Gloucestershire Royal Hospital

0300 422 8561

Cheltenham General Hospital

0300 422 4206

The day of your operation

Before you arrive

Don’t eat!

Morning admission – do not eat anything after midnight and drink water only until 7:00 am.

Afternoon admission – do not eat anything after 7:00 am and drink water only until 10:00 am.

Get clean

To stop any unwanted bacteria coming into hospital with you, it is important that you have a bath or a shower and wash your hair before you come in. Remove any nail polish. Dress in freshly-washed clothes.

Medicines

Do not take diabetic medicine or insulin on the day of your operation, take your usual medicines at the normal time (unless you have been told otherwise by your doctor or pre-op assessment clinic) with a small amount of water.

Bring your current medication and inhalers with you, preferably in the original packaging, and a written list of these with doses. If you hold X-rays or scans, bring these with you too.

Pack a bag

The chances are, you will be discharged from hospital the same day as your operation, or the day after. You will therefore only need a small overnight bag with clean clothes such as comfortable shorts, knee length skirts and t-shirts, avoid clothes with zips or metal buttons where possible. Please bring your washbag and a towel. Please don’t bring valuables like watches or jewellery.

At the hospital

1. Please go to Orthopaedic Admissions suite (OAS) on the 2nd floor of St Paul’s Wing, Cheltenham General Hospital. You will be told your position on the operating list, which will give you an idea of how long you have to wait. Space is limited so please arrive with only one carer or friend who is welcome to stay for about 30 minutes.
2. Relatives can ring the ward after 1:00 pm for a morning admission or after 5:00 pm for an afternoon admission so that they can find out if your operation has gone ahead and the name of the ward you are in.
3. The anaesthetist and surgeon will take you to one of the private cubicles to discuss your operation.
4. You will be anaesthetised by a specialist doctor who will look after you during the operation. For most patients having a knee replacement, a spinal anaesthetic will be used. You will be sleepy but awake and you won’t feel a thing.

After your operation - On the ward

Pain relief

Your knee will hurt, but the pain will vary and some days will feel worse than others. It is important to take sufficient pain relief that enable you to do your exercises - this is the case at home too.

If you’re finding it hard to manage, tell us. We want to help you get better as quickly as possible.

Remember, it will get better!

Getting up and about

We aim to get you out of bed and moving on the day of surgery wherever possible - a member of the team will help you. You will be assisted to get dressed into your day clothes as soon as possible after the operation

Therapy

Our therapy team are here to help you regain movement, strength and control around the knee. Our job is to encourage you to get back to normal as soon as possible, including being able to walk comfortably and manage stairs.

Be prepared to work hard with your rehabilitation and be motivated. Your knee will be painful when you first start physiotherapy, but it will get better!

Aim to achieve each of these goals:

• Getting yourself washed/ bathed
• Getting yourself dressed without help
• Mobilise with a walking aid
• Managing steps/stairs if appropriate

Exercise

Thigh squeezes

With your legs out straight in front of you:

Push the back of your knee down by tightening the muscles at the front of your thigh. This can be done on the bed or when you are sitting with your leg on a footstool. Hold 5 seconds, Repeat 10 times.

Knee Bends

Sitting in a chair - Bend your knee as much as possible by sliding your foot under the chair. Then try and straighten your knee out fully in front of you.

Repeat 10 times.

Squats

In standing and holding on to a work surface or something stable. Keep your feet shoulder-width apart and bend your knees as far as you feel comfortable. Keep your weight over your heels equally through both legs. Repeat 10 times.

Lunges

Stand in front of a step and make sure you have something to hold on to for balance. Place the foot of your operated leg onto the step.

Gently lunge forwards, taking your knee over your toes to feel a stretch in the front of your knee. Try to keep your body upright.

Then, keeping your operated foot on the step, move backwards and try to fully straighten your knee. You should feel a stretch in the back of your leg. For an extra stretch lift your toes up. Hold for 5-10 seconds. Repeat this sequence 10 times.

Knee Extension Stretch

Sitting with the heel of your operated leg supported on a chair/stool (as shown).

Let gravity assist your leg to straighten in this position.

Build up to 5-10 minutes.

For images, see the PDF below.

More Advanced Exercises

Add in the following exercises once you are happy with how you can manage the exercises on the previous pages.

Hamstring Curls

Stand and hold on to a work surface or something stable for support. Take your operated leg slightly backwards and then bend your knee to take your heel towards your bottom.

Hold for 3 to 5 secs. Repeat 10 times.

Sit-to-Stand

Try to stand up from a chair and then sit down slowly, without using your arms. Try not to flop back down on the chair when sitting.

Repeat 10 times

(This can be made easier or more difficult by changing the height of the chair)

Balance

As soon as you can take all your weight, practice balancing on your affected leg. You may need to hold on to a work surface for safety.

After your operation - At Home

Leaving hospital

The aim is for you to go home the same day as your operation, or the day after. Your discharge date will depend upon:

• Your ability to get around safely.
• Your ability to wash and dress yourself.
• Your general health and pain control.

When you leave hospital, you will be given:

• An outpatient appointment to see a member of the orthopaedic team 3 to 12 weeks after your operation.
• Pain relief medication.
• In the unlikely event of you needing outpatient physiotherapy, this will be arranged.

Walking

It is important to take regular pain relief so that you can walk comfortably. You may need to continue doing so for a few months.

Try gradually building up the amount of walking you do, making a note of daily progress, including distance, terrain, gradient and pace.

Sticks

When you feel safe and confident with two sticks, try using one stick at home, holding it in the opposite hand to your joint replacement. It is

important not to limp or lean heavily on one stick. If you find yourself doing so, return to using two sticks.

It is up to your own ability and confidence when you decide to do without sticks entirely.

If you go home with elbow crutches, check at your next clinic appointment before using one crutch.

Stairs

You will be taught how to use stairs safely before you go home. When going upstairs you should place the non-operated leg on the step first, followed by the operated leg and finally your stick or crutch.

When going downstairs, place your stick or crutches on the lower step first, followed by the operated leg and then your un-operated leg.

Swelling

Swelling around the knee is very common after this surgery.

Exercise

Although it’s important to exercise your knee, it is also important not to overdo it. This may lead to increased swelling.

Ice

Ice can help to reduce the swelling; try wrapping a bag of frozen peas in a tea towel and putting this on your knee. Don’t leave it on longer than 20 minutes.

Elevation

It’s important to rest your knee as well as to exercise it. Sit with your leg up on a stool to reduce swelling.

After your operation - At home

In the bathroom

You will find it easier to have a shower rather than a bath. Step into the shower cubicle with your un-operated leg first and step out with your operated leg first. If you don’t have a shower and you don’t feel confident about getting into and out of the bath, continue to strip wash. If you are planning a bath, be aware it takes quite a lot of bending and strength in the knee to be able to get up from the bottom. It is harder to get out of the bath than in!

Frequently asked questions

Getting back to normal

I am taking regular pain relief but my knee still hurts

You may need to try a different pain relief medication. If your pain is not well controlled and if your sleep is significantly disturbed, speak to your GP or local pharmacist.

When can I drive my car?

You should be able to return to driving after six weeks - you must be able to perform an emergency stop. You will need to tell your insurance company about your surgery before you start driving again.

When can I do the housework?

You should be able to manage light housework (i.e. dusting) the day after you get home. Increase gradually to heavier housework (i.e. vacuuming) when you feel able.

When can I go swimming?

You can swim after six weeks as long as your wound is completely clean, dry and healed. Avoid breast-stroke until you’ve built up your leg strength.

When can I return to work?

It depends what work you do. Ask your GP for guidance.

When can I walk my dog?

Once you are confidently walking with one stick you can walk your dog. Walking over uneven terrain is good exercise for your knee. Just be careful of being pulled over by your dog.

Can I kneel on my new knee?

Yes, although 30 to 40% of patients find they are unable to do so.

Anaesthetics

What’s a spinal anaesthetic?

The anaesthetist will inject a local anaesthetic into your lower back. This will numb the nerves from your waist down to the toes for two to three hours. You will also usually be given a sedative, which makes you feel sleepy although you will remain conscious.

Why are they used?

Spinal anaesthetics are used whenever possible for knee replacements because they have fewer side-effects than general anaesthetics. They deliver excellent pain relief immediately after surgery which means that there’s less need for strong pain-relieving drugs and you’re less likely to suffer from nausea and vomiting. See page 22/23 for side effects of spinal anaesthesia.

What does it feel like?

Usually, you will have no unpleasant feelings and should take only a few minutes to perform. As the injection is given you may feel pins and needles or a sharp tingle in one of your legs - if you do, try to remain still, and tell your anaesthetist about it.

The spinal anaesthetic works quickly, usually within five to ten minutes. To start with your skin feels numb to touch and your leg muscles feel weak. When the injection is working fully you will be unable to move your legs or feel any pain below the waist.

During the operation you may be given oxygen to breathe to improve oxygen levels in your blood.

I’ve been told I’ll need a general anaesthetic

If you have a medical condition that would make spinal anaesthesia unsuitable, you may need to have a general anaesthetic for your knee replacement. Please see page 22/23 for information on side effects of general anaesthesia. Any decision will be discussed with you before your operation.

Frequently asked questions

Blood clots

Why could surgery increase my risk of developing a blood clot?

If you are inactive for a prolonged period of time, blood tends to collect in the lower parts of the body, often in the lower leg. This makes your blood move around the body more slowly, which could allow a blood clot (also known as thrombus (blood clot) or thrombosis (formation of blot clot).

Where might a blood clot form?

When a clot forms in one of the ‘deep veins’ in the leg, thigh, pelvis or arm it is known as Deep Vein Thrombosis (DVT). Blood clots may travel to the lungs from the deep veins. A blood clot in the lung is called a Pulmonary Embolus (PE), which can cause shortness of breath and chest pain. Very occasionally a PE can be fatal.

How do I know if I’m particularly at risk?

Some factors can increase your risk of getting a blood clot:

• Past or family history of a DVT or PE
• Cancer
• Over 60
• Problems with heart or lungs
• Immobility or inactivity
• Obesity
• Going on a long journey (more than three hours) in the four weeks before or after your operation
• Inflamed varicose veins
• Specific blood disorders

How can I reduce the risk of a blood clot?

• Get moving as soon as possible after your op (take your physiotherapist’s advice).
• Drink plenty of fluids.
• Use devices that help stop the blood collecting in your leg veins (we use calf or foot pumps on our wards).
• Quitting smoking will reduce the risk of blood clots as well as make it easier for you to recover from surgery. Ask your GP or pharmacist for advice.

Side-effects, complications and risks

Common and very common side effects

All anaesthetics

• Pain around injection sites and general aches and pains.
• You may not be able to pass water (urine) or you may wet the bed. This is because you are lying down, you may have pain and you may have received strong pain relieving drugs. A soft plastic tube may be put in your bladder (a catheter) to drain away the urine for a day or two. This is more common after spinal or epidural anaesthetics.

Spinal or epidural anaesthetics

• You will not be able to move your legs properly for a while.
• If pain relieving drugs are given in your spinal or epidural as well as local anaesthetic, you may feel itchy and /or sick.

General anaesthetics

• Sickness - treated with anti-sickness drugs.
• Sore throat or damage to lips or tongue - treated with pain relief drugs.
• Drowsiness, headache, shivering, blurred vision - may be treated with fluids or drugs.
• Difficulty in breathing at first - this usually improves rapidly.
• Confusion and memory loss are common in older people, but are usually temporary.

Uncommon side effects and complications

All anaesthetics

• Heart attack or stroke

General anaesthetics

• Damage to teeth
• Chest infection
• Awareness (becoming conscious during a general anaesthetic)

Rare or very rare complications

All anaesthetics

• Serious allergic reactions to drugs
• Damage to nerves
• Death

General anaesthetics

• Damage to eyes
• Vomit getting into your lungs

Anaesthetists take a lot of care to avoid all the risks given in this section. Your anaesthetist will be happy to give you more information about any of these risks and the precautions taken to avoid them. You can also find more information in ’Anaesthesia explained’ and in the leaflets about risks found on www.rcoa.ac.uk/patientinfo

Useful numbers

If you are a patient at Cheltenham General Hospital

Before admission

Tel 0300 422 2559

During inpatient stay

Bibury Ward

Tel 0300 422 4261

Snowshill Ward

Tel 0300 422 4004

After leaving hospital

Wound service.

Monday to Friday 9:00am to 3:00pm

Tel 07815 997068

Out of hours and Bank Holidays call Bibury Ward

Ward Therapy Team

Tel 0300 422 3247 or

Tel 0300 422 2222 and ask the

operator to bleep 1590

Pharmacy Patient Helpline

3:00pm to 4:00pm

Tel 0300 422 2805