> Before treatment
You will have a formal consultation with Mr Whitehouse to review your symptoms, perform an examination and review your investigations. On the basis of this, a proposed treatment plan will be formulated. This may or may not involve surgery depending upon what is most appropriate for you and your circumstance. This will also be an opportunity to discuss any concerns and questions you may have.
It is important that you stay active before and during any treatment, this will help to speed up your recovery and reduce the risk of any complications occurring.
> If I do need surgery, what happens after the first appointment?
If you decide that surgery is the right thing for you, we will find you a suitable date for this to happen. Our team will be in touch with you to confirm the date for surgery and confirm this is appropriate. In the week or two prior to the operation, you will have a pre-operative assessment with our nursing and/or anaesthetic team.
This appointment will involve going over your past medical history to determine if there is anything we need to do prior to surgery to make things safer for you. Your medications will be reviewed and you will be given instructions on what medications you should take or omit prior to your operation. You will also be told when you need to avoid eating food from prior to the operation and when you can drink clear fluids up until. It is important to know that chewing gum has the same effect on your stomach as eating food so this should be avoided too.
Please do tell us about any allergies that you have as this is important for us to know prior to your treatment. This includes things like allergies to metals such as nickel and plasters or dressings so these can be avoided. Rarely, we may need to arrange some tests, called patch testing, so allergies can be ruled out or confirmed.
> If I do need surgery, what can I do to prepare before coming into hospital?
If you do need surgery, it is important to get prepared prior to coming into hospital. There are simple measures that you can make to ensure things are as easy and safe for you when you get home as possible. If you have loose rugs in the house, it is a good idea to remove or move these so that you won’t catch your toes on them whilst you are still getting used to walking around after your joint replacement. Position furniture so that things will be easy to reach from the chair you use primarily and near your bed. We recommend using a chair that is easy to sit in and get up out of for the first 6 weeks after surgery. Typically, this would be a chair that when you are sat in with your feet on the ground, your hip and knee will both be flexed to 90 degrees. The same applies to your toilet if you have a choice.
It is a good idea to have stocked your fridge or freezer before coming into hospital. If you have someone at home with you, they will be able to help you with preparing meals so this may be less of an issue. If you do not live with someone else, it is a good idea to see if someone can come and stay with you when you first get home to help you in the first few days.
You may find that having a pair of shoes or slippers that you can slip on, but that are secure, rather than needing you to do up laces or buckles easier when you first get home.
> If I need a joint replacement what kind of joint replacement will be used?
Mr Whitehouse will discuss with you the kind of joint replacement that will best suit your requirements. His particular focus is on maximising the chances of relieving your pain, improving your function and minimising the risk of you needing to undergo further surgery in the future. Redo surgery, although sometimes necessary, carries higher risks and therefore the aim is to avoid this where at all possible.
One of Mr Whitehouse’s particular expertise and areas of research is in determining which kinds of operation work best for which patients. He uses this expertise in selecting the kind of joint replacement will be most suitable for you. If you have any particular concerns or preferences in this area, please let him know and he is more than happy to discuss these with you so you are completely happy with the kind of operation you will have.
> On the day of surgery
We understand that having surgery can be a time of worry and anxiety. Our experienced and caring medical staff will be there for you every step of the way.
It is advisable to have a bath or shower before you come into hospital on the day of surgery. If you have an early admission time, this can be the day before. Please avoid putting on moisturiser, talcum powder or oils after you wash as this can affect the effectiveness of the solutions we use to clean your skin in theatre prior to surgery and our ability to put the required arrow on your leg when Mr Whitehouse sees you prior to surgery. Do not shave or wax the area around the joint prior to surgery as this can increase bacterial colonisation of your skin.
You will be given a time to arrive at the hospital for prior to your operation. Please report to the hospital reception at this time. You will then be shown to the ward where you will meet the staff that will be looking after you and admitted to the hospital.
Your anaesthetist will visit you prior to surgery to discuss the options for your anaesthetic and determine which will be the safest and most appropriate for you. Please let them know if you have any strong preferences. You will also see Mr Whitehouse to confirm the operation you are expecting (a safety requirement), go over any questions you may have and confirm the consent you have provided for the operation.
You will then be taken down to the theatre complex and into the anaesthetic room or preparation area. Once you have had your anaesthetic, you will move to the operating theatre where the theatre team will look after you whilst your operation is carried out.
Following your operation, you will move to a recovery area where you will be closely monitored whilst you recover from your anaesthetic. When you wake up, if you have undergone a hip replacement, you will have a dressing over the wound and you will have a wedge loosely secured between your legs to keep them in the optimum position whilst the anaesthetic wears off. If you have had a knee replacement, you will have a dressing on the knee and a wool and crepe bandage over this.
Once you are fully recovered from the anaesthetic, you will move back to the ward where your rehabilitation will commence. Once you are safe to do so, you can commence exercises in your bed as you will be shown by the physiotherapists. Depending upon the time of day of your operation, you may sit out in the chair or commence mobilisation with the guidance of the physiotherapists.
> How long will my operation take?
First time (primary) hip and knee replacements typically take between 1 and 2 hours. You may be in the theatre area for longer than this though, typically half an hour or so before the operation starts and an hour or 2 in recovery after the operation so it may feel like it takes longer than this.
If you are undergoing revision, or redo, surgery, the operation typically takes longer, between 1 and a half hours and 3 hours. This is because we have to deal with more scar tissue, remove any implants that need replacing and then fit your new joint replacement.
> What will it feel like after the operation?
You will receive medication to make the operated area as comfortable as possible after your operation. This comes in a variety of forms, a lot of which will be administered in the operating theatre whilst your operation is carried out. These include measures such as spinal anaesthetic or nerve blocks that will still be working when you first get back to the ward. During the operation, Mr Whitehouse will inject local anaesthetic in and around the operated area which will again make things more comfortable for you.
Pain relieving medication will be administered during the operation and afterwards in recovery. This will carry on when you are back on the ward. The pain relief will be prescribed for regular doses but you will also be prescribed additional pain relief on a “as needed basis” so please do let the nursing staff know if you are uncomfortable so they can provide this when it is needed.
At the end of your operation, we routinely put your hip or knee through a full range of motion to make sure that all is working as planned, the joint is stable and there are no blocks to movement. Most patients will feel that the specific pain they have been suffering from before the operation is either relieved or gone after the operation, particularly in the case of hip replacement. There will be some pain associated with the incision and the operation itself, this is normal and not anything to worry about. It is this pain that you need the pain relief for as we aim to keep you as comfortable as possible to improve your experience but also allow you to do your exercises and rehabilitate as safely and comfortably as possible. You will be given pain relief to take home with you, remember to take this regularly to start with so that you are comfortable enough to do your exercises.
The area around the wound may feel numb initially, this improves with time after the operation. The joint may also feel a little stiff or restricted, again this improves with time and your exercises will help greatly with this. It is normal to have some swelling of the operated leg after the operation, indeed this is often the last thing to fully resolve.
> How long will I be in hospital?
You will usually be in hospital for 2 to 3 days after your operation. Medically, most patients are well enough to go home on the day after surgery, the rest of your time in hospital is focused on your rehabilitation. This will involve initially mobilising with a Zimmer frame, once you are safe with this, your physiotherapist will guide you in progressing to mobilising with walking sticks or crutches. They will teach you to transfer from bed to standing, standing to sitting and standing to bed safely. They will also show you how to walk, turn and do stairs safely. The last check to determine whether you are safe to go home is usually whether you can mobilise up and down a flight of stairs using a stick in one hand and supporting yourself with the bannister in the opposite hand.
> What medication will I need to take after I go home?
As described above, you will have pain relief to take when you first go home and we advise you take this regularly initially so that you are comfortable enough to do your exercises. You will need to wear compression stockings in hospital but the current recommendations are that you do not need to wear these when you go home unless you are at very high risk of developing a blood clot in the leg. You will be given medication to thin the blood and reduce the risk of developing blood clots after your operation. If you already take medication to thin the blood for another reason, you will be put back onto this. If not, Mr Whitehouse will perform a risk assessment for you to determine which option will be best for you. Wherever possible, he will use oral medication to avoid the need for injections once you go home and select an option that does not require monitoring with blood tests. The choice is a balance between the risk of developing a blood clot, the risk of bleeding following surgery and avoiding the risk of other adverse events after surgery.
> How long do joint replacements last?
Hip replacement is a very reliable and successful operation. For the kind of hip replacements that Mr Whitehouse uses, the chances of your hip replacement lasting for 10 years are over 97%. Approximately 90% will last for 15 years. Beyond this time point we become more reliant on estimates that are derived from older designs of hip replacement but the best available data suggests that 70% will last for 20 years and 58% for 25 years or more. Mr Whitehouse has published research on how long hip replacements last that may be of interest to you, it is available as an open access (free) paper in The Lancet at the following link: http://www.thelancet.com/article/S0140673618316659/fulltext
Knee replacements are also reliable and successful operations. Mr Whitehouse selects proven implants with a good track record of success for your operation. Within each type of operation, there are subtle variations that are associated with chances of undergoing a further operation, again Mr Whitehouse selects the options for you that have the best chance of success and longevity. For the kind of knee replacements Mr Whitehouse uses, the chances of your knee replacement lasting for 10 years are 97%. Beyond this time point we become more reliant on estimates from older designs of knee and other sources but the best available data suggests that 93% will last for 15 years, 90% for 20 years and 82% for 25 years. Mr Whitehouse has published research on how long knee replacements last that may be of interest to you, it is available as an open access (free) paper in The Lancet at the following link: http://www.thelancet.com/article/S0140673618325315/fulltext
> Recovery time
Mr Whitehouse and your physiotherapist will advise you on how what to do in your early recovery period when you first get home. It is important to do your exercises regularly but if you find you are struggling, doing frequent short bursts of exercises is better than doing one longer session that means you are too uncomfortable to do more for the rest of the day afterwards. Not all patients require routine physiotherapy after they have gone home, it is more important that you are doing your exercises than spending time getting to somewhere where someone can be with you while you do them. If you have particular needs that mean physiotherapy following discharge would be of benefit for you, this will be arranged for you prior to discharge.
You will probably need crutches for between two and six weeks after your operation. You should continue to use these whilst you find they help you walk with a normal gait and until you feel safe without them.
Most patients find that they are much improved by 6 weeks after surgery, but full recovery does take time with slow improvements each day. If we use questionnaires to monitor your recovery, we generally see that 80% of the recovery happens within 2 to 3 months of surgery with further slow improvement continuing up until a year after surgery.
> When can I drive again after surgery?
In order to drive, you need to be in full and safe control of the vehicle. This means that your pain must be under control, you should not be on strong pain relief any more, such as opiate medication, your reaction times must have returned to normal and you must be able to control your vehicle. After joint replacement surgery, this typically takes 4 to 6 weeks for driving your own, non-commercial vehicle.
Advice regarding the effect of arthritis in your ability to drive is available here: https://www.gov.uk/arthritis-and-driving
The DVLA recommend that if you have had a hip or knee replacement that you follow the advice for Limb disability available here: https://www.gov.uk/limb-disability-and-driving
If you still can not drive 3 months after surgery, it is important that you inform the DVLA: https://www.gov.uk/surgery-and-driving
> When can I return to work after surgery?
If you can work from home, this can happen reasonably soon after surgery. After an anaesthetic, it is advised not to make any critical or financial decisions for the first few days while the effect of the anaesthetic wear off. Most people are more limited by their ability to get to and from work rather than their ability to do their work if their job is desk based or reasonably light. You may need reduced hours or amended duties when you first return to work. For heavy manual work, you should plan on 3 months off work in the first instance to allow for a full recovery before you return.
If you do need a fit note (https://www.gov.uk/government/publications/the-fit-note-a-guide-for-patients-and-employees) for work, please let us know when you are admitted so we can write this for you so that it is ready for you before you go home. The note that you are provided with will cover you at least until your first follow up appointment with Mr Whitehouse, at which point it can be extended if required. You can, in conjunction with your employer, decide when you are fit to return to work, you do not need to be “signed back on” for work, if your employer asks you for this, please direct them to the following information: https://www.gov.uk/government/publications/the-fit-note-a-guide-for-patients-and-employees
> What do I do if I have a problem after surgery?
If you feel well but there is a problem after your surgery, you can either contact Mr Whitehouse’s secretary or the hospital to let them know and arrangements will be made for you to be reviewed and ensure there are no concerning issues. Outside of office hours, your call will be directed to the ward so that you can receive advice when the office is not staffed.
If you feel very unwell after surgery and feel you need an urgent review, then please contact your GP surgery, Out of Hours GP service or attend an Emergency Department for urgent review. If you attend an Emergency Department and it is required, review by the on call Orthopaedic team will be arranged.
For routine questions, Mr Whitehouse can address these for you at your next planned appointment.