Orthopaedics – Total Knee Replacement

Patient information Leaflet

Date created and amended September 2012

INTRODUCTION Knee replacement operations have been regularly used to relieve knee pain since the early 1970s. In the UK alone, more than 50,000 knee replacements are performed annually. The operation helps to relieve pain and allows many people to regain their mobility and therefore their independence. Ninety-five percent of knee replacements last over 10 years. We hope that this booklet will help answer some of your questions. We believe that it is important for you to be as best prepared as possible before this operation; to give you some idea of what the operation and your hospital stay will involve; and to give you practical advice. Our aim is to help you improve your quality of life and benefit fully from your new knee replacement. THE KNEE JOINT

WHAT IS A KNEE REPLACEMENT? A knee replacement is an artificial joint, usually made from plastic and metal, which is used to replace your worn (or damaged) knee joint. The knee joint is a hinge-like joint which unites two leg bones the femur (thigh bone) and tibia (shin bone). The front of the knee is protected with the patella (kneecap) which articulates with the femur. Inside the joint bones are covered with thick elastic and smooth tissue called articular cartilage

WHY IS IT NECESSARY? The operation is advised for pain relief and to improve mobility, which is usually the result of arthritis in the joint. For various reasons, the articular cartilage (which covers the bone in the joint) can become soft, cracked or flaky. The cartilage itself does not readily heal and so over the course of time the quality and depth of the cartilage is reduced. The joint space

then becomes narrowed and irregular. When damage is Severe, often a joint replacement is necessary.

REPLACING YOUR KNEE JOINT The operation essentially involves removing the damaged arthritic cartilage and bone of the knee, and resurfacing the joint with high-grade stainless steel components and a plastic ‘polyethylene’ spacer between them. The metal components may be fixed to the bone using a grouting agent/cement.

DIFFERENT TYPES OF KNEE REPLACEMENT:

Uni-compartmental knee replacement (UKR): if damage is confined to just one side of the knee, this procedure replaces just that side, whilst the other side of the knee remains intact

Total knee replacement (TKR): this replaces both sides of the knee. Sometimes the underside of the patella (kneecap) is resurfaced with a plastic ‘polyethylene’ button

Patellofemoral resurfacing: this procedure is done if the damage only affects the joint between the trochlea/end of the femur and the patella. The weight-bearing knee joint is preserved

WHAT ARE THE RISKS OF KNEE REPLACEMENT SURGERY Although all necessary precautions are taken occasionally complications may occur. There is a risk of respiratory problems from the anaesthetic. Bleeding or deep bruising can occur around the operation site. A blood clot could form in the legs called Deep Vein Thrombosis (DVT). Rarely one of these clots may travel to the lung and cause a Pulmonary Embolism (PE). An infection may develop either immediately after your surgery or sometime later that may require other procedures which could involve a return to theatre. Skin changes such as blisters, discolouration or numbness may occur around the scar. As with all major operations, during or following surgery, death is a risk. However it must be emphasised that this is extremely rare.

WHAT ARE THE ALTERNATIVES The decision to have the operation is yours, although your doctor will be happy to advise you. If the knee is not replaced the deterioration will continue, the pain will become worse with the stiffness and deformity increasing. Eventually the constant use of walking aids or even a wheelchair may be needed. However, the condition isn’t life threatening but it can limit your mobility and quality of life.

BEFORE YOUR SURGERY It is important that you are as fit as possible before your operation. You should try not to be overweight as this increases the risks associated with surgery and may reduce the life expectancy of your new knee. It may be useful to see your GP for advice. You should continue with any exercise the Physio or Occupational Therapist has advised. The stronger your muscles are before surgery the easier you will find your recovery. Any blood pressure problems should be known to and being treated by your GP. Smoking and Alcohol Smoking prior to surgery delays wound healing and increases your risk of developing chest complications during and after surgery not to mention increasing your risk of long term chest problems. Prior to hospital admission we advise that you stop smoking at least 2 weeks before and for at least 6 weeks after. If you require assistance with stopping smoking prior to surgery please inform the clinic nurse or visit your GP for advice. Tameside Hospital is a non smoking site. Alcohol intake should also be reduced prior to admission and for around 6-8 weeks after. If your intake is excessive please inform clinic staff. Before coming into hospital think how you will cope when you return home, you may need to rearrange your kitchen and wardrobes so that items can be easily accessed. Your Occupational Therapist or Physio will be happy to offer advice.

PRE-OPERATIVE KNEE EXERCISES These exercises are designed to mobilise the knee joint, stretch tight tissue structures and strengthen muscle groups around the knee, prior to surgery. Try to do as many as possible, ideally daily, prior to your admission. Calf Pumps

briskly move your feet up and down, and round in circles, from the ankles for 1 minute

Static Quadriceps

lie on your back with your leg straight, tighten your thigh muscle and push the back of your knee down into the bed then pull your foot up towards you, hold for 5 seconds and repeat x 10

Straight Leg Raise

tighten your thigh muscle to fully straighten your knee, pull your foot up towards you, now lift your heel approximately 4inches off the bed, keeping the knee straight! hold a few seconds then slowly lower back down, repeat x 10

Seated Extension

in sitting, tighten your thigh muscle and slowly lift up and straighten your leg out in front of you, hold for a few seconds, then slowly relax it down to the floor

repeat x 10

Knee Flexion

in sitting, slowly bend your knee as far as you can hold for 5 seconds

repeat x 10

Inner Range Quads

lie on the bed with both legs straight out in front of you place a rolled up towel under the affected knee pull your foot up, pressing your knee into the towel tighten your thigh muscle so the foot lifts off the bed and the leg straightens, hold for 5 seconds then slowly lower down

repeat x 10

DIETARY INFORMATION Before and After Surgery Research shows that if you are well nourished and hydrated before and after your surgery you may recover better and more quickly. You should try to eat as normally as possible up until your surgery.

- Eat regular meals containing protein foods such as meat, fish, eggs, cheese, lentils and milk.

- Include carbohydrate foods at each meal such as cereals, bread, rice, pasta and potatoes.

- If you are underweight or experiencing unintentional weight loss Avoid using low fat foods / drinks – use full fat milk, margarine / butter, cheese,

and yogurts Include extra snacks e.g. yogurts, cheese and crackers, rice pudding etc. and

nourishing fluids e.g. full fat milk It may be advisable to see your GP to investigate causes of weight loss After your surgery you should eat and drink as soon as you feel able, and try to continue to eat as normally as possible. This will help you in your recovery. If you are having difficulty eating, the nurses will monitor your intake, and refer you

to the dietician.

Developed by Nutrition and Dietetic Dept, Tameside General Hospital. March 2011

Pre-operative Assessment Clinic The purpose of your pre-operative assessment visit is to provide information and prepare you for your surgery. You will be given information about your surgery, and what we expect from you to prepare for surgery. We will also ask you questions about your medical history, general health and wellbeing. This is allows us to ensure you are at optimum health before your surgery. It also gives us the opportunity to make sure arrangements have been made for your admission and discharge. Routine bloods tests and an electrocardiogram are ordered. Whilst in pre-operative assessment clinic you will see a Pre-op assessment nurse and an Occupational Therapist. This is your opportunity to ask any questions you may have. Planning your discharge begins at pre-operative assessment clinic. You will need to make arrangements for family and/or friends to support you on discharge from hospital. If this is not possible please inform the nurse at clinic as it may be necessary to arrange some support for you at home. You will need to bring contact details of the person who will take you home after discharge, if there is nobody available to do this please inform the clinic nurse.

Medications Please ensure you bring all your current medications, inhalers, creams, eye drops, ointments and any non-prescribed/herbal medications with you to clinic and on admission to the ward. Where possible please bring your medications in their original packaging. In pre-op clinic the nurses will go through your medication and identify any which need to be stopped prior to admission for your operation, ideally herbal medication should be stopped at least two weeks prior to your operation, as these can sometimes cause complications during your surgery.

Role of OT in Pre-operative Clinic When you attend the clinic the Occupational Therapist will:

Measure your Leg Length to establish a suitable height for you to sit on after surgery

Assess your furniture at home according to the measurement form you return to determine the need for any equipment.

Discuss how you will manage at home after surgery and inform you of the support available on discharge.

ELECTIVE UNIT On the day of your operation, you will be admitted to the Elective Unit. This ward accommodates patients undergoing orthopaedic and general surgical procedures. Male and Female patients are nursed in separate areas. Please be assured that it is a very rare occurrence that we have to cancel patients on the day of planned surgery.

The visiting times are 3pm to 4.30 pm and 6.30pm to 8 pm every day. The ward has a quiet period every day after lunch to allow patients to rest. The ward is closed to visitors in this time. Please nominate one person to ring the ward with any enquiries as answering multiple phone-calls greatly impacts on the time nurses could spend with patients. Please advise your family members that specific details of your condition cannot be discussed over the telephone. Flowers are not permitted on the unit.

DAY OF ADMISSION Please bring in the following items:

All medications in their original packaging if possible.

Day clothes- practical shoes which must have backs, Comfortable, loose clothing is recommended whilst in hospital- shorts, tracksuits or comfortable skirts are ideal.

Nightclothes, dressing gown and slippers (practical and well fitting, mule type slippers are not safe for walking around the ward after your operation)

Toiletries and towels (please note there are no facilities for washing patient’s belongings in the hospital)

We advise that expensive jewellery, personal belongings and large amounts of money are NOT brought into hospital. We suggest that patients keep no more than £10 with them at any one time. Most patients will be admitted the morning of their surgery. Research has shown that this reduces anxiety. If the healthcare team feel you need to be admitted sooner you will be contacted. You will be able to eat normally up to 6 hours before your operation and be allowed clear fluids up to 2 hours before surgery, unless otherwise directed. Clear fluids means water/black tea or coffee or cordial no milky drinks are allowed.

DAY OF SURGERY On the day of surgery a shower should be taken (this should be at home prior to arrival to the hospital). This ensures your skin is as clean as possible prior to your surgery, assisting to reduce the risk of wound infections. You will also be required to change into a hospital gown. The staff on the ward and escort staff will ask you some questions on what is called a “pre-operative check list”. You will be asked to confirm your signature on your consent form and whether you understand what the surgeon is planning to do and that you are aware of potential risks/complications. (Consent for surgery will either be gained in clinic or on the ward/unit prior to surgery). An Anaesthetist may see you prior to theatre to discuss the options available for pain relief. You will be escorted to theatre for your operation either via a trolley or walking, depending on your preference. When you wake up from surgery you will be in the recovery room, you will have oxygen in place through a facemask and an intravenous drip (which gives you fluid directly into a vein). Once the Recovery Nurse feels you are stable enough to return to the elective unit, your transfer back to the ward will be arranged. Sometimes after surgery it is necessary for patients to go to a High Dependency Unit (HDU) for closer monitoring. Often this decision is planned and the Anaesthetist will have discussed this prior to surgery, however, there are occasions when an unplanned transfer to HDU is required. On return to the Elective Unit your nurse will closely monitor you vital signs, including:

Blood Pressure

Pulse

Respirations and oxygen levels

Temperature

Urine output

Conscious level

Nausea and Pain scores

Your nurse will also need to regularly check your wound and assist you in adjusting your position on a regular basis. Please be aware that these observations are important and staff will have to wake you in the night to continue to monitor you safely. After your surgery it is essential you perform deep breathing and circulatory exercises as explained in pre-op clinic.

PAIN CONTROL The majority of patients undergoing orthopaedic surgery will receive both a general anaesthetic, and a spinal to help ensure your pain is controlled following your surgery.

What Is A Spinal? A local anaesthetic drug is injected through a needle into the small of your back to numb the nerves that supply the lower half of your body for a few hours.

How Is A Spinal Performed? 1. Your anaesthetist will ideally discuss the procedure with you, before your surgery. 2. You will meet an anaesthetic nurse who will stay with you throughout your time in

theatre. They will assist you when getting into the correct position for the spinal. You will be asked to either sit upright on a trolley with your feet on a stool or lie on your side, curled up with your knees tucked up towards your chest. In both cases the nurse will support you and reassure you during the spinal.

3. The anaesthetist will explain what is happening throughout the procedure so that you are aware.

4. As the spinal begins to take effect, your anaesthetist will measure your progress and test how well the spinal is working.

What Will I Feel? Usually a spinal should cause no unpleasant feelings and should take only a few minutes to perform. However as the medicine is given into your back 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. When the injection has been completed you will be lay flat as the spinal works quickly and usually works within 5 – 10 minutes. To begin with the skin usually feels numb to the touch and the leg muscles feel weak. When the spinal is working fully you will be unable to move your legs or feel any pain below your waist. Oxygen is usually given during this procedure to improve the level of oxygen in your blood stream.

What Are The Benefits Of Having A Spinal? Reduced blood loss during surgery and less need for a blood transfusion.

Less risk of blood clots forming in the leg veins

Less risk of chest infections after surgery

Less effect on the heart and lungs

Good pain relief immediately after surgery

Less need for strong pain relieving drugs

Less sickness and vomiting

Earlier return to drinking and eating after surgery

Less confusion after the operation in older people

Nursing Observations Following your spinal the nurses will regularly assess how effective the spinal is in controlling your pain. They will also monitor your other observations such as blood

pressure, pulse and pain score. This enables them to monitor the effectiveness of your spinal and identify when it is beginning to wear off.

After Your Spinal It takes approximately 1½ – 4 hours or maybe longer for the feeling to return to the area of your body that has been numbed. If you have any worries about this please speak to the staff. As the sensation/feeling returns you may experience tingling in the skin as the spinal wears off. At this point you may start to feel discomfort at the site of your operation, and it is important that you let the nurses know so that they can give you some more pain relief to prevent the pain from becoming too severe. As the spinal wears off you will also need to ask the staff for help when first getting out of bed, to ensure that you do not fall.

What Are The Alternatives To Spinals? Oral Tablets and medicines: These are used for all types of pain and take at least 20-30 minutes to have some effect. However they may not be as effective as spinal anaesthetic/analgesia in treating severe pain and are usually given with a spinal to promote comfort. Injections: can be given directly into your vein for immediate effect or into your leg or buttock muscle. This method of administration usually takes 20 minutes before the pain relief starts working. Injections administered directly into a vein are very effective as it enables the pain relieving medication to be given according to your individual level of pain. Suppositories: are inserted into your back passage, where they dissolve and eventually enter your bloodstream, they will not make you open your bowels. Suppositories may be given if you are ‘nil by mouth’ or unable to tolerate fluids. Patient Controlled Analgesia: This system relies on a special pump, which contains opiates and sometimes anti-sickness medication. The pump is connected to a hand held button, which when pressed by yourself gives a small amount of pain relieving medicine straight into a vein usually in your arm or hand. Epidural Analgesia: This is a method by which a small tube is placed close to the spinal cord. The tube is then connected to a machine, which gives drugs, to numb the nerves at and around the site of the operation. Peripheral Nerve Block: Local anaesthetic is injected around tissues and nerves in and around the site of your operation, to numb them. These drugs continue to work for a number of hours post-surgery.

WHAT ARE THE SIDE EFFECTS OF SPINALS?

Very common and common side effects – Affects 1 in 10 people Headache When the spinal wears off and you begin to move around there is a risk of a headache occurring, but it is easily treated with fluids and pain relieving tablets. Low blood pressure As the spinal starts to work, it can lower your blood pressure and make you feel faint or sick. This can be controlled with fluids given by a drip and by occasionally giving you medicines to increase your blood pressure. Itching This may occur as a side effect of the Morphine like drugs used in the spinal. If you experience itching, please let staff know so that they can give you something to ease it. Difficulty passing water (urinary retention) You may find it difficult to empty your bladder normally for as long as the spinal lasts. Once the spinal has worn off, you should be able to pass water normally. Occasionally a tube (catheter) may be placed into your bladder temporarily, either until the spinal wears off or as part of your operation. Pain during the injection As previously mentioned, you should tell your anaesthetist immediately if you feel any pain or pins and needles in your legs or bottom as this may indicate irritation or damage to a nerve and the needle will need to be repositioned.

Rare Complications – affects 1 in 10,000 people Nerve Damage This is a rare complication of spinal anaesthetics. Temporary loss of sensation, pins and needles and sometimes muscle weakness may last for a few days or even weeks but almost all patients who have these symptoms make a full recovery in time. Permanent nerve damage is even rarer. In the unlikely event that you experience persistent tingling, heaviness or weakness in your legs after the spinal has worn off or you have an increasing pain in your back, whilst in hospital inform the ward nurse immediately. If There Is a Problem In the unlikely event that you experience persistent tingling, heaviness or weakness in your legs after the spinal has worn off or you have an increasing pain in your back, whilst in hospital inform the ward nurse immediately so they can contact a doctor or the acute pain team to review you as soon as possible. If you experience any of these symptoms and have been discharged it is important that you contact the on call anaesthetist at the hospital immediately via switchboard on 0161 922 6000. After speaking to the on call Anaesthetist they may arrange to see you in the Accident and Emergency Department in order to examine you. . Local infiltration Prior to the closing of your wound, your surgeon will administer a local anaesthetic into the surrounding tissue to help with your pain control.

AFTER SURGERY It is important that after surgery you follow the daily routine that is outlined for you by your Physio . You may have a wound drain in place which will be removed 24-48hours after surgery. For the first 24 hours you will have Flowtron boots (intermittent compression boots) in place which are designed to reduce the incidence of clots in your legs also known as DVT’s. You will also receive a small injection each day to reduce to risk of DVT’S, and this will continue for a short period after discharge from hospital. Alternatively you may be given tablets to thin your blood for a short time after your discharge from hospital. You may also wake up with a ‘cricket pad splint’ (CPS) which is to keep your knee straight. This will be in place for around 24 hours Blood tests and X-rays will be ordered in the days after your surgery this will be done by your team of doctors. Diet and Fluids You can eat and drink as normal and to your tolerance, we may monitor your food intake to ensure you are eating and drinking enough to help you in your recovery. Please also refer to the Dietary advice section within this booklet (page 9). Sickness Sometimes people experience feeling or being sick after an operation. If you do develop such symptoms please inform staff and they can give you some medication (sometimes in injection form) to help relieve this. Pain You be provided with regular medication to control the pain, which will be prescribed according to your requirements. It is important that you inform staff if you are experiencing pain and is not relieved by the medication provided. As adjustments can be made. Severe pain on very rare occasions could indicate a problem with the surgery and therefore should be reported to staff. Please also refer to the pain section of this booklet (page 13). Mobility Patients will be expected to sit out of bed or around 2 hours on the day of surgery. You will be assisted to do this by the physiotherapists and the staff on the Elective Unit. Staff will remind you regularly of the benefits of the breathing and circulatory exercises that you should be performing. You will be seen by the Physiotherapy team on a daily basis, the staff on the unit will also be encouraging you to increase your mobility a little further each day. Please also refer to the detailed Physiotherapy section of this booklet (page 18). Occupational Therapy Following your surgery you will be seen by the dedicated Orthopaedic Occupational Therapy team, who will assess your needs in preparation for discharge home. Wounds

It is not unusual for your wound to be slightly red and uncomfortable for the first 1 to 2 weeks. However, please let us know if your wound becomes:

Inflamed, swollen or painful

Begins to discharge fluid

Or separates in any place

Use of Ice Ice can help control swelling and relieve pain. When appropriate, your Physiotherapist will show you how to apply an ice pack. You may need to continue this at home. Remember to protect your skin from the ice pack (with a damp towel) and only leave the ice pack in place for 20 minutes at a time.

POST-OPERATIVE PHYSIOTHERAPY Physiotherapy commences on the day of your surgery – try to start doing some of the circulation exercises ( see page 7) as soon as you come round from your operation . Your Physiotherapist team may visit you on the day of your surgery and will see you the morning after when they will assist you to get out of bed and sit in a chair .You will also be able to take your first few steps / have a short walk. Your Physiotherapist will visit you each day and monitor your progress, but it is important that you continue to practice walking and exercises regularly (as directed by your Physiotherapist): either with the Nursing staff or independently. Your Physiotherapist will provide you with education on walking on your new joint. You will initially walk with a walking frame, then progress onto crutches. They will assess the range of movement of your knee. You should start the exercises in this booklet as soon as possible once you have woken after your surgery. You will be assessed for safety in managing steps and stairs before you go home, as appropriate. Your Physiotherapist may use a machine called Continuous Passive Motion (CPM) which may help to bend your knee. MOBILISATION: Getting out of bed: Your Physiotherapist will assist you to stand from the bed. It is easier to get out on the operated side:

- using your hands, push yourself to the edge of the bed - allow your knee to gently bend over the side of the bed as you come forward (your

Physiotherapist will assist you initially) Sit to stand:

- slide your operated leg slightly forward - using your arms beside you, push up into standing before reaching for your walking

aid

Walking: To begin with, you will use a walking frame, and then progress to crutches as appropriate. The correct sequence when walking is:

1. move the walking aid forwards/in front first 2. step the operated leg forward 3. step the un-operated leg forward, so it is level with the other

When turning you must always be careful not to pivot on your new knee: always step round towards your good knee, picking up your feet. Sitting down:

- always ensure you have turned and backed up to the chair so that it is aligned behind you (i.e. never twist into the chair)

- let go of your walking aid - feel for the chair arms - slide the foot of your operated leg forwards as you slowly lower yourself down into

the chair - once sat in the chair slide your foot backwards allowing the knee to bend

Getting into bed: - sit on the edge of the bed - using your hands beside you, push yourself back to sit far enough back on the bed

so that the operated leg is supported - turn to position yourself on the bed

EXERCISES: Start the following as soon as you feel able after coming round from your surgery: (see previous explanations in the pre op physiotherapy section page 7)

calf pumps

static quadriceps

straight leg raises

buttock squeezes: clench/squeeze your buttocks, hold for 5 seconds, relax, and repeat x 10

breathing exercises o take 4-6 deep breaths in and out then finish with a cough o this will help to clear away any build up of mucus

Repeat these circulation and breathing exercises hourly. These exercises are important. Blood clots can develop in the legs following surgery. These exercises will help to increase the circulation in your legs and help prevent blood clots. Start the following as soon as you are able (after your bandages have been removed): (perform these 3 x daily in addition previous exercises)

Supported Knee Bends

bend your knee by sliding your foot up the bed or stool

initially, you can hold under your thigh to assist the bend

try to use your muscles as much as possible

hold your knee in the bent position for a few seconds, then straighten

repeat x10 Unsupported Knee Bends:

whilst sitting in a chair with your thigh fully supported,

slide your foot backwards- bending your knee as much as possible *aim for a 90 right angle*

hold for a few seconds then straighten your knee fully

repeat x 10 Extension Stretch: It is very important that you are able to fully extend (straighten) your knee: try to achieve full extension as soon as possible after your operation

place a rolled towel just above your heel so that the back of your knee is not touching the bed

tighten your thigh

fully straighten your knee

hold for 5 seconds

repeat x 10

progress this to an unsupported stretch i.e. sitting with your heel resting on a stool

TACKLING STAIRS/STEPS: Before you go home you will be taught to use stairs safely. Going up:

1. pass one crutch in front of your body into your other hand (so crutches are in a cross + shape)

2. hold onto the banister/handrail with your free hand 3. step up with your good/un-operated leg 4. bring up your bad/operated leg 5. bring your crutch up last

Going down:

1. place your crutch down onto the step below 2. slide your hand down the banister 3. lower your bad/operated leg down first 4. bring your good/un-operated leg onto the same step

GENERAL ADVICE Progression is largely dependent on you. You must exercise regularly to regain movement, strength and independence. Periods of rest in between are equally important. Do not sit still for too long: get up and walk and exercise regularly. Little and often is the key! By approximately 3 months post-op you will be largely back to your normal activities, although improvement continues for up to a year.

Points to remember:

avoid excessively twisting your knee when turning- always pick up your feet

do not sit or lie with a pillow under your knee- this may cause a permanently bent knee

do not discard your walking aids until advised to do so (then please return them to the Physiotherapy Department, Hartshead North Building) or arrange to return them to Rosscare 0161 344 0482

avoid kneeling

avoid long periods of standing

stand with your weight evenly distributed through each foot

do not drive until advised to do so by your Doctor

You will be invited to attend a post-op group session between 3 and 6 weeks after your surgery. Once you are home you must continue with all of your exercises.

OCCUPATIONAL THERAPY (OT) INFORMATION Your Occupational Therapist will advise you on aspects of your day to day activity following discharge. They will assess your activities of daily living including:

- personal care, - Mobility and transfers on and off the chair/bed/toilet - Kitchen and domestic tasks - and generally how to return to normal everyday life

At the discretion of your Consultant, you may after 10-12 weeks attempt to

- Drive a car (however we strongly advise you speak to your insurance company first)

- Attempt sexual intercourse - Try general household activities - Commence hobbies e.g. gardening, bowling and swimming

DISCHARGE HOME It is our aim for you to be in your own home recovering as soon as possible. It is important that adequate support from your family and friends is organised prior to your surgery, as adequate rest is also an important part of your recovery. We aim to discharge you from hospital in line with your expected date of discharge so please take note of the number of days assigned to your procedure.

Preparing to leave the hospital You must arrange for a family member or friend to collect you from the elective unit on your day of discharge. You will need to bring into hospital appropriate outdoor clothes to go home in.

When you leave hospital A discharge letter will be sent to your GP detailing the events of your hospital stay. A 7 day supply of your medications/pain relief will be provided from the hospital pharmacy it is important that you contact your GP before your supply runs out. A referral to the District Nurses will be made; you will be given a copy of the referral form. This referral will be for administration and/or teaching of self administration of fragmin injections, for wound check/dressing change and clip removal, if required. When you first return home you are likely to feel tired for a while. We recommend that you build your strength up before coming into hospital with gentle exercise and a good dietary intake. Before you leave the unit, you will be given a phone number for the clinic and you will receive an appointment in the post for approximately 6 weeks following surgery. Only contact the clinic if you have not received an appointment through the post after 3 weeks. At the discretion of your consultant, you may after 10-12 weeks attempt the

following:- - Drive a car. - Attempt sexual intercourse. - Try general household activities. - Commence hobbies, e.g. gardening, bowling and swimming.

Driving You should always speak with your insurance company before coming into hospital as your insurance policy may be affected. We advise that you should not start driving again until your strength and speed of movement are up to coping with an emergency stop. This is also at the discretion of your consultant. Travel Please check with your consultant/GP before flying especially long flights. Long car journeys are also best avoided for at least 12 weeks following your operation. If this is unavoidable, we recommend you take regular stops. Consideration must be given to the height of the seat, perhaps discuss with your Occupational Therapist. Air travel should be avoided for four months following surgery. Work If you work we advise that you discuss with your boss the need for time off work after your operation, and support on your return to work before coming into hospital. Be prepared to take around 12 weeks off work. Please ask your nurse or doctor for a sick note/fitness for work form prior to your discharge to hospital. If available, talk with your Occupational Health Department. The length of time off will depend on what job you do. Complications are a very rare occurrence however it is important to know what to do if one occurs. Below are several useful contact numbers where you can seek advice:

Useful Contact Numbers: Elective Unit: 0161922 6235/6208 (24hrs) Orthopaedic Physiotherapy 0161 331 6313 (Mon-Fri 8.30 am- 4.30pm) Occupational Therapy Dept 0161 331 5171 (Mon-Fri 8 am-4.00 pm) Rosscare Equipment Services 0161 344 0482 Go to Doc (GP service) 0161 785 0805 (Out of hours) NHS Direct 0845 46 47 (24hr helpline) Emergency Services 999 You can also contact your own GP or District Nurses for advice.

Useful Websites/information

Department of Health (www.dh.gov.uk) NHS Choices (www.nhs.uk/conditions/enhanced-recovery) NHS institute for innovation and improvement (www.institute.nhs.uk/enhanced_recovery_programme) NHS Improvement (www.improvement.nhs.uk/enhancedrecovery) Patient Information Centre Royal College of Anaesthetists

Source of good practice In compiling this information leaflet a number of recognised professional bodies including the The Department of Health, NHS improvement - Enhanced Recovery, Royal College of Anaesthetists have been used. If you have any questions you want to ask, you can use this space below to remind you If you have a visual impairment this leaflet can be made available in bigger print or on audiotape. If you require either of these options please contact the Patient Information Centre on 0161 922 5332

Document control information Author: Dawn Fletcher, Jenna Gilbert, Janet Perkins, Jillian Barlow,

Emma Brown. Division/Department: Orthopaedics Date Created: September 2012 Reference Number:

Version: version 1.0