Bone surgery
Wanting more information about knee replacement
The people we interviewed got information from many sources, including health professionals, the internet and others who’d had a partial knee replacement in the past (see ‘Sources of information on knee replacement'). Some said that they had all the information they needed from health professionals, often describing it as excellent and informative. David said that his questions were always answered and Geoff that the care and information he got was ‘first class...like going private’ (see ‘Views and experiences of healthcare from people who had a knee replacement').
The doctor explained to Phillip why he needed surgery, which he’s had to both knees. Medical staff made him feel at ease. He recovered quickly.
The doctor explained to Phillip why he needed surgery, which he’s had to both knees. Medical staff made him feel at ease. He recovered quickly.
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They, well, they sit you on the bed and try and move your leg. The phy-, the doctor said that, “You, there’s so much floating bone in there. We don’t know whether we’re going to have to give you a full knee or a half knee.” Which, I’ve heard that the full knee’s worse, but the half knee is, I’ve had two half knees. So a lot of it was really get me to walk. And she said, “Oh.” She said, “You’re very, very bandy.” And that’s, she said, “Oh, we’d best get it done. Get it done straight away.” And then, and she showed me the video of the actual Oxford knee, what was going to do to me, then the rehabilitation. And once I knew what was, still very apprehensive. That’s the first time I’ve had a real, well, I call it a major operation. But they made me feel at ease. Really good, really lovely people.
The first time, did you, were you shown a video the first time as well? Or only the second?
No, the first and second time, yes, yes.
Did they give you any leaflets to take away?
Yes, they give me leaflets to read on all the operation and then the physio afterwards and how long. I mean they said that every person’s an individual. But she said, “Considering you were a sportsman, we hope that you will probably recover in a quick, quicker time.” Which was quite amazing really, how quickly I did get about actually.
Information before surgery
The information that people felt was missing before going into hospital focussed on:
• the pre-operative assessment
• the cleanser, Hibiscrub
• waiting around on the day of surgery
• having anaesthetic
• using bedpans
• length of stay in hospital and what to take in
Several people felt that watching the TEPI videos about the pre-operative assessment before the actual appointment would be helpful. Although they’d got a letter from the hospital with details about the appointment and who they’d see, having a web address for the videos at the end of the letter would have been useful.
Lesley wishes she’d taken someone with her to the pre-op assessment. She was given a list of professionals she’d see but would have liked to watch the video beforehand.
Lesley wishes she’d taken someone with her to the pre-op assessment. She was given a list of professionals she’d see but would have liked to watch the video beforehand.
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And you mentioned at that appointment you were told about the video. That you, you know, you could go online and on a certain website and then you would see a little video about the pre-assessment, about the operation and recovery?
Yes.
You were told at that appointment? But you didn’t look at it at the hospital? You came home and looked at it? Is that right?
When I saw the physio she put it on the screen for me. She showed me how to get it and she showed me the procedure. So I did watch. But I didn’t, obviously didn’t know about that before I went for the assessment. So she did show me it. Which I thought was good. And then when I came home, that’s when I went and I looked at the second video, which was about the operation.
Would it have been helpful to see the video about the pre-op assessment appointment? Would it have been helpful to see that beforehand?
It was nice to see. And, yes, if you were able to, it probably would have been.
So if you’d been sent a letter with the appointment for the pre-op assessment --
Yes.
-- and then the web address?
Yes, yes, because people that are on the computer would find that easier than reading what to expect. But I did have a sheet with it all on. I read it all, understood it all. But, yes, it probably would have been nice to see it.
Beforehand?
Yes.
On the day of surgery, some participants were told to come to hospital at 7am but weren’t seen by medical staff until the afternoon. They wondered why and felt that they should have been warned that this might happen and the reasons for it. Most were given general anaesthetic before the operation so that they would sleep through it. A few who had other medical conditions said they were given a spinal nerve block and would have liked to have known more about this beforehand.
A doctor talks about general anaesthetic and a spinal nerve block.
A doctor talks about general anaesthetic and a spinal nerve block.
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General anaesthetic involves a patient going to sleep throughout the procedure, waking up afterwards. And probably that’s the commonest route that people go down, certainly in our hospital.
The second route is a spinal anaesthetic, where your legs are put to sleep so you don’t feel any pain in your legs. But the patient sleeps during the operation rather than being completely unconscious in a general anaesthetic.
And there are advantages to both techniques. And both techniques can be used in many patients, although in some patients spinal is more applicable or general anaesthetic is more applicable. And there’s a conversation between a patient and the anaesthetist. It’s a shared decision in terms of which route you go down. But the key point is both are really safe techniques.
Lesley, who had a nerve block, was worried why she couldn’t feel her legs when she came round. When the anaesthetic wore off, she could move her toes and felt fine.
Lesley, who had a nerve block, was worried why she couldn’t feel her legs when she came round. When the anaesthetic wore off, she could move her toes and felt fine.
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No, I can’t remember feeling any pain or anything. It was just the effects of the anaesthetic. So you’re sort of tired and groggy. Wasn’t, didn’t feel too bad. When I went up to the ward and they check things. Because I wasn’t aware that, it’s common sense that they would probably numb you, but I didn’t realise. And when they felt the bottom of my feet and the top of my feet and said, “Can you feel that?” And I’m thinking, “Oh, its like pins and needles” and, “Oh, I’m not sure about that.” And they prodded the rest of my leg and I couldn’t feel anything. And then I realised that I’d had an injection and then that was the reason why it was numb, yes.
Quite a few people actually haven’t been aware of that.
Yes.
So they might have told you but it wasn’t in, it wasn’t in the video, was it? This information about the anaesthetic and how your leg would be for a few hours, a bit numb.
Yes, I can’t remember reading anything like that.
Would that have been helpful?
Yes.
To have had that written down?
Yes, I think --
Sometimes you can’t remember everything on --
That’s true.
the day.
Because you did, ‘was I was told’, was I told and I’ve forgotten? I don’t know. But, yes, I think that would be helpful if you knew. You’d expect it to be numb and you know that it’s going to come back. I mean I still have numbness now round the knee, which is taking its time to come back. If ever it does, I don’t know.
So then that was on the ward where it was numb? Did it start easing off then? Could you, you know, feel your toes and everything after a few hours?
Yes, yes. They make, they ask you to move your toes. I could move my toes. I could do everything that they asked me to do. Yes, that was fine.
Janice felt a bit tearful after surgery and having to use a bedpan came as a ‘big shock’. It was fine after the first time, and the physio got her up the next day.
Janice felt a bit tearful after surgery and having to use a bedpan came as a ‘big shock’. It was fine after the first time, and the physio got her up the next day.
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If Alice has knee surgery again, she’d take more clothes in case she stays longer than expected and shoes she can slip on easily before exercising.
If Alice has knee surgery again, she’d take more clothes in case she stays longer than expected and shoes she can slip on easily before exercising.
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And no, I mean I went home after four nights and that seemed, and there was no way I would have gone home before that. And in fact it just changed on that fourth day that I thought, that it suddenly seemed like a possibility whereas up to that time I wouldn’t have considered it.
So I wish I’d taken more stuff in. The other thing was the shoes, they said, “Bring sensible shoes so that you can do your exercises.” Well I mean I don’t wear heels so I thought well what are sensible shoes? I thought ones that are going to slip off aren’t sensible so I took a pair of gym shoes, and they said, “Well you can’t get those on yourself can you?” And I thought well no of course I can’t. But so they got me a pair of slipper socks, they were seen to be giving out slipper socks but I think, I mean what you needed was shoes that you could slip your feet into but weren’t going to slip off your feet once you’d got them in. They wouldn’t let you walk around in bare feet and so I mean next time there are things that I have learnt from this time that I would do differently. Try and figure out some shoes that I can slip on but that are going to stay on. And take more clothes.
Most people left hospital with painkillers, injections to prevent blood clotting, stockings to prevent deep vein thrombosis and a booklet of exercises to do at home. Many wanted more information about these, especially exercising (see ‘Information about exercises for knee replacement’).
Some people wanted to know more about the anticoagulant injections they’d have to give themselves once they were home again. An anticoagulant is a medication that helps to prevent blood clots. It is often taken as a pill, but is sometimes given as an injection. The injection should be given in the fatty areas at the sides of the waist. This was usually for about two weeks. Lesley didn’t realise she’d have to have them for so long, and Helene didn’t know about the injections until she was leaving hospital. Janice felt it would have been helpful to have more information about them on the videos as well as in leaflets. Because she has a blood clotting disorder (Factor V Leiden), she had to have the injections for six weeks.
Janice was shocked to learn that she’d have to inject herself every day at home. She hated having the injections and dreaded doing them in the evenings.
Janice was shocked to learn that she’d have to inject herself every day at home. She hated having the injections and dreaded doing them in the evenings.
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I hated it, I absolutely hated the thought. How people that are diabetic have to do that every day for life must be quite a thought. You take it in the e-, I was taking mine every evening. Now whether that’s relative to when you have your surgery and they give it you, I don’t know. For me, I would have preferred to have done it every morning. Because like you’d get up and you’d do it and it’s done. It was almost like once you’re, because you’ve been asleep all night and you’re not thinking about it. So you get up and you just think about it and you do it. So you haven’t got to think...
For me, I hated doing it so much that come teatime I was thinking, “Oh, I’ve got to do that injection later. I hate the thought of that.” And I almost sort of thought like, “Oh, I’m not going to go to bed. Because if I go to bed, I’ve got to do my injection before I go to bed.” Silly, it sounds silly, but I didn’t want to have to do that. And it’s not for the fact that it actually always hurt, because they show you how to do it. And you, apparently you can do it in your leg, but it’s absorbed better and quicker if you do it in your tummy.
A doctor explains why injections are needed and how to do them.
A doctor explains why injections are needed and how to do them.
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And following a partial knee replacement these injections will go on for 2 weeks on average and involves a small injection of a few mils of fluid, drug, into your tummy. And this is a routinely performed procedure and most patients find this very acceptable and something that they’re able to master.
But it’s very important as blood clot is a real issue for patients, although rare. And we really like to try and make sure that we’re as safe as possible in protecting patients from that.
And you will show patients how to do that?
Yes, in hospital the nursing staff, and they’re very skilled at doing this, will go through an education programme with patients in terms of their learning for how to do this. So we will make sure that patients will absolutely know how to do this before they go home.
Peter was in a lot of pain for about 2 days and couldn’t sleep. He wasn’t told when he left hospital that he should be taking codeine as well as paracetamol.
Peter was in a lot of pain for about 2 days and couldn’t sleep. He wasn’t told when he left hospital that he should be taking codeine as well as paracetamol.
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I left hospital on the Tuesday and I had, on the Tuesday night I slept here and I had a terrible night, really, really bad night. I had, I was up in the night because I couldn’t sleep with the pain. I sat down here in this chair about from 3 o’clock onwards. Couldn’t, I think probably exhaustion got me off to sleep eventually here in the chair, just sitting in the chair with my knee up on the cushion there. And when my wife came down and we discussed the bad night that I had, we decided it was time to start talking to somebody and find out why. And that was when we found out about the problem with the pills.
Because, what had you been sent home with?
I’d been sent home with paracetamol. And that was it. That was all I was sent home with was paracetamol. I think everybody else was sent home with paracetamol plus something to go alongside it. And in most cases I think it was probably codeine. Because it wasn’t until we rung up we found out that I should have been told to be using my own painkillers alongside the paracetamol. And once we started doing, once we started sorting that out with some help from the GP, then we got the pain under control. But it still took another 24 hours before all the medication kicked in. So I’d spent really one night and one day in a lot of pain. I mean on a 1 to 10, it was 12. It was really, really bad.
Did you speak to the GP as well or he-?
Oh, yeah, yeah, yes, we spoke to the GP as well. Because I was under some medication for other things and we had to make sure that everything was okay with the GP for me to take these extra tablets. So once we got that sorted out with the hospital and the GP, things started to ease off. But, as I say, it, by that time, by the time we’d got it, [clears throat] by the time we’d got it sorted out, we’re looking at probably late afternoon on the Wednesday. And it was still painful through the Wednesday night into the Thursday. And by the, we’d got halfway through the Thursday, everything was kicking in and the pain was easing off. But those first 24, 36 hours, really bad, really, really bad.
But what they, what somebody should have told me was that the pills that I had of my own would take over and do the job that the hospital should have given me. In other words they should have given me codeine, I think it was, and paracetamol. And I had co-codeine of my own, which was prescribed by my GP. And they should have said, “Carry on taking your pills and we won’t need to give you ours.” But they didn’t tell me that.
So until we got that sorted out, once we got that sorted out, the pain, we got the pain under control and it’s been pretty successful up to, you know, up to now. We’re now three, just three weeks after the op. I’m up and about, no sticks, up and down the stairs, out for nice walks with the dog, and everything seems to be going well now.
Geoff was only given a week’s worth of painkillers. He phoned an emergency number to get a prescription for more but was unsure how long to take them for.
Geoff was only given a week’s worth of painkillers. He phoned an emergency number to get a prescription for more but was unsure how long to take them for.
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And I had to phone the emergency number in [hospital name] to get some more which meant I had to go into Sainsbury's on the Sunday to get some. And I didn’t know what to do really; I didn’t know whether to keep taking two every two hours or to gradually cut them down.
So some information on that would have been helpful?
Yeah, yeah. I wasn’t sure how long I needed to take two every four hours for.
You were given a week's supply of taking two every?
Yeah, I think it was about eighty three/eight four I think they gave me which was two; I was sixteen a day for, or eight - two, four, six, eight a day, eight a day.
So you were originally taking eight a day for the first week?
Yeah
And then you weren't sure what…
No, I didn’t know what to do after that. They said control your own pain relief. The first week I was taking two of those and two paracetamols every day.
So when they say control your own relief they hadn’t really given you much more information other than that?
No, no
What would have been helpful to… for them to say to you?
I don’t know really because everybody's pain threshold's different so I would imagine that would be quite a difficult thing to plan for someone. But I don’t know if he said, "If you get any problems visit your GP," well he probably did actually. But when you're in a hurry to get out the hospital you don’t really listen to everything. But I did eventually go to the doctor and he said, you know, "Just try and wean yourself off them if you can."
Peter delayed having surgery until he retired because of the time he’d need to take off work. He’s been taking painkillers for a long time and plans to wean himself off.
Peter delayed having surgery until he retired because of the time he’d need to take off work. He’s been taking painkillers for a long time and plans to wean himself off.
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Yes, I’ve been taking painkillers for probably the best part of that 10 years.
Painkillers that you bought over the counter?
No, no. Painkillers that were prescribed by my GP. That’s my next, probably my next big problem is, is obviously they were fairly heavy-duty painkillers and at some stage I’ve got to get off of them.
Can you remember the name of those painkillers?
Yeah, I’m on co-codamol and tramadol.
And you’ve been on that for..?
A long time.
A long time, yes.
So it’s quite possible that, to a certain extent, I suppose I’m addicted to them. So that will be the next big problem is getting off of them. Because I don’t want to be addicted to anything, not, certainly not them. So, yes, they were doing a fantastic job because they’ve kept the pain away. They’ve allowed me to carry on working up until my retirement, which was last year. And although my working day was probably shortened a little bit, at least I’ve been able to earn a living. You know, being self-employed, I need to work.
So you took, through the GP you were prescribed these. Can you remember for how long? For the whole of the 10 years or were they, was it just paracetamol to start with?
No, I think it might have been, it might have been something milder to start with. But, you know, we’ve progressed. And I’m not blaming the GP in any way, shape or form. It was probably me saying that I don’t want to go in for the op. Because I knew that if I’d gone in for an operation, I would have been in a situation where I would have, if both knees were done separately, one after the other, I could have been off work for, I don’t know, 8, 9 months. That’s a long time if you’re self-employed. And, you know, customers will wait a short period of time if they want you to do the work. But you can’t expect people to hang around when they’ve, when they want things done, you can’t expect them to hang around for 9 months. So I’d be losing, not only losing the work but losing the customers as well. So I made a decision there and then that I would not have new knees until such time as I got to retirement age.
Geoff was unsure how long to take tramadol. When he was weaning himself off, he felt hot, shaky and couldn’t sleep. It took 1½ weeks.
Geoff was unsure how long to take tramadol. When he was weaning himself off, he felt hot, shaky and couldn’t sleep. It took 1½ weeks.
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Quite difficult, yeah it was difficult.
Can you tell me about that because what was difficult?
Well I'd just get so hot and shaky. I'd just shake like anything when I started only taking one, I was sort of shaking like I had like, not DTs or whatever you know.
Because you'd been taking them for a while?
Yeah, yeah. I was shaky and all terrible things. Really hot, couldn’t sleep, could sleep for nearly a week, just cat-napped.
So which tablets…which tablets were these now?
Tramadol.
Right. Did you have any idea this could happen?
No.
Nobody mentioned anything?
Hadn't a clue. I slept in the other room. Well I didn’t sleep, I laid in the other room because I just kept my wife awake all night and luckily we've got a spare room so I just laid in there listening to my music and cat-napped in the day time.
What would have made this situation easier?
I don’t know.
Any information, would information have helped or?
I don’t know any, but I suppose if they told you how to wean yourself off a little bit better maybe or have some sort of timescale, say please don’t take these tablets after four weeks or, after four weeks if you're still on the maximum dose try and wean yourself down to one an hour.
Would it have been helpful to know what could happen while you're trying to wean yourself off, so you know if you were being shaky but you knew that this might happen.
Yeah, if you read the leaflet on tramadol you could have anything up to two hundred symptoms I would think. There's so many – I read the leaflet and oh I got that, you know.
Did you phone the GP at all or you carried on?
I just sort of carried on. I thought, 'I've got to get off them.'
And how long did it take to wean yourself off?
A week and a half. Had a week with no sleep and then gradually got better.
A doctor talks about pain relief and how to manage it.
A doctor talks about pain relief and how to manage it.
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And we tend to move from painkilling drugs which are given into your bloodstream to oral tablets. And by the time you go home there’s a fairly well-established protocol with the sort of tablets you should take and how often you should take them.
And over the first 2 weeks following surgery I would expect you to initially need quite a lot of support from the tablets. But that tails off over a 2 week period, such that most patients are probably needing only small amounts of tablet medication by certainly 2 to 4 weeks following surgery.
Should they just take it as they need it then after that point?
Yes. We’ll give you a lot of advice in hospital about how to do that. We’ll probably encourage people to take tablets very regularly for the first two or three days, and then to take them as you need them over the next week to two weeks.
And if pain is a problem and your knee is becoming really painful and sore, then we’ll advise you to speak to your General Practitioner. And in those circumstances, which are unusual, we would like to see you again back in hospital to make sure all is well.
Keith kept waking up because of knee pain. His GP prescribed sleeping tablets for 10 days. Other people he spoke to also had disrupted sleep after surgery.
Keith kept waking up because of knee pain. His GP prescribed sleeping tablets for 10 days. Other people he spoke to also had disrupted sleep after surgery.
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So being prepared for that would have been helpful?
I think so. I mean I can understand that surgeons or staff may be reluctant to give warnings about, you know, these sort of negative things in case it might put people off. Or it may make them so worried about it that, you know, the experience is even worse. I don’t know. But I think it should be mentioned that “You may have, you may find this. It will last for four or five weeks.” Which is what happened to me. Again talking to other people, it’s what they’ve had, you know, I know they’ve experienced. And then will gradually get easier, yeah.
So it would have been helpful to know that beforehand?
Yes.
A doctor talks about the effects of surgery and medications on sleep.
A doctor talks about the effects of surgery and medications on sleep.
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I think a lot of patients will find certainly in the first week after surgery that your sleep is affected by the operation and the medications that you take. Pain is probably the biggest factor here. And so after the operation your knee will be sore.
It will gradually start to improve, but in the first two or three days it may be difficult to sleep through. And certainly we will support you in the use of tablet medications to try and make your knee more comfortable, to allow you to get as full a night’s sleep as possible.
Certainly the way forward with this is that patients become increasingly comfortable and sleep is increasingly easier for them to have. And the medications on the whole allow you to do that rather than making it more difficult. Sometimes certain medications may interfere with sleep, certainly in the initial period following surgery. But actually overall the trend should be for your sleep to improve, although it will be disturbed in that first week.
Geoff would have liked to know more about looking after the wound, preventing infections and how long to wear the stockings.
Geoff would have liked to know more about looking after the wound, preventing infections and how long to wear the stockings.
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So more information about how long to wear that; how to look after the wound and, you know, make sure that you can prevent infections.
Yeah, yeah. Because if you’ve got hairy legs, those stockings drive you mad. So the first thing you want to do is pull them off. You know if they say, "Well you should wear them full-time for a week," then you'll have some information, somewhere to go instead of just putting them on when you need to or when you think you need to.
A doctor talks about how long a partial knee replacement usually lasts and the timing of surgery in terms of age.
A doctor talks about how long a partial knee replacement usually lasts and the timing of surgery in terms of age.
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If you want some simple figures to remember... Perhaps at 10 years following surgery, 90 per cent of these operations will still be functioning really well and the patients will be happy. And at 20 years, 80 per cent of patients will still find the knee replacement functions very well. So I think they probably last to a greater degree than people might imagine.
I think the discussion with patients about the timing of joint replacement is critical in the shared decision-making process. So, regardless of age, it’s very clear for some patients who are having such a difficult time with their knee arthritis that joint replacement is appropriate. And some patients who seem very young, in their 40s, will have joint replacement. But those numbers are small.
The average age of people having joint replacement in this country is in your mid to late 60s. And for those patients, the discussion is about the degree of symptoms that you have and the proposed benefits there are from having the joint replacement.
In the slightly younger age group patients, if you’re in your late 50s or early 60s, the question is whether or not you would want to invest in having a knee replacement to get rid of the pain and stiffness that you have. Weighing that up against the risks, relatively few that they are, but the risks that do exist. And that’s an individual choice that you make with your surgeon in terms of how you feel about your arthritis and how you’re coping.
Many people we interviewed were unsure what would happen at the follow-up appointment or who they’d be seen by, some saying they’d have liked to have watched a TEPI video about follow-up (see ‘Views and experiences of healthcare from people who had a knee replacement’). Some wondered whether they’d have x-rays or physiotherapy and others wanted to ask about having the other knee replaced, something they’d discussed with the consultant at previous appointments.
Penelope wondered when the follow-up appointment would be and if she’d have x-rays. She’d had knee surgery before but couldn’t remember.
Penelope wondered when the follow-up appointment would be and if she’d have x-rays. She’d had knee surgery before but couldn’t remember.
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No, that’s something I need to phone up about. They said, "After three weeks, if you don’t get the letter, contact us," because I should get a follow-up…it should happen six weeks later shouldn’t it? Well it's been four weeks now so I'd better give them a ring I suppose [laughs].
And because you’ve had the other knee done, you kind of know what's involved with the going back?
I don’t actually, I've forgotten all about it. I don’t know what will happen; whether maybe they’ll do another x-ray will they?
I'm not sure.
I'm not sure, yeah. They will probably ask me questions – how I'm going on, what I can do, what I can't do and things won't they? Things like that.
Would it be helpful like you were shown the three stages – pre-op, what happens in the operation and then recovery – would it be helpful to know like what happens in follow-up or, you know, when you're discharged, that kind of information?
Yes, yes, I think so especially for the first knee you'd want that I think.
A doctor explains what happens at follow-up and who to contact if there are knee problems after that.
A doctor explains what happens at follow-up and who to contact if there are knee problems after that.
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It’s also a point where patients, if they are having problems, can raise that with a health care professional. And in the small number of instances where there are real problems, we can address them. And we can bring you back into hospital to make sure that you’re back on track.
I think patients are really reassured by that follow-up appointment because it’s an opportunity for you also to ask questions that may have arisen in your rehabilitation, reinforcing the amount of activity you can do, what you can expect going forward from that 6 week point. So I think it’s a really useful meeting, the follow-up appointment.
Is it usually the physiotherapist who they’ll see at the follow-up appointment?
There are two real streams. A lot of our patients are routinely followed up by our physiotherapist practitioners, who are highly experienced in seeing patients after joint replacement. And I think patients enjoy that contact with them.
A smaller number of patients are seen by the doctors involved in looking after the patients. And there may be reasons why you are brought back to a physiotherapy clinic or to see a doctor, which are specific to each individual. But overall everybody is seen at 6 weeks, and it’s a great check to make sure everybody is moving in the right direction.
Some people were wondering if they’d be having x-rays at the follow-up appointment. So what usually happens when they get there?
The follow-up appointment usually doesn’t involve an x-ray. X-rays are taken whilst you are in hospital, before you leave hospital. And then at the 6 week point you’ll have a meeting, an interview with a physiotherapist or a doctor, where we will check the wound, make sure the knee is moving well. And that improvement in movement is a key marker for us of how the patient is progressing.
We’ll check that, we’ll ask you a lot of questions about how you’re doing. And we might take a score to see, so we can try to measure your progress.
Last reviewed August 2018.
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