Making decisions about knee replacement as an older person with multiple conditions

If we think about what happens to a patient when they go to have a knee replacement, I would say across the country it's a very similar pattern wherever you go in terms of what's going to happen. There will be subtle differences, but what I'm about to describe is fairly universal in terms of what you expect to see.

So I think it's always-, the patient’s always surprised how early you have to turn up to the hospital on the day of surgery. That doesn't happen in every hospital because some people will be- they'll stage it and you might have to come, say, in the morning or at lunchtime. But most people have to turn up fairly early. And what happens is when you turn up at hospital, there's a whole bunch of checks and assessments and getting you ready for the surgery that are required. So a nursing team sees you to settle you in on the ward to make sure that nothing untoward is going on. Take some observations about your blood pressure and pulse, and just make sure that we're in good shape to move forward.

You're seen by an anaesthetist who'll talk to you about the techniques involved in having surgery. You will almost certainly have had information about this at the pre-assessment visit. So none of this is particularly new to you. But the detailed decision making about the type of techniques that the anaesthetists will be using will be discussed and finalised at that point.

The patient will also see the surgeon. The surgeon will make sure that everybody's happy with the decision to have the operation, that you've importantly marked the side, I think patients always find that amusing that we've put a big mark on one side or the other but t's critically important to do that. So we make sure that everybody knows what we're going to do. So you mark up your knee and make sure that the consent process has been finalised. You may have signed a consent form before you come into hospital, or you may sign it on the day, but that consent process is finalised.

Okay, now we're good to go. So at some point during the day when you will have been scheduled, you will move from the ward to the operating theatre. You'll meet the anaesthetist who will undertake the procedures that have been planned. You will go to sleep, which is either a general anaesthetic or a very deep sleep where we sedate you if we're using, say, spinal technique and you'll be taken into the operating theatre. A series of checks are in place very much like, say, you'll be aware-, you'll think about pilots flying a plane where they check that everything is okay before they set off. Exactly the same thing happens before surgery. We check all the things are in place. We check that you've had your medication to stop infection. We check you've had your medication to stop clotting, if that's what we're doing. And then the surgery begins.

Surgery for knee replacement typically takes an hour. Sometimes if it's more complex, an hour and a half. And you then you move at the completion of surgery into what's called the recovery area, which is a sort of ward which is close to the operating theatre, to just check that you've recovered well from the operation and that you are good to go back to the ward.

And you'll typically then be given something to drink, maybe something small to eat. You return to the ward and we enter this phase of the operation where we begin your rehabilitation.

And I think patients are always surprised that the rehabilitate really starts the moment that you get back to the ward. So, in other words, you might find that if you've recovered really well from your anaesthetic, the physiotherapist will come and help you get up almost straight away and start walking. Clearly for some people who are a little older and frailer, who've got other conditions, that may be a challenge, but certainly for younger people - and I would say now it's the norm - we'll try and get you up and get you walking straight away. You can walk on a hip or knee replacement straight away and it's completely safe. And in fact getting going and walking early on is the safest way to manage patients because it improves your outcome, reduces your rate of blood clot and a number of other complications that can occur.

Now, in that first day, if you are having-, if you're really fit and well after the operation, even if you have other medical complications, if you recover in a way that's very, you know, there are no problems here and we've got you up and walking and it's all safe, then there's a certain group of people who will be able to go home, who can have day case surgery. And day case surgery and joint replacement, say, if I talk specifically around knee replacement, has really increased over the last 10 years, it's much safer and we're more experienced at doing it.

There are many, many patients say in the hospital I work at are suitable for day case surgery. You have your operation on the day, if all goes well, you've mobilised and you recover well in that first, say, six hours after the operation, it's entirely safe to go home. You need some support at home. So we couldn't send you home on your own. We give you tablets to manage your pain to help you avoid having a blood clot. All of the things we've thought about and helped you plan. And you can go home the same day. There are safety nets for if there are problems, there are people to contact. But it's safe to do that and many, many, many hospitals now around the country, in fact, I would say almost all will offer day case surgery for a percentage of patients who are able to do that.

Two things I think that patients would find reassuring here is that no one's trying to force people out of hospital if they're not ready to be out of hospital, so it's safe. The second thing is something that was surprising, I think, to even us, where we were trying to drive this day case pathway, is that - it's interesting - if you, it's entirely safe to do it and we've studied it and the complication rate-, and the satisfaction rates were very high, complication rate low, readmission rate low and satisfaction rate very high. And our observation, and I think this is a critical thing to take on board, is if you do a knee replacement on a patient and it goes well, when they come back, or if they come back to have the other side done, most of those patients request to have this done as a day case because of the advantages of getting back to the home environment, feeling that they're managing this partly themselves and actually this realisation that I think it's important for patients to understand that many, many patients don't want to be in hospital. It's an unusual and sometimes a bit scary environment. So getting you home is a good thing, if we can do that safely. So day case joint replacement surgery has really come of age and it's quite common. You might see this in 20 to 30% of patients who will be eligible for it. So don't be surprised to hear of that happening. But also if you're going to have a knee replacement, it might be something that's suitable for you as an individual.

So the biggest decision in someone thinking about having surgery is whether or not you would have a knee replacement; that, there's no doubt, that is the biggest decision to have.

If you're a candidate to have knee replacement, there are different ways of performing that operation. And perhaps the biggest thing to think about is whether this would be partial or total knee replacement. And that they're both very good operations and they both-, a lot of these procedures are done, say, in the UK for treating osteoarthritis and around the world, there's no doubt that more people have total knee replacement than partial knee replacement. But partial knee replacement is being done more commonly.

And the thing to consider is if there are patients who are candidates who could have partial or total knee replacements; there are some patients whose osteoarthritis damage is at the more severe end of the spectrum where they're not a candidate to have a partial knee replacement. But if you are someone who has arthritis which is localised, say, to one compartment, there is now a choice: partial or total knee replacement. And again, as part of your shared decision-making process, you need to understand the benefits and risks of both of those procedures.

And if I might kind of summarise that for you: partial knee replacement in some respects could be thought of as a slightly smaller and less invasive procedure. And some of the advantages of that are a faster recovery in the, say, first six weeks after surgery. In the first 4 or 5 years after the operation, you're perhaps more likely to be at the top end of the functional outcome group. So partial knee replacements do a little better - or some of the partial knee replacements do a little better. And there is a reduced risk of complications. So the risk of infection, blood clot, problem with your heart, problems, say, with your kidneys after the operation is reduced with partial knee replacement. So there's the good things stacking up.

The thing to weigh against that is that if you look in the, data or the evidence across the country, you will see that partial knee replacements have a slightly higher chance of being revised. Now, it's important to understand that if you are going to consider partial knee replacement, you would want that being done by someone who is experienced in partial knee replacement and is able to do that. So you talk with your surgeon about that. If they can't do partial knee replacement and you're a candidate for it, they should refer you to see someone who does do partial replacement. But as long as the operation is being done well and we're optimising the ability of the partial knee replacement not to be revised, then it's a pretty good option. But you're balancing slightly faster recovery, slightly higher function, slightly reduced risk profile against a slightly higher revision rate. And you've got to make that balance. So, a slightly higher reoperation rate and you've got to make that balance. And that's the summary of kind of partial or total knee replacement.

But I go back to where I came into this point. The big decision is whether you would have a knee replacement or not. That I think is the key decision and then partial or total plays into that.

Right well, what I was surprised at was I didn’t even have to stay overnight, and the operation was done at lunchtime and then I was sent home six o’clock that night, which was very surprising, [chuckles] But apparently that’s the way they are doing it these days. So, it was done by the needle in the back, so you don’t have to be actually put off, are you with me?

With the anaesthetic?

But I don’t know what it’s called. Yeah.

Is it the epidural, the back one, the spine—?

That’s it, that’s it, that’s the word, yes. So you’re not given so much anaesthetic, so they can just sort of, yeah, turf you out, [laughs] but, so I was surprised at that.

No, I mean obviously just before the surgery, and you saw the anaesthetist, and he just asked you questions before you went down, but that was on the day of the actual surgery, yeah.

And had you talked or thought about the anaesthetic? So, I know you went for an epidural or you had a—

I didn’t go for, it’s what they give me, I didn’t have the choice of having an ordinary operation, it was the epidural or not at all, so, you know?

With the first one they didn’t give me a choice of having the injection in the back and only-, and going home the same day, I wasn’t even told about that with the first surgery, you were in, you stayed your three days and you had proper surgery, you were put out properly and, you know? But this second one it was this other way, or not at all, so there you go.

Well, to begin with, well I suppose I did have an option, is to have it, or not have it, because of my age and because of-, [coughs] excuse me, previous medical problems I had, i.e., heart condition and two years after that, lung cancer, which everything is cleared up now, but I was a bit concerned about having it-, operation and a risk, all that, under the anaesthetic, so I just went for epidural.

Well, you’re awake for a start, you don’t feel a thing, you hear it, you hear what’s going on, and if you’re not squeamish you hear the drilling, you hear the banging—

Wife: You’ve got earphones...

I mean, you know, you hear the banging. I had earphones on and I was listening to a couple of comedy programmes that I had previous recorded for the actual operation, and I was listening to that and it was great.

Wife: You got peace of mind...

Yeah that’s right, I got peace of mind—

Wife: That you’re going to come out of it at the end.

That I was awake, and we’re going to come out it, and I wasn’t going to sort of have it on my mind as you-, as the anaesthetic is first working: ‘am I going to wake up?’

You know, that I knew that I was going to wake up because I was awake.

Oh, I thought that was fantastic. The anaesthetist asked me how I felt about being unconscious or, you know, if he put me out or what, what would I prefer. And I said the minimum required - just to control the pain - because I’ve never really liked being unconscious. I’ve always avoided it.

So, he got it a hundred percent right, I was awake throughout, quite amazing operation, what they do. And I was totally lucid as they wheeled me back to the recovery room, and I thought it was absolutely first class.

I was in for about two, three days I think because I have an obscure blood problem. It’s not anything that amazing - it’s just that the platelets don’t behave properly so I can have post operation bleeding.

Yeah, they go through all the usual risks about anaesthetic, because I had a spinal, like an epidural into my spine and because they tell you about all the risk with that, you know, anything, which scares [chuckles] the hell out of you because they tell you could be paralyzed or anything.

But that’s - you know - they have to go through all that; they have to tell you all that. But honestly, that as well was amazing. I hardly felt that because they put like a little anaesthetic in beforehand, before I had the spinal and I didn't really feel much of it at all.

And then during the operation they said to me, “Do you want to listen to some music?” So, because I had ear buds in, I said, “Oh yeah, yeah, I'll listen to the music.” He said, “I'm just giving you a little anaesthetic into your hand, it won’t knock you out but it will make you feel a bit woozy.”

Well, it did perfectly knock me out: I went to sleep, so I didn't hear much of my music and the next thing, he woke me up and says, “It’s done!”

Wow, goodness.

So, [chuckles] so that was quite a - if you have to say it - a good experience, you know? Because I was a bit worried because you don't get - it’s not a general anaesthetic - so you can more or less see what’s going on. They put a sheet in front, and he’s behind the sheet, but I thought, ‘oh, I don't want to hear noises and things,’ but I didn't, because I was so woozy, I think I went to sleep.

Yeah, wow, gosh.

So...

When you came back from the anaesthetic, how were you after that?

I was fine, yes, they watched me for a while and then took me back to the ward and I was okay.

So, you did wake up in the HDU?

Yeah, they did the operation then I woke this and then I was sort of glad. And the staff there because it’s like a one-to-one care, yeah.

And they had a trainee nurse, so there’s two of them, you know, looking after me, coming quite often into the room, you know. “Would you like to drink water?” Get me drink water because I’m thirsty and, “would you like to eat something?” Well, I said, “What about a cup of tea, a sandwich?”

They keep-, you know, so they looked after me there.

And then they had to put all kinds of monitors on me, they were taking four or five different readings, you know, temperature, blood pressure, pulse and all sorts of thing. And I had that-, like the airbag you know to-, and it stops any blood clot and all that, on my leg, which was a bit painful. So I had that.

Then a doctor came - must have been seven o'clock, something like that. They say hello to me, he said, “Yeah, yeah, we realise you’ve got some underlying condition and we’ll look after you,”

And they give some antibiotic, and then the nurse came and they give some injection intravenously, she gave me some antibiotic, just as a precaution.

As a precaution, yeah.

Yeah, yeah, because the risk of infection. And then I think they gave me three - I had three of those the night, and then I think about midday the next day, the results were-, or that-, I was okay, so then they moved me to the ward.

Well, I think in the long run, I think I'm glad that-, because although I might have got it-, it would have been nice to have got it done sooner, yes, but on the other hand, I don't think I would have had the option, if I hadn't gone privately. I wouldn’t have had the option of the bespoke knee, of the robotic assistant operation, and that’s been such a good outcome that in the long run it turned out for the better.

Can you feel a difference between your knees?

I can in the way that they bend, yes. The new knee is so much better, it bends further, and that’s without me doing many exercises. So-, because, you know, I couldn’t-, I was trying to do exercises for my back rather than for my knee, so no, it was-, it’s really, really, they've done a brilliant job on this knee, I'm very, very happy with it.

Good, yeah.

Yes.

In fact, I wouldn’t know it wasn’t my own knee.

Okay, well, I got call from the hospital to say would I be willing to go for- into trials for a CT scan on your knee prior to having an operation.

I said, “Oh, that sounds interesting,” she said, “Yes,” I said, “What’s that all about?” she said, “Well, we’re finding that people with- have a knee op and they get a lot of pain,” and they say that during the operation is when they’re doing the operation, they get your knee and they line it all up straight, basically.

But they’re saying that the- because of that, because over the years, you know, you're walking around waiting for an operation, your knee goes out of a different alignment.

So, they want to check the alignments, so it could be a thing of the future, they actually don’t put it back straight, they leave it where it did sort of grown into.

So I don’t know what’ll happen to that now I’m at this [private hospital network] hospital, I don’t know where that’s going to be done or not.

Oh, that’s interesting, it sounds like an interesting study.

Ah, yes, it- yes, and, you know, well you, because they have to ask you because if there’s additional radioactive measurements taken or something.

So, they ask you if you're willing to do it, and I said, “Yes, of course I am”.

Apparently, the robot makes much better, or more accurate, rather than better, more accurate decisions as to where to make the incision and whatnot.

I don't know how much more of a part it plays in the actual surgery.

Did you have any concerns about the robotic trial when you were offered it and you agreed to take part?

No, I was quite excited about it actually.

Do you mind me asking why?

Just because it’s an innovation and just I'm going to be part of history here.