Precautions are taken to try to minimise the risk of infection. The use of antibiotics during and after surgery and the use of a dedicated orthopaedic theatre are examples of those precautions. Despite this there remains a small risk of wound infection. If you, the district nurse or your GP suspect a wound infection please contact our service immediately.

Common signs of infection include:

• Redness around the site of your wound
• Wound discharge or leakage. Wound leakage may occur in the first few days following surgery and may be normal
• Increase in heat and/or swelling
• Increased body temperature (above 38 degrees Celsius)

Late infection can occur many years after your operation. This is often detected by the patient experiencing pain in the knee joint. If late infection is detected this might result in revision surgery to replace/remove the knee joint.

Your Surgeon may request further investigations to confirm infection.

You should note that if you are found to have infection before your knee replacement surgery, your operation will be delayed until you are free of infection. This is to reduce the risk to your ‘new’ knee joint.

As mentioned during your pre-assessment visit, it is very important that you have no breaks in your skin-including deep scratches, any broken teeth or other dental issues, ingrown nails, or other signs of infection such as urinary infection, cold or sickness.

If you develop any of the above following your pre-assessment please let us know prior to your admission for your surgery on 01324 566464.

Thrombosis (blood clot) in the legs or pelvic veins is called deep venous thrombosis (DVT). A thrombosis in the lungs is called pulmonary embolism (PE).

Common signs of DVT:

• Swelling in the thigh, calf or ankle that does not improve with elevation of the leg
• Pain, tenderness and heat in the calf muscle
• Common signs of PE:
• Sudden shortness of breath
• Chest pain or pain between the shoulder blades
• Sweating/confusion
• Feeling faint or unwell

You should call ‘999’ if you suspect a pulmonary embolism as this is a life threatening emergency.

Certain actions are taken to reduce the risk of DVT and PE and are discussed later in the booklet. The risk cannot be completely removed.

This is rare but can give rise to pain in the leg or weakness of some muscles. It can make walking difficult. This is often temporary and will improve over a number of weeks or months. However it can be permanent.

Sometimes patients can lose a large amount of blood during the operation. If this happens you may require a blood transfusion. Like any medical intervention it will only be offered if necessary.

You may find that after your surgery you cannot flex (bend) or extend (straighten) your knee as well as you would like to. IT IS VITAL THAT YOU PERFORM YOUR EXERCISES AS SOON AS POSSIBLE AFTER YOUR OPERATION AND TO CONTINUE THEM WHEN YOU ARE AT HOME.

If you cannot flex your knee beyond 80 degrees your Consultant will be informed. You may be advised to undergo a ‘manipulation under anaesthetic’ of your knee. This will only be offered if it is thought that it might help improve your knee movement. It will involve further anaesthetic and stay in hospital. As with any surgical procedure it carries a degree of risk.

Despite the best of efforts there is a small risk that your knee movement does not improve or move as well as you would like.

Most knee replacements will last between 10-15 years. After around 15 years 25% will appear loose on x-ray and 5-10% will become painful and require revision surgery.

Knee replacement surgery carries a small risk of death. Your Surgeon will be happy to discuss this with you.

Your Surgeon will try to ensure that your legs are of equal length. However if the damage to your bone is too extensive this may not be possible. This is rare but if it happens a small shoe insert or heel raise can be provided.

Incidence of dislocation of the knee joint is very rare. Signs of dislocation are:

• Sudden onset of severe pain
• Unable to weight bear or move the leg.

Swelling of the foot, ankle and knee is very common following knee replacement surgery. This may persist for many months. You have little or no swelling when you first get up in the morning but find that the swelling increases as the day progresses.

Some heat around the knee is usually noted and is caused by increased blood flow through the tissues during healing. Bruising can also be extensive and run the length of your leg.

To ease heat and swelling you can try the use of ice over the knee. Please do not apply ice or very cold substances directly to the skin as this can cause skin burns. The ice pack can be left in place for 10-15 minutes at a time and then should be removed for a couple of hours before using again. Elevating your leg for a period of time can also help to reduce swelling.

You can expect pain around the knee and anywhere along the length of the leg. The pain is due to to the surgical procedure and manipulation of the leg during surgery.
Many patients report that night time is a particular time that they struggle to control pain and discomfort.

You can expect pain to take approximately 3-6 months to gradually improve. You should use analgesia regularly and may need to do so for up to 12 weeks after your surgery.

Around 1 in 4 people can experience ongoing pain despite surgery.

Occasionally, slight numbness around the scar or part of the leg can happen but this is not anything to worry about. Typically you will experience a numb area on the outer side of your operated knee, lateral to your scar. This is usual and will not affect your knee.

It is common for many surgical patients to become constipated in hospital. The reasons for this include surgery, fasting before surgery, change in diet, effects of medication, lack of fluid intake and reduced physical activity. If your bowels do not move as often as normal do tell your nurse. A laxative may be prescribed until your bowel function returns to normal.

You may feel nausea (sickness) or actually vomit after your operation. In this case you can be offered anti-sickness medicines and your painkillers may be reviewed.

You may suffer from indigestion which may be as a result of medication. While it is probably nothing to worry about you should go and see your GP. Your painkillers may need to be changed, or rarely, it can indicate a problem with your heart.

Following surgery you will be transferred to the Theatre Recovery Area where specially trained nurses will remain with you while you recover from the anaesthetic.

Once awake and alert your Ward Nurse will escort you back to the ward.

You will most likely find the following:

• A cuff around your arm, which will record your pulse and blood pressure at regular intervals
• Oxygen mask
• A drip (intravenous infusion) will be attached to your arm. You will have clear fluids or possibly a blood transfusion in progress.

Nurses will assist you with personal hygiene where necessary. The ward will provide towels: however, you are expected to supply your own washing cloth/sponge, toiletries, nightwear and daytime clothing. Please do not bring flip-flops or mules. Closed foot wear should be worn to prevent trips or falls. Please advise staff when you need to use the toilet, you will be assisted as necessary. You can alert staff by using the nurse call buzzer. Buzzers are situated by the beds.

With the assistance of staff you may attempt to get out of bed the same day as surgery. You should NOT attempt to get out of bed on the first occasion on your own. Many people feel faint and light headed on the first attempt. This is because your blood pressure drops and makes you feel unwell.

Your new joint should not cause discomfort but you may experience some pain from the actual surgery itself.

• Advise nursing staff whenever you experience pain. It is vital that your pain levels are under control so that you can move and do your exercises
• You do not have to wait until drug rounds should you require painkillers
• Relevant pain relief would be administered
• As pain reduces tablets are usually adequate
• Some painkillers can be dissolved in water if you have problems swallowing tablets.

• The outer bandage will be removed on day 1 after your operation. The primary dressing (next to the wound) will be left in place for up to 2 weeks undisturbed if possible to reduce the risk of infection
• The nurse will only clean your wound and change the dressing if required, for example, if there is excessive wound soakage on the dressing
• The district nurse will attend to remove clips and check the wound at 12-14 days
• A further dressing will be applied for a further week and this can be removed by the patient at the 3 week mark.

You may have a special wound dressing that has a battery unit attached. When the batteries run out around 5-7 days, the dressing will remain in place as a normal dressing would, until the district nursing team remove at 2 week check.

You may develop bruising and swelling on the operated leg. This is very common and may persist for several months after surgery. The swelling may be better in the morning and increase as the day progresses. Swelling may be evident along the length of the operated leg as can bruising. You will experience a degree of warmth/heat around the knee and this is part of the healing process.

Your wound will be vertical over the front of your knee and approximately 6 inches in length. It should eventually fade to a thin white line.

To avoid constipation once you have recovered from the anaesthetic:

• Drink plenty of fluids
• Eat fruit and vegetables
• If you feel constipated and/or your bowels have not moved for 2 days advise your nursing staff or GP if you are at home
• Oral medications (laxatives) or rectal preparations (enema or suppositories) will be available for you on prescription if required.

Measures are taken to prevent blood clots e.g.

• Ensure you are mobilising regularly, as able, with the support of your walking aids
• Anticoagulant (blood-thinning) medicine will be given whilst in hospital and on discharge if required
• Ankle and leg exercises as described by the physiotherapist will be encouraged.

Very occasionally this complication may still arise.

When you are still on the ward, please advise your nurse or doctor if any of the following occur:

• Pain at your calf (lower leg)
• Swelling and/or increased tension at your calf
• Pain in your chest
• Shortness of breath.

If these signs occur when you are at home please contact your GP immediately.

Thrombus (blood clot formation) is treatable with medication.

Knee surgery increases the risk of blood clots. To reduce this, you may be prescribed a short course of blood-thinning tablets (such as rivaroxaban) or injections. These must be taken exactly as prescribed.

Seek medical help if you notice:

• Calf pain or swelling
• Chest pain or sudden breathlessness
• Unusual bleeding (e.g. blood in urine/stool, nosebleeds lasting >5 mins, coughing blood, heavy cuts that won’t stop bleeding)

Rivaroxaban tips:

• Take with food
• Don’t double up if you miss a dose
• Inform your GP if you feel dizzy, faint, or notice side effects
• Tell your doctor about any other medicines, as some increase bleeding risk

You may be prescribed a short course of antibiotic injections around the time of surgery to prevent infection. Occasionally you may require a longer courseof antibiotics if you develop an infection following surgery. Again it is important to complete the course even if you feel well as this will help prevent joint infections. Side effects of antibiotics may include rash or diarrhoea. You should inform healthcare staff if your side effects are troublesome. Please also advise staff if you are allergic to penicillin, for example.

An important part of your care is to ensure that you do not experience excessive pain. A range of painkilling medications are used. Most patients will receive paracetamol, which is a very effective and safe painkiller on its own or in combination with other painkillers. You are advised to take these on a regular basis until the pain is negligible.

You are also likely to be prescribed a stronger opiate painkiller according to your requirements. Opiate painkillers include codeine, dihydrocodeine, tramadol, morphine and oxycodone. These may be given regularly or when you need them in either tablet or liquid form. Other painkillers are sometimes added if you have inflammation or nerve pain.

It is particularly important to take adequate pain relief before movement and physiotherapy. Your painkillers will be rationalised as your pain improves. If you are in pain, please do not suffer in silence and ask your nurse for assistance.

Side effects you may experience with the stronger (opiate) painkillers include drowsiness, nausea and constipation. These side effects can be managed with other medicines or by taking the painkillers at a lower dose or only when needed.

It is common for many surgical patients to become constipated in hospital. The reasons for this include: the effects of surgery, fasting before surgery, change of diet, effects of painkillers and through lack of fluids and reduced physical activity. There is therefore no reason to worry if your bowels do not move as often as normal, but do advise staff if you feel uncomfortable and would like laxatives to help. These can usually be stopped within days when your bowel function returns to normal.

You may feel nausea (sickness) or actually vomit after your operation. In this case you can be offered anti-sickness medicines and your painkillers may be reviewed.

Your pharmacist, doctor or nurse can offer advice and help you with a range of potential medication problems and to respond to any other symptoms that may trouble you.

Because you have had an anaesthetic and are not as active as normal, it is important that you perform some deep breathing exercises to help keep your lungs clear.

• Take a deep breath in through your nose until you feel that your lungs are full of air, hold for a second then sigh the air out through your mouth. Keep your shoulders relaxed.

Perform this exercise 3 times every hour while you are awake.

These exercises will improve your circulation while you are immobilised in bed. This will reduce the risk of developing a blood clot.

Point your toes down towards the end of the bed and then pull them up towards you as far as you can. You should feel your skin and calf muscles tightening as you do these exercises.

Pull your foot up towards you, then push the back of your knee down onto the bed. You should feel your kneecap tightening. Hold for 5 seconds, then relax.

Tighten your buttocks together as firmly as you can. Hold for 5 seconds, then relax.

Perform 20 of each exercise every hour while you are awake.

The exercises are performed initially on a sliding board to minimise resistance. Place the sliding board under your leg and the tubigrip “doughnut” under your heel. Slowly bend and straighten your knee as far as possible. Aim to get a little further each time. The sliding board is NOT provided on discharge from hospital.

Sit comfortably in your chair or at the side of your bed. With your foot on the floor, try to slide your foot back as far as possible. You can use your UNoperated leg to assist. Make sure that you keep your bottom flat down as you bend to avoid cheating. (It is natural to feel some “pulling” at your wound with these exercises).

Place a folded towel under your heel with your leg straight. Gravity and the weight of your leg will help to stretch out the back of your knee.

Never rest with a pillow under your knee. This can encourage tightness to develop at the back of the joint and make it very difficult for you to fully straighten your leg.

Use the following pattern when walking with your frame/sticks:

• Move frame/sticks forward
• Step forward with operated leg followed by UNoperated leg

When you are ready you will normally progress from the walking frame onto 2 sticks.

Once you are at home and gaining in confidence and strength you can consider weaning off your sticks. You should only do this if you are no longer limping. You should begin by reducing down to the use of one stick. That stick should be held in the opposite hand to the operated leg. The sequence of walking with one stick should be to move the stick and operated leg forward and then walk through with your unoperated leg. Please note that everyone will progress at different rates.

Once you are confident with your sticks, your physiotherapist will show you how to safely go up and down stairs. The method is as follows:

Down

Place the sticks down onto the stair below, step down with the operated leg, followed by the UNoperated leg

Up

Step up with the UNoperated leg first, then step up with the operated leg followed by the sticks

This is the easiest and safest method for negotiating stairs and places the least amount of strain on your new knee.

Please note that there is reduced Physiotherapy and Occupational Therapy services at the weekend. Patients must take responsibility to carry out exercises without the need for instruction from nursing staff. You must therefore do your exercises at the weekends as shown previously by physiotherapy staff. Nursing staff will be available for advice.

Occupational Therapy is part of your rehabilitation. Initially the Occupational Therapist will discuss with you any day to day difficulties you may have had and how to remain independent following your surgery.

Whilst you are in hospital the Occupational Therapist will assess your ability to manage everyday activities safely and independently, so that you will be able to manage these yourself at home. These may include:

Dressing

Within a couple of days you should be able to put on your lower garments unassisted. If you are experiencing difficulties the Occupational Therapist will be able to discuss these difficulties and offer practical advice.

Personal Activities of Daily Living

Before you are discharged from hospital, an Occupational Therapist will check your ability to perform everyday activities such as getting in and out of bed, getting on and off the toilet and coping with bathing. You will find it easier to strip wash or shower immediately following surgery. It is advised NOT to have an immersion bath too soon because you may be too weak to raise yourself from the bottom of the bath.

Domestic Tasks

Before you come into hospital you may want to consider organising friends or relatives to help you in the short term with shopping and other domestic tasks. You should not attempt any activities which involve kneeling until you feel comfortable.

You can expect to be able to return to carrying out activities in the kitchen as you did prior to your operation and an Occupational Therapist will assess your capabilities before discharge. Advice will be given on how to cope with various kitchen tasks whilst you are still dependent on walking aids.

Leisure Activities

Your Orthopaedic consultant surgeon will advise you about recommencing activities such as swimming, bowling, dancing, gardening etc. Do ask him or her for guidance. Initially all these activities should be undertaken gently and without excessive effort.