This leaflet can be made available in other formats including large print, CD and Braille and in languages other than English, upon request.

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1 Information for patients This leaflet can be made available in other formats including large print, CD and Braille and in languages other than English, upon request. Contents Page What is a normal knee joint? 2 Do I need a knee replacement? 2 How will a knee replacement help me? 2 What are the different types of knee replacement? 2 How long will my new knee last? 4 What are the risks and possible complications of this operation? 4 What will happen before my surgery? 6 What will happen when I come into hospital? 7 What will happen during my operation? 7 What will happen after my operation? 8 What will happen when I go home from hospital? 9 When can I have a bath or shower? 9 When can I drive again? 9 Do I need to sleep in a special position? 9 When can I kneel? 10 Will I need any follow-up appointments? 10 Contact numbers 10 Visiting times for Elective Care, Ward 4, Hartlepool 11 Visiting times for Ward 32, North Tees 11 Further information is available from 12 References 12 Ortho/121.6 S1 (2017) Page 1 of 13 For Review Spring 2020

2 This booklet tells you about your knee replacement operation. It also explains why you need this operation and the care you will receive. What is a normal knee joint? The knee is a hinge joint between the lower end of the femur (thigh bone) and the upper end of the tibia (shin bone). The kneecap (patella) is at the front of the knee joint. The ends of the bone are covered with a smooth, slippery layer known as cartilage. This allows the knee to bend and straighten easily and stops the ends of the bone from rubbing together. Femur Patella Fibula Tibia Do I need a knee replacement? A knee replacement is for advanced arthritis and is only considered when the pain in your knee becomes severe, affecting your daily life. Non-surgical options should be tried first such as painkillers, exercise and weight loss, you may also be offered a steroid injection into the joint. How will a knee replacement help me? Having a new knee joint should help to reduce pain, stiffness and improve your mobility, allowing you to carry on with most of your usual activities. What are the different types of knee replacement? Your surgeon will discuss the type of knee replacement best for you. This will depend on the condition of your knee joint. The different types of knee joints are: Total knee replacement A total knee replacement operation involves removing the worn surfaces of the joint and replacing them with smooth metal surfaces which have a plastic part between Ortho/121.6 S1 (2017) Page 2 of 13 For Review Spring 2020

3 them. The total knee replacement may also involve replacing the surface of the kneecap, if needed. The new metal parts are fixed to the bone with bone cement. Femur Tibia Unicompartmental (partial) knee replacement If your arthritis only affects one part of your knee, it may be possible to have a partial replacement. This involves replacing the worn part rather than the whole knee. Usually the recovery is faster and the joint bends and moves more naturally. Femur Tibia Patellofemoral (partial) replacement If your arthritis is only behind the knee cap, it may be possible to replace just the worn parts. This involves replacing the back of the kneecap with a plastic button and the area on the end of the thigh bone with a smooth metal part. Femur Tibia Ortho/121.6 S1 (2017) Page 3 of 13 For Review Spring 2020

4 How long will my new knee last? Your new knee joint should last about 15 years, some may not last as long while others may last longer. The younger you are when you have your surgery, the more likely you are to need another knee replacement on the same knee. This is known as revision surgery. What are the risks and possible complications of this operation? There are risks and complications involved with knee replacement surgery. The most common are: deep vein thrombosis - DVT (blood clots in the leg veins) or pulmonary embolism PE (blood clots in the lungs). Sometimes a clot forms in the deep veins of the leg after an operation. This can cause the leg to swell and become painful. If the blood clot in the vein becomes dislodged (moves) it can travel to the lung and cause a PE. A DVT or PE can be due to the effects of the surgery or reduced activity during your recovery. 1 patient in every 100 develop symptoms of DVT and/or PE up to 3 months after a knee replacement. 1 The risk of a DVT can be reduced by: fitting inflatable cuffs around your calves which squeeze the veins in your legs, every so often, to improve blood flow medication to thin your blood. You may be given: - an injection into your abdomen (tummy) every day during your stay in hospital and for up to 14 days after your surgery. Arrangements will be made to teach you how to give yourself the injections, if you are able. You may notice some bruising around the injection site; this is quite normal and will disappear once the injections stop. It is very important that you get out of bed when advised to do so. You will be given medication in theatre to make your knee more comfortable so you can get out of bed and walk around. The best way of preventing a DVT or life threatening PE is by moving around as soon and as much as possible after your operation. infection. To reduce the risk of infection, you will be given antibiotics before and after your operation. A small number of people may still develop an infection Ortho/121.6 S1 (2017) Page 4 of 13 For Review Spring 2020

5 either in hospital or after they have gone home. If this happens, you will be prescribed a course of antibiotics. It is more common to have an infection on the surface of the wound. Sometimes these can develop into a deep infection. The risk of developing a deep infection is less than 2 patients in every In very rare cases of deep infection, the knee replacement may have to be taken out and a new one put in when the infection has cleared. nerve damage. Reduced sensation or numbness close to the wound is common after the operation. This may resolve (get better) with time. This reduced sensation will not affect the movement of the knee. If the peroneal nerve is damaged it could cause reduced sensation, numbness, or tingling in the outer part of the lower leg. It can also cause weakness in the ankle or foot (foot drop). Nerve recovery varies. Half the patients who suffer from this fully recover. Patients with some remaining nerve function recover more than those with complete loss of nerve function. 3 swelling and bruising. Your leg can be very swollen which may last for several weeks or even months. It can also sometimes be bruised, which will settle in time. loss of blood. During any operation there will be some blood loss. Depending on how much blood you lose during your operation and the results of your blood tests after your operation, you may need a blood transfusion. You will be given a leaflet explaining about blood transfusion. stiffness. Your knee may feel very stiff after your operation. It is very important you follow the exercises given to you by your physiotherapist and do these 4 times a day. You must continue your exercises after you leave hospital. If the stiffness continues for 6 weeks your surgeon may need to bring you back into hospital and manipulate (bend) your knee under a general anaesthetic, (a state of carefully controlled and supervised unconsciousness (deep sleep) which means you are unable to feel any pain). Some patients have less movement in their knee after the operation than they had before their surgery. instability. Very occasionally your knee may click and can feel unstable. In rare cases revision surgery may be needed. wear and loosening. The polyethylene liner can wear over time or the knee implant can become loose. Patients may have symptoms such as pain, swelling and increasing deformity in the knee. Diagnosis is confirmed by x-ray. Ortho/121.6 S1 (2017) Page 5 of 13 For Review Spring 2020

6 Treatment may include: - continued observation - replacing the polyethylene liner - revision knee replacement if the components are loosening. on-going discomfort. Some pain can be expected after your operation and you will be given painkillers to help with this. You should notice a gradual improvement in your pain levels in the following weeks after your operation. Some patients may always have mild discomfort. fracture. A fracture (break) around the artificial joint could happen during or after the operation. Your treatment will depend on the location and extent of the fracture. reaction to bone cement. Bone cement can be used during your operation to fix the metal parts to your bone. This could cause a temporary fall in your blood pressure. In rare cases there have been reports where this low blood pressure was linked to cardiac arrest and sudden death. Your anaesthetist will be monitoring (checking) your blood pressure, pulse and breathing carefully and will treat any changes immediately. death. The risk to life increases for patients the older you are and if you have a severe heart or lung condition. retention of urine. After your operation you may find you have difficulty in passing urine for a short period. This can happen because the muscles which control your bladder have been affected by the anaesthetic drugs you were given. You may need to have a catheter (small tube) passed into your bladder to allow your urine to drain until the effects of the drugs have worn off. What will happen before my surgery? Pre-operative assessment You will attend a pre-operative assessment to make sure you are fit for surgery. Your general health and medical history will be discussed. Tests will be carried out, this could include taking a blood sample and an electrocardiogram (ECG - heart tracing). Your blood pressure, pulse rate, height and weight will be checked. You will be screened for Methicillin Resistant Staphylococcus Aureus (MRSA). Swabs will be taken from your nose and groin (top of your leg). You will be given a leaflet MRSA screening and decolonisation. Information class When your name is on the list for surgery, you will be contacted by the Joint Replacement Service inviting you to come to an Information Class which usually Ortho/121.6 S1 (2017) Page 6 of 13 For Review Spring 2020

7 lasts about 1½ hours. It is very important you attend, as you will learn all about your care, rehabilitation and what is expected of you before and after your surgery. The healthcare professionals you will usually meet at the Information Class are: joint replacement nurse, occupational therapist, physiotherapist and pain nurse specialist. There may also be a member of the Total Hip and Knee Support Group present. Occupational Therapy The occupational therapist (OT) will contact you before you come into hospital to arrange a visit to your home. This is to advise on any adaptations (changes) you may need to make it safe when you return home. The OT will measure the height of your chair, bed and toilet. You may need a raise on these items. Any equipment needed will be ordered and delivered before your operation. Validation clinic You will be invited to attend a validation clinic about 2 weeks before your surgery. At this appointment all your test results will be checked and updated if needed. You will be asked to complete a short questionnaire and sign any forms if needed. You will need to bring your glasses (if you wear them), the medications you are taking and a sample of your urine. Medications When you come into hospital, please bring all your medications with you. They will need to be in the original boxes with your name on, dose and when you take your tablets as you will be given your own tablets while in hospital. What will happen when I come into hospital? You will need to attend the Access Lounge on the day of your surgery. Your letter will state whether this is at Hartlepool or North Tees Hospital. You will be seen by your surgeon who will check you have signed your consent form for the operation and will mark your leg with a marker pen. You will also be seen by your anaesthetist and have a chance to discuss the details of your anaesthetic. You will be taken to theatre from the Access Lounge. What will happen during my operation? You will usually be offered a spinal anaesthetic which involves a small injection into the middle of your lower back. It is a safe and effective anaesthetic, numbing you Ortho/121.6 S1 (2017) Page 7 of 13 For Review Spring 2020

8 temporarily from the waist down. Sedation (a drug which makes you feel comfortable and relaxed) may also be given to help you sleep during your surgery and you may be unaware of what is happening. Spinal anaesthetic has many advantages over general anaesthetic. You will feel more awake after your operation and be able to move around quicker if you have a spinal anaesthetic. Once you have been given your anaesthetic, you will be taken into theatre. Your operation will take 1 1½ hours. After your operation, you will be taken to the recovery room. You will be in the recovery area for 1 2 hours. What will happen after my operation? When your general condition is stable you will be taken to the special post-operative area on the ward where you will stay for the first hours for monitoring and close observation. Once you are fully conscious and the feeling in your legs has returned you may be helped out of bed to walk, this will be on the day of your operation. Pain relief You will be given regular pain relief medication, but if you feel it is not helping you must let the nurses know. Some discomfort can be expected but anything greater than this will slow down your recovery. You will be given an ice pack and shown how to use this regularly. It is important to ask for the ice bucket to be refilled when you need it and to continue using this several times during the day. You can use the ice pack every hour to help reduce the swelling and should be used for only 20 minutes each time. Physiotherapy As part of our Enhanced Recovery Program, you will be helped out of bed on the evening of your operation. You will be shown how to walk correctly using a zimmer frame and be allowed to walk short distances. You will also be helped to use the commode when you need to go to the toilet. You will be shown how to do your knee exercises while you are in bed. You will be given an exercise board and a bandage to help bend your knee. It is very important to carry out these exercises at least 4 times a day. Your physiotherapist will check how far you can bend and straighten your knee. Once you are safe using a zimmer frame, you will progress to walking sticks or crutches. You will then be shown how to manage stairs. Your physiotherapist or occupational therapist will check you are able to get in and out of bed and get on and off the toilet without help. Ortho/121.6 S1 (2017) Page 8 of 13 For Review Spring 2020

9 It is very important you are up and walking around often throughout the day and you gradually increase the distance you walk. You should continue to take your painkillers regularly. You must ask for extra painkillers if you need them. During the first or second day after your operation, you will be taken to have an x-ray of your new knee. Before your discharge from hospital you will need be able to: use your sticks or crutches safely bend your knee to 90 degrees do your exercises go up and down the stairs get in and out of bed. The usual inpatient stay is about 3-4 days. What will happen when I go home from hospital? You must use your sticks or crutches when walking for at least 6 weeks after your operation. Your physiotherapist will discuss this with you. Remember you must: not sit for long periods do your exercises 4 times a day get up and walk around regularly continue to use your ice pack regularly attend your outpatient physiotherapy appointment. When can I have a bath or shower? During the home visit before your operation, your occupational therapist will look at your bathroom and give you advice on how and when you can shower or bathe safely after your operation. When can I drive again? You must not drive a car for at least 6 weeks. You can travel in a car as a passenger. Do I need to sleep in a special position? You do not need to sleep in any special position after your knee operation, but you must not sleep with a pillow under your knee. It can lead to tightening of your Ortho/121.6 S1 (2017) Page 9 of 13 For Review Spring 2020

10 muscles and your knee stuck in a bent position. You might find it takes time before your normal sleep pattern returns. When can I kneel? You are advised not to kneel for the first 8 12 weeks after your surgery. Most patients find it uncomfortable to kneel at first. This should become easier over time. Will I need any follow-up appointments? You will: receive a telephone call from the Joint Replacement Team, about 48 hours after you have been discharged from hospital to check you have no problems be informed when your clips or stitches will be removed. This will be days after your operation and can be carried out in the Physiotherapy Department. If you are having physiotherapy at home or live out of the area, arrangements will be made to remove them at home. receive an outpatient physiotherapy appointment within 1 week of going home (if you are attending for physiotherapy at North Tees, Hartlepool or Peterlee). If you are having intermediate care at home, you will have physiotherapy at home. If you live out of the area, then you will be referred for physiotherapy. receive a letter from the occupational therapist within 6 weeks of your operation to ask if you need any further help or equipment to help you in your home. You will be given an outpatient review appointment for 6-8 weeks after your surgery. Contact numbers If you need further advice, or have any problems, please contact the appropriate number below: University Hospital of Hartlepool Elective Care Unit (Ward 4) telephone: hours a day, 7 days a week Joint Replacement Nurses telephone: or Monday - Friday, 9.00am 5.00pm Ortho/121.6 S1 (2017) Page 10 of 13 For Review Spring 2020

11 Physiotherapists telephone: Monday - Friday, 8.00am 5.00pm Occupational Therapists telephone: Monday - Friday, 8.00am 5.00pm University Hospital of North Tees Joint Replacement Nurses telephone: or Monday - Friday, 8.30am 4.30pm Ward 32 telephone: hours a day, 7 days a week Physiotherapists telephone: Monday - Friday, 8.30am 5.00pm Occupational Therapists telephone: Monday - Friday, 8.30am 4.30pm If you have any worries or concerns you should contact the Joint Replacement Department. Outside surgery hours you should contact your GP s surgery for the Out of Hours Service number. Visiting Times for Elective Care, Ward 4, Hartlepool 3.00pm 4.00pm, Monday Friday 7.00pm 8.00pm, Monday Friday 2.00pm 4.00pm, Saturday and Sunday 6.30pm 8.00pm, Saturday and Sunday Visiting times on day of surgery is only 7.00pm 8.00pm 2 visitors to a bed. 1 visitor only on day of surgery. Visiting Times for Ward 32, North Tees 2.00pm 4.00pm, 7 days a week 6.30pm 8.00pm, 7 days a week Ortho/121.6 S1 (2017) Page 11 of 13 For Review Spring 2020

12 Further information is available from: NHS Choices telephone: 111 (when it is less urgent than 999) Calls to this number are free from landlines and mobile phones or via the website at References 1. Januel JM, Chen G, Ruffieux C, et al. Symptomatic in hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review JAMA 2012; 307: Wilson MG, Kelly K, Thornhill TS. Infection as a complication of total knee replacement arthroplasty. J Bone Joint surg Am1990; 72: Asp JP. Peroneal nerve palsy after total knee arthroplasty. Clinical Orthopaedics and Related Research 1990; Ortho/121.6 S1 (2017) Page 12 of 13 For Review Spring 2020

13 This leaflet has been produced in partnership with patients and carers. All patient leaflets are regularly reviewed, and any suggestions you have as to how it may be improved are extremely valuable. Please write to the Quality Assurance Team, University Hospital of North Tees or Comments, Concerns, Compliments or Complaints We are continually trying to improve the services we provide. We want to know what we re doing well or if there s anything which we can improve, that s why the Patient Experience Team is here to help. Our Patient Experience Team is here to try to resolve your concerns as quickly as possible. If you would like to contact or request a copy of our PET leaflet, please contact: telephone: Monday Friday, 9.00 am 4.00 pm Messages can be left on the answering machine and will be picked up throughout the day. freephone: Mobile: (can use text): patientexperience@nth.nhs.uk Out of hours if you wish to speak to a senior member of Trust staff, please contact the hospital switchboard who will bleep the appropriate person. telephone: hours a day, 7 days a week The Patient Experience Team is available to discuss your concerns in person Monday Friday, 1.30 pm 4.30 pm. The office is based on the ground floor at the University Hospital of North Tees. Data Protection and use of patient information The Trust has developed a Data Protection Policy in accordance with the Data Protection Act 1988 and the Freedom of Information Act All of our staff respect this policy and confidentiality is adhered to at all times. If you require further information please contact the Information Governance Team. telephone: or information.governance@nth.nhs.uk University Hospital of North Tees, Hardwick, Stockton-on-Tees. TS19 8PE University Hospital of Hartlepool, Holdforth Road, Hartlepool. TS24 9AH Telephone: Fax: Ortho/121.6 S1 (2017) Page 13 of 13 For Review Spring 2020