Enhanced recovery is an evidence-based programme which is being used nationwide in various types of surgery, including hip and knee replacement surgery.

It aims to optimise your health before surgery through you attending pre-operative assessment clinics and addressing any medical requirements to ensure you are fit for your orthopaedic surgery.

Attending our mandatory Joint school and reading your joint replacement information booklet will give you a thorough insight, as to what will happen to you during your stay in hospital and your recovery after surgery.

Improved pain management strategies at the time of surgery and during your recovery ensures that you can fully-participate in your rehabilitation to achieve the best outcome.

Having a short-acting spinal anaesthesia reduces the risk of complications such as blood clots and chest infections after your surgery and reduces the pain you may experience if you do not move your new joint, as it relieves the effects of stiffness. These are achieved because we are able to get you moving up and about safely with a walking aid within a few hours of your operation ending. You are also less likely to feel nauseous after surgery, so you will be able to start eating and drinking normally much sooner.

All of these factors ensure that you have a safer, faster recovery with better outcomes after surgery.

Please:

• Attend your Pre-Operative Assessment appointment for relevant tests and advice – it is essential that you are as healthy as you can be before your surgery and that you have your surgery at the right time for you to achieve the best results.
• Attend a mandatory Joint school – understand what will happen during your hospital stay and what is expected for your ongoing recovery.
• Read your knee/hip replacement advice booklet – thoroughly understand the risks and benefits of your surgery and ask any questions you may have for your surgeon.

You should:

• Stop smoking – to reduce complications associated with your wound healing and the risk of infection in your wound and chest after surgery. For support and advice please click here.
• Reduce your alcohol consumption – to reduce complications and promote good skin healing and safe, stable walking after surgery! Click here for more information. 
• Eat a healthy diet – to help with your digestion before you come in for your surgery and for healthy weight management if required. For support and advice click here.
• Dental/gum hygiene – For support and advice click here, and plan a routine check-up with your dentist
• Skin – keep your skin in the best condition possible. Avoid having any cuts, abrasions, open wounds at the time of surgery. Do not shave the skin on your legs or groin region for seven days before your surgery
• Prehabilitation – Practice and familiarise yourself with the therapy exercises. Increase your muscle strength and maximise the movement at your joint if you can.
• Arrange your transport to and from hospital on the day of your surgery – ask your friends and family members to help you.

Your home:

• Make your home safe and ready for your return after surgery, when you will be using a walking aid. Declutter and remove any trip hazards to give you more space to walk about safely.
• You may also find it awkward to carry items whilst using walking aids, so you may choose to use a rucksack/small bag or consider buying a trolley aid.
• If you live on your own, think about asking a friend or relative to come and stay with you, or to visit you frequently, in the first few days/weeks if you feel that you may need help and support when you arrive home.
• Ask friends or family to provide support with domestic tasks such as shopping, cleaning or caring for your pets whilst you are in hospital and when you go home.
• Kitchen – Arrange frequently used items at an easily accessible height. Place a dining room chair in a convenient place to rest on/eat meals/prepare food. Use a thermos mug to keep drinks warm. Think about doing some on-line shopping for a few weeks. Plan-ahead and prepare/freeze some extra meals before your surgery.
• Personal needs – You may prefer to have a strip wash for few days after surgery until you are confident enough to get in/out of shower. Place a dining room chair/stool in the bathroom to use whilst you wash, shave, brush your teeth, etc. See wound care advice regarding your shower-resistant dressing.

Please ensure that you complete the Therapy Heights assessment form with the required information regarding the height of your own bed/chair/toilet at home and return as soon as possible with any additional information you wish to provide to: rjah.therapyheightsform@nhs.net

The Therapy Team will aim to provide you with any necessary equipment before you come into hospital.

Please pack light: there is very limited space on the orthopaedic wards. You will not need heavy, excessively warm clothing as the wards are pleasantly warm and blankets are available should they be required. Please bring the following:

Clothes:

• Shorts or skirts are ideal following a knee replacement to accommodate the compression bandage and allow for monitoring of your wound dressing
• Wide-bottomed trousers or skirts are suggested after hip replacement surgery to ensure that your clothing is not too tight over your wound/dressing
• T-shirts, blouses, shirts, cardigans, light pullover/jumper
• Light nightwear, underwear
• You are unlikely to require a dressing gown

Footwear

• A pair of supported, non-slip shoes/slippers with backs, which your feet are familiar with, as your feet will be warm and can swell all the way to your toes after surgery.

Personal needs

• Your usual walking aids, please bring in two crutches if you have them at home. Glasses, contact lenses, dentures, hearing aids and any required sanitary products.

Entertainment

• You are welcome to bring a book, magazine, iPad, smartphone, chargers and headphones.

Exercise sheets/hip or knee information booklets

• We suggest that you make a record of any questions you may have for your Consultant Orthopaedic Surgeon, Anaesthetist, Therapy team, Nursing team or Enhanced Recovery Practitioners.

These are provided at Pre-Operative Assessment Clinic, and you are asked to use them to reduce the risk of infection at the time of surgery.

• Body wash – will reduce the number of dead skin cells on your body at the time of surgery. Please wash your hair and body daily for the four days before you come in for surgery and on the morning of surgery – for five consecutive days in total.
• Nasal ointment – to reduce the risk of MRSA bacteria in your nose. Apply a pea-sized amount up each nostril with a cotton bud or your finger – morning and evening – for four days before you come in for surgery and on the morning of surgery – for five consecutive days in total.

You will receive a letter (admission letter) advising you what day/date/time to come in for your surgery. This will include when you should stop eating (fasting) and drinking. Please follow your own instructions.

On the morning of your surgery, please do not have milk in your drink or use chewing gum. When you see your Anaesthetist on the morning of your surgery, we suggest that you ask them to confirm what time you should stop drinking clear fluids/water.

The Pre-Op Assessment Nutricia drinks are a carbohydrate-rich drink which will help to reduce the effects of fasting before your surgery. If you are not a diabetic, you should be given two, still (not fizzy), clear, lemon-flavoured drinks to give you energy, improve hydration and reduce your body’s stress-response to your surgery.

Please drink them as a clear fluid as per the instructions in your admission letter.

Please report to Baschurch Day Unit (location 12) on the date and time shown on your admission letter. The day of your operation will feel long. Please try to have a restful and relaxing day the day before, so you are not too tired on the day.

You may be waiting for a while – please bring a book, magazine, or iPad to read and entertain you.

You will be met by the nursing team, your orthopaedic team and the anaesthetist, and you will have the opportunity to discuss the options for your anaesthetic and pain management after your surgery.

Before you are ready to go home, you will be taught/advised how to:

• Walk safely with an appropriate walking aid, usually crutches
• Get in and out of bed, on/off the toilet and chair
• Negotiate the stairs, if required
• Be independent with your exercises
• Deemed to be medically fit
• Know how and when to take your medications
• Monitor your wound dressing and know when to arrange a wound review appointment
• Contact the Enhanced Recovery Team Helpline

Some patients will be safe to go home on the same day as surgery.

Please mention at the earliest opportunity that you require a sick note so that this can be given to you with other discharge information prior to leaving hospital.

Any further sick notes, if needed, can be provided by your local doctor.

If you go home on the same day as your surgery, the Enhanced recovery team will telephone you the next day to provide support and answer any questions you may have. A further call will be made two days later, on day three after surgery.

For general enquiries relating to your joint replacement surgery or your surgical wound, please contact the Enhanced Recovery helpline on 07756 876 847.

After your joint replacement surgery, it is normal to experience pain, stiffness, swelling and bruising. Swelling and bruising can affect the whole limb after surgery.

Everyone experiences pain differently. The type of pain which you will experience after your surgery will be different to the discomfort you have had with your arthritis but this operation-pain is short-lived and will reduce over time.

Remember that experiencing pain is expected and normal. You have had major surgery and the best way to manage your pain is changing your posture frequently, walking about with an appropriate walking aid, and gentle movement of your new joint, interspersed with rest and high elevation.

P.R.I.C.E:

• Protection of your soft tissues by using your crutches
• Rest
• Ice after knee replacement
• a Compression bandage may be applied to your knee for twenty-four hours after surgery
• Elevation

We provide pain medication in line with current evidence. You should take your pain medications as prescribed to enable you to perform your therapy exercises, achieve your rehabilitation goals and gain the very best outcome from your joint replacement surgery. You can reduce the amount of pain relief you are using as you feel able.

Before you leave hospital, the nurse looking after you will have explained how to take all your medications, including pain relief. If you run out of pain medication and still feel that you need them, you should obtain a further prescription from your local Doctor.

We also suggest that you try some non-medical methods of pain relief, such as engaging with your physiotherapy exercises, taking regular short walks, ice therapy as advised by the therapy team and distracting yourself during the day, such as by making a phone call or watching a favourite film/TV programme.

This is a strong pain medication and should only be taken when pain is severe. It may cause you to feel disorientated, sick and drowsy.

Some pain medications are known to be addictive.

A leaflet that explains the risks has been given with your medicines: “OPIOID MEDICINES AND THE RISK OF ADDICTION”.

Some people do become constipated after surgery and there are many possible reasons. You will not eat or drink as per your normal diet on the day of your surgery. You will walk about less for a few days or weeks after your surgery and so your gut will be less mobile too. You will be taking medications for pain relief and a common side effect of these is that your gut motility will slow down. If constipation is not managed effectively, it can lead to serious medical complications.

We will give you laxatives after your surgery, but it is also very important that you eat a good, balanced, nutritious diet and drink plenty of fluids. Your urine should be straw-coloured. It is important to take your laxatives as prescribed until your bowel habit has returned to normal for you, or you are no longer requiring strong pain medications. You should also use natural remedies such as dried prunes, apricots and fresh fruit and vegetables.

In addition to your pain relief medications and laxitives, we will also prescribe anti-sickness medications and blood thinning medications in accordance with your surgeons’ preference.

The dressing over your wound should not need to be changed until you see the practice nurse at your doctor’s surgery. The ward staff will advise you on discharge when your wound needs to be reviewed and any clips or sutures removed, if applicable. This is normally 2 weeks following surgery and you will be asked to arrange this appointment yourself directly with your doctor’s surgery when you go home.

If, however you notice any of the following before your practice nurse appointment, please contact the Enhanced Recovery Helpline for advice:

• Excessive or persistent bleeding /oozing onto your dressing
• The dressing pad becomes fully soaked with blood or ooze seeps out at the edges
• Your wound dressing becomes loose at the edges

Swelling is normal and can affect the whole operated limb for up to a year following surgery. You may notice that it can be worse in the evening when you have been sitting or standing all day, but it will usually improve after a period of high elevation, for example in the morning after lying on your bed overnight.

We recommend putting some pillows, a blanket or duvet under the foot-end of your mattress to elevate your feet higher than the level of your heart. This will help with the force of gravity, to reduce excess swelling during the night and for periods of rest on the bed during the day.

WHEN TO ACT…..

If you notice that you have persistent swelling in your limb which is not improved with high elevation, a blood clot such as a deep vein thrombosis (DVT) may be suspected. Other symptoms of a DVT include pain, redness, tightness and heat in the calf.

If you experience chest pain and breathlessness, a pulmonary embolism (PE) may be suspected.

Both DVTs and PEs could be life threatening emergencies, so contact 999 or attend your local A&E as soon as possible.

For a medical emergency please contact 999 or attend your local A&E department.

If you do attend A&E for any reason relating to your joint replacement, please inform the Enhanced Recovery Helpline when you are able to do so.

You may have a shower following a hip and knee replacement as you will have a shower-proof dressing covering your wound. We suggest using a non-slip mat on your shower floor and you may benefit from some grab rails to help you to step in and out safely.

• Hip replacement - We do not recommend using a bath for twelve weeks, as excessive bending or twisting as you get in/out of the bath can dislocate your new hip.

• Knee replacement - You may have a bath once your wound is fully healed, providing that you are able to safely get in and out of the bath.

• Hip replacement - You are not required to sleep on your back following a hip However, some patients do sleep on their back with a pillow placed between their legs or position a pillow or rolled blanket alongside their leg. You may sleep on the operated side when comfortable to do so with a pillow between your knees.

• Knee replacement - You may prefer to sleep on your back for four to six weeks following your knee replacement. If you are unable to do so, you may sleep on your side with a pillow between your knees. If you lie on your back, please rest with your operated knee straight. Do not be tempted to place a pillow under the knee for comfort, as this may cause the soft tissues at the back of your knee to become tight and develop a permanent/fixed bend at your knee.

Hiccups can be a side effect of some of the medications that you are given during/following surgery. If you do have hiccups, please try home remedies such as drinking ice-cold water, peppermint tea or peppermint water, or attend your local pharmacy for advice.

• Hip replacement - We recommend that you gradually increase your confidence and distances walked with your crutches and continue with the therapy exercises you will have been taught whilst in hospital. You will not receive any outpatient physiotherapy.

• Knee replacement - You will receive outpatient physiotherapy at your local provider. This will be discussed during your hospital stay, and you should receive an appointment within two weeks of your surgery. If you do not hear from your provider, please contact them directly.

The Therapy Team will be able to advise you during your stay how long you should expect to be using walking aids. This will often be determined by what you used to walk with before your surgery and if you require any more joint replacement surgery.

Most patients will be safer using two crutches if walking outside, until their 6-week follow-up appointment.

An appointment will be arranged for follow-up with your Consultant and this will be confirmed by letter with a date and time, as decided by your Consultant. This is usually between six and twelve weeks after surgery.

This depends on the type of work that you do. If you have a sedentary job, you may feel well enough to return after six weeks. However, for more active/physical jobs you should be able to return after twelve weeks. If you are unsure, we suggest that you check with your consultant at your follow-up appointment.

It is your responsibility to assess when you are safe to return to driving. These are our guidelines. You must be able to:

• Perform an emergency stop without discomfort
• No longer require the use of your crutches to walk
• Experience no discomfort from the site of your joint replacement which would distract your concentration from the road
• No longer require strong pain medications (e.g. morphine)
• Inform your motor insurance company of your recent surgery and have confirmation that they are happy to cover you

When you feel safe to drive again, we recommend that you start with a short journey and gradually increase the distance that you travel.

You can return to low-impact activities such as walking on the flat or gentle incline, cross trainer, exercise bike, cycling, swimming or low-impact gym equipment. For any specific activities, we suggest that you discuss this with your surgeon at your outpatient review.

Avoid high-impact activities such as running, jumping, twisting, and pulling. Examples include sports such as tennis, netball, rugby, and trampolining.

You may return to swimming six weeks after your surgery, when your wound has fully healed. Be very careful walking around the outside of the swimming pool where the floor is wet and slippery. Think about the access in and out of the pool.

You may experience some clicking as the joint mechanics change following joint replacement surgery. The soft tissues around the joint will be swollen and it can take time for everything to settle down.

You are recommended to avoid flying long haul for at least three months following surgery due to the increased risk of blood clots forming in your legs or lungs. Short haul flights may be safe to take sooner, but we suggest that you discuss this with your surgeon.

This will depend on the sensitivity of the scanning equipment. We suggest that you advise the security personnel of your new implant and where it is located. We do not provide any medical alert cards as proof of surgery due to the ease of falsification.