A Patient’s Guide to Hip and Knee Joint Replacement Surgery

Why joint replacement surgery now?
Before suggesting surgery your doctor may have offered alternative treatments including anti-inflammatory medication, weight loss advice, physiotherapy and/or walking aids. Only when these treatments no longer control your pain will your doctor suggest a total hip replacement (THR). Osteoarthritis is the most common reason for joint replacement surgery. It usually occurs in weightbearing joints, such as the hip and knee. The cartilage on the end of the bones becomes worn down. This can be very painful, cause joint stiffness and result in reduced mobility.

There are other conditions which can also affect joints which require replacement such as rheumatoid arthritis, structural or functional abnormality that occurs from birth, treatments that reduce the blood flow to the bone and bone infection.

How does surgery help?
Your surgeon will discuss the aims of your joint replacement surgery. These may include some of the following:

• Alleviate / Relieve pain
• Correct / Modify alignment
• Improve function
• Increase mobility
• Improve quality of life.

The implants are designed to last for many years (15-25 years). Your goal will be to return to your normal activities as soon as possible.

The National Joint Register
www.njrcentre.org.uk
You will be asked to give consent for your hip / knee replacement to be added to this register. This will be explained close to the time of your surgery by the Clinical Nurse Specialist.​​​​​​​

The National Joint Register (NJR) for England, Wales and Northern Ireland collects information on joint replacement surgery. It monitors the performance of joint replacements and effectiveness of different types of surgery to improve clinical standards benefitting patients, clinician and the orthopaedic industry.

• Uncemented replacement - a porous surface or other type of surface which enables bone to grow into the pores to hold the new parts in place. It takes time for natural bone to grow/ attach, so your activity might be limited for several months after surgery.
• Cemented replacement - a specialised cement fastens the artificial parts to healthy bone.
• Hybrid replacement - use a cemented femur part and uncemented acetabular part.

The surgery takes between one and two hours.

All operations have risks. A hip replacement is a major operation and will place the body under stress. Any underlying illnesses may worsen due to the operation.

COMMON RISKS (2-5 people in every 100 hip replacements)

Pain
You will experience discomfort in your operated hip joint after the surgery but this will usually improve over the first few months. However, a degree of this ongoing pain or discomfort can occur and in some cases be permanent.

Bleeding
There will be blood loss during the operation. A blood transfusion is rarely required. If you do not wish to have a transfusion, please discuss this with your surgeon.

DVT (Deep Vein Thrombosis)
A blood clot in a vein due to the surgery. It can cause leg swelling and pain. All patients will have an individualised risk assessment completed by a doctor. Most patients are suitable to be fitted for compression stockings before surgery, which are to be worn whilst in hospital. All patients’ will be prescribed blood thinning medication, to continue for 28 days after surgery. This will be explained in full before discharge. Starting to move your legs early is one of the best ways to prevent blood clots from forming.

For more information please read A Patient’s Guide to Preventing Deep Vein Thrombosis and Pulmonary Embolism via our website at www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides

Loosening and wear of the hip replacement
The implants are designed to last for many years (15-25 years), but in some cases problems may occur earlier and require replacement surgery.

Altered leg length
The operative leg may appear shorter or longer than the other side. This can be for a number of reasons. Patients usually adjust to this but occasionally a shoe raise is required.

Joint dislocation
A further operation is usually required to relocate the hip. This may be followed by the application of a hip brace. If the hip keeps dislocating, a revision operation may be necessary.

LESS COMMON RISKS (Less than one in every hundred)

Infection
The operation is performed under sterile conditions and you will be given antibiotics at the time of the operation. Despite this, infections may still occur. Post operatively the signs of infection include redness around the wound, discharge on the dressings, a fever greater than 38°C and occasionally feeling unwell. If you display any of these symptoms you need to contact the CNS Team for Hip and Knee on 020 8909 5279. If the matter requires immediate attention, please contact your GP or go to your local Urgent Care Facility.

RARE RISKS (Much less than one in every hundred)​​​​​​​

PE (Pulmonary Embolism)
When a blood clot moves to the lungs and affects your breathing. This can be fatal.​​​​​​​

Major nerve damage
It is normal to have a numb area around the scar. Larger nerves can also be damaged leading to temporary or permanent weakness (footdrop) or altered sensation in the lower leg.

Bone damage
If a bone is broken or weakened during the insertion of the hip replacement further metalwork may be required to stabilise it, either at the time of surgery, or at a later operation.

Blood vessel damage
The vessels around the hip may be damaged which would require further vascular surgery.

Death
A rare complication and can occur as a result of a PE or other pre-existing medical conditions not related to the hip.

Revision surgery
Some people will need further surgery and there are many reasons for example repeated dislocations of the ball from the socket, infection, fracture, loosening or significant wear of the artificial parts.

This can range from exchange of a worn socket liner to a more complex operation involving the entire artificial joint and bony structures around it. Your surgeon will explain more about your individual circumstance and how it can be managed. Your recovery time may be longer than after the primary surgery, you might be instructed to avoid putting weight through the hip for a period of time.

Guidance on length of stay
• Your time in hospital is SHORT. Total Hip Replacement including revision surgery = 3 nights or LESS Can be day case surgery, please see below.
• Newer anaesthetic agents also have a much shorter duration and your normal mental processing is quicker.
• Before your operation your surgeon will discuss your estimated length of stay. Be aware that you may go home sooner than expected. Ensure travel arrangements are flexible.
• Some patients are suitable for daycase surgery; that means they can go home on the same day as surgery. Daycase hip surgery is well established internationally and has displayed high levels of patient satisfaction along with being very safe.

Other patients may need to stay a day or two longer. You will be discharged when considered clinically safe. If you are staying overnight, we aim to discharge patients at 11am in the morning. Please ensure that your family, carers and anyone you have arranged to assist you on this day are aware of this.

Patient’s recover more quickly after this operation when compared to total knee replacement.

Risks of knee replacement surgery
All operations have risks. A knee replacement is a major operation and will place the body under stress. Any underlying illnesses may worsen due to the operation.

COMMON RISKS (2-5 people in every 100 knee replacements)
Pain
You will experience discomfort in your operated knee joint after the surgery but this will usually improve over the first few months. However, a degree of this ongoing pain or discomfort can occur, and in some cases be permanent.

Bleeding
There will be blood loss during the operation. A blood transfusion is rarely required. If you do not wish to have a transfusion, please discuss this with your surgeon.

DVT (Deep Vein Thrombosis)
A blood clot in a vein due to the surgery. It can cause leg swelling and pain. All patients will have an individualised risk assessment completed by a doctor. Most patients are suitable to be fitted for compression stockings before surgery, which are to be worn whilst in hospital. All patients’ will be prescribed blood thinning medication, to continue for 14 days after surgery. This will be explained in full before discharge. Starting to move your legs early is one of the best ways to prevent blood clots from forming.

For more information please read “A Patient’s Guide to Preventing Deep Vein Thrombosis and Pulmonary Embolism” available at www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides​​​​​​​

Knee stiffness
Can occur, especially if the joint was stiff before surgery. Further manipulation of the joint is occasionally necessary. Working hard with the physiotherapists to push the range of movement in your new knee is the best way to prevent stiffness.

Loosening and wear of the knee replacement
The implants are designed to last for many years (15-25 years), but in some cases problems may occur earlier and require replacement surgery.

LESS COMMON RISKS (Less than one in every hundred)
Infection
The operation is performed under sterile conditions and you will be given antibiotics at the time of the operation. Despite this, infections may still occur. Post operatively the signs of infection include redness around the wound, discharge on the dressings, a fever greater than 38o C and occasionally feeling unwell. If you display any of these symptoms you need to contact the CNS Team for Hip and Knee on 020 8909 5279. If the matter requires immediate attention, please contact your GP or go to your local Urgent Care Facility.​​​​​​​

RARE RISKS (Much less than one in every hundred)
PE (Pulmonary Embolism)
When a blood clot moves to the lungs and affects your breathing. This can be fatal.

Major nerve damage
It is normal to have a numb area around the scar. Larger nerves can also be damaged leading to temporary or permanent weakness (footdrop) or altered sensation in the lower leg.

Bone damage
If a bone is broken or weakened during the insertion of the knee replacement further metalwork may be required to stabilise it, either at the time of surgery, or at a later operation.

Blood vessel damage
The vessels at the back of the knee may be damaged which would require further vascular surgery. In exceedingly rare cases the leg itself is at risk and amputation is a possibility.

Death
 A rare complication and can occur as a result of a PE or other pre-existing medical conditions not related to the knee.

Revision surgery
Some people will need further surgery and there are many reasons for example infection, fracture, loosening or significant wear of the artificial parts.

Your surgeon will explain more about your individual circumstance and how it can be managed. Your recovery time may be longer than after the primary surgery, you might be instructed to avoid putting weight through the knee for a period of time.

Guidance on length of stay
• Your time in hospital is SHORT.
Total Knee Replacement including revision surgery = 3 nights or LESS. Can be day case surgery, please see below.
Partial Knee Replacement = Day case or overnight.
• Newer anaesthetic agents also have a much shorter duration and subsequently return to cognitive function is quicker.
• Before your operation your surgeon will discuss your estimated length of stay. BE aware that you may go home sooner than expected. Ensure travel arrangements are flexible.
• Some patients are suitable for Daycase surgery; that means they can go home on the same day as surgery. Daycase knee surgery is well established internationally and has displayed high levels of patient satisfaction along with being very safe.

Other patients may need to stay a day or two longer. You will be discharged when considered clinically safe. If you are staying overnight, we aim to discharge patients at 11am in the morning. Please ensure that your family, carers and anyone you have arranged to assist you on this day are aware of this.

​​​​​​​

Before you come into hospital
 

Prehabilitation
It is helpful to maintain yourself in as good a shape as possible during your time on the waiting list as this will improve your recovery after surgery. This is termed ‘prehabilitation’ or “waiting well”.

• You should receive a number of general patient information guides, which are sent to all patients who are preparing for admission. Take some time to read through them.
• Exercise can help decrease pain and help maintain leg strength.Be sure to exercise your arms too; this can make it easier to use a walking aid, stand from sitting position and get in and out of bed.
• Keep walking as much as you are able. This will help keep your heart in good condition before surgery.
• If you are overweight, you should try and lose weight to minimise complications after surgery. Your GP will be able to help you with this.• Good nutrition aids recovery. A Patient’s Guide to Eating Well Before and After Surgery is available via our website at www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides
• Discuss / Address your health conditions with your GP to ensure they are being managed in preparation for surgery.
• Bowel management. It is important to have a regular habit before surgery, as constipation can be a problem afterwards. To reduce the risks you may need to include fibre in your meals such as fruit, vegetables and bran. Drinking plenty of fluids is also important. If you have any medical conditions which might be affected, please discuss this with your GP.
• Stop smoking before surgery, even for a short time, can reduce risks associated with surgery. People who smoke are at higher risk of developing complications with their lungs and circulation.The hospital has a No smoking policy. Patients and visitors are not permitted to smoke (including e-cigarettes) in the hospital buildings or in the grounds around the hospital.​​​​​​​

Plans you to need to make

• You will only be in hospital for a short time - check “Guidance on Length of Stay” (for hip replacement see page 9; for knee replacement see page 14) section in this page. Share this information with those people who need to know early, so everyone is organised.
• Have your home ready, laundry done, bed made with clean sheets.
• Think about how you will walk safely about your home and remove clutter. Check rugs or mats are secure. Check your stair rails too.
• Ensure items you might need from low cupboards are brought up to waist level.
• Have the fridge/freezer well stocked with easy to prepare foods.
• Find someone who can help with shopping/household chores in the early days of recovery.
• You may wish to purchase or hire long handled aids.
• Consider keeping some sort of ice pack in the freezer. It must be flexible to be able to apply over the joint and must be placed in a towel before applying. NEVER apply directly on to the skin.
• Make sure you have enough of your prescribed medicines.
• You should have some comfortable and loose clothes which you can bring to wear after your surgery.​​​​​​​
• Arrange your own transport to and from the hospital. It is unwise to drive yourself to hospital as you will not be fit to drive home again. Please make suitable arrangements for your transport home before you come into hospital. Ensure your travel arrangements are flexible.​​​​​​​

Patient transport is only available for patients who are deemed medically unable to make their way using their own transport or public transport. For more information, please visit our Transport website page at www.rnoh.nhs.uk/patients-and-visitors/transport​​​​​​​

Pre-operative assessment screening
This usually happens shortly before surgery.​​​​​​​

It is a medical review to make sure you are well enough for surgery and to consent to an operation. If you are on any regular medication, please ask the pre-operative assessment staff what medication you can take on the day of surgery.

If you are taking the Contraceptive Pill or Hormone Replacement Therapy (HRT): depending on what treatment you are having, you may need to stop taking the contraceptive pill or HRT six weeks beforehand. The doctor / Pre-Assessment Pharmacist should have discussed this with you.​​​​​​​

If the pre-operative assessment identifies concerns about managing at home after surgery, you may be reviewed by the Complex Discharge team or a member of the Therapy team. They will discuss practical considerations to ensure a smooth and timely discharge from hospital. This will be recorded in your medical record.

Illness before surgery
If you are unwell or if there are any changes in your medical condition such as dental or urinary infection, or infected cuts or ulcers on your skin in the days prior to surgery, please let us know as soon as possible by contacting the Schedulers on telephone 020 3947 0041.​​​​​​​

Your operation may need to be rescheduled. This is in your best interests to reduce the risk of developing post-operative infection in the new joint.​​​​​​​

When you arrive for admission to hospital
Most patients are admitted on the day of surgery. You will be asked not to eat for approximately six hours or drink for two hours before your operation, depending on your anaesthetist’s instructions. Failure to follow these instructions will result in your operation being delayed or even cancelled.

You will be admitted to hospital on the day you have your surgery. On admission, you will see several members of the multi-professional team who will complete final checks to make sure you are fit for surgery. The Clinical Nurse Specialist for Hip and Knee will make contact with you too. If you have any questions, please ask a member of staff.

The surgery
Before your operation, one of the surgical team will discuss the procedure with you and answer any other questions you may have. You may have signed a consent form before your admission. The surgeon will still ask you to confirm you are giving your consent to the operation. The limb to be operated on will be clearly marked.​​​​​​​

You will be reviewed by the anaesthetic doctor before your operation to discuss your anaesthetic options. Further information can be found in “A Patient’s Guide to Anaesthetic Options for Hip or Knee Surgery” Please visit our website page at www.rnoh.nhs.uk/patients-and-visitors/ patient-information-guides

You will be escorted to the operating theatre. A nurse will accompany you and hand you over to the care of the theatre team.

Primary Hip Replacement Surgery - between one and two hours.
Primary Knee Replacement Surgery - two hours.

You may be away from the ward longer than this as you will be taken to the recovery area and cared for there until you are well enough to return to the ward.

After surgery
You may have a drip to replace lost fluids and an oxygen mask. This will be removed as soon as possible after surgery.

After the operation you will feel some pain and discomfort, which will be managed by medication.

You will be offered pain relief every few hours which may include a combination of regular pain relief such as paracetamol as well as stronger opioid based painkillers. We advise that you take the pain relief regularly during the first 48 - 72hrs (as per the prescription). After this you may be able to reduce the dose or frequency of some of these medications.

• Deep breathing exercises. The physiotherapist / ward nurse will advise. Take 3 or 4 deep breaths - breathing as deeply as possible. After the last breath, try to make a “huff” sound. This may cause you to cough but will also help clear your chest after the anaesthetic.
• Ankle exercises. The physiotherapist / ward nurses will advise. To maintain good circulation, this should be done regularly after surgery, for approximately 5 mins at a time or longer. If you have any calf pain/ tenderness please inform the nursing staff.
• Your goal. To return to normal activities as soon as possible. Please remember that you are not unwell: you will recover quicker from surgery by following the advice in our information guide “On The MEND” available at our website page www.rnoh.nhs.uk/patients-and-visitors/ patient-information-guides

Primary Knee Replacement
Surgery Unless you have been told otherwise by a doctor or a physiotherapist, you can move as you feel comfortable after your knee replacement. Routine knee replacement surgery allows patients to put their weight through the operated leg with the assistance of crutches.

Primary Hip Replacement Surgery
Unless you have been told otherwise by a doctor or a physiotherapist, you can move as you feel comfortable after your hip replacement. You should avoid sudden or extreme movements. You should move your hip slowly and in a controlled way so that your muscles can support your hip fully while you are moving. Routine hip replacement surgery allows patients to put all of their weight through the operated leg with the assistance of crutches.

If your surgeon decides your hip needs extra support and time to heal, they may advise you to avoid performing certain movements for 6 to 12 weeks. If you have been instructed to avoid these movements, you will be given an additional booklet called “Hip Precautions following Primary or Revision Total Hip Joint Replacement” by your physiotherapy team.

Tracking your progress
Once you have returned to the ward and the anaesthetic has worn off, a member of the physiotherapy team or nursing team will help you get out of bed and into a chair. If all is well, they will walk with you a short distance.

Please remember that the sooner you move, the easier it is to prevent complications after surgery.

You will be offered regular painkillers as prescribed. It is advisable to take pain relief when offered even if you are not in pain. Discomfort in the operated joint is normal at this early stage. Taking regular pain relief will help and enable you to walk around the ward today as expected.​​​​​​​

A member of the physiotherapy team will show you some exercises to begin to strengthen your muscles, which you should aim to complete as instructed at regular intervals. (The exercises are also in this guide. Exercise for hip patients page 24-27. Exercise for knee patients page 30-33) They will teach you to walk using a walking aid. You can turn around in either direction but you must prevent twisting or pivoting on your new joint. You should therefore lift your feet with each step and step around with small steps. You will notice how quickly you are recovering. The physiotherapy team and other ward staff will help you gain confidence with this. If you need to be able to go up and down the stairs when you go home, the physiotherapist will do this too.

If required an occupational therapist will review you.
Once you can walk on your own, it is essential that you get up and walk regularly, even if this is only a short distance to begin with. All walking is part of your rehabilitation. This includes any activities carried out with the physiotherapist and nursing staff. Remember, little and often is the best way forward.​​​​​​​

You should try to be as independent as possible. This includes getting dressed, sitting in the chair and walking on the ward. You should bring comfortable and loose clothes to wear after your surgery.

Your checklist​​​​​​​

• I have taken all medication as prescribed.
• ​​​​​​​ I drank water, (tea/coffee) and have had some food.
•  I have passed urine.
•  The physiotherapist has explained the exercises I must do.
• I understand how to do these exercises.
• I can safely get in/out of bed. I walked with a walking aid.
• I can get in/out of a chair. I have practiced safe technique on stairs.
• I have my discharge travel arrangements. The Healthcare team have discussed my discharge plans.

Preparing for discharge and going home
Before the operation your surgeon will have discussed your estimated length of stay, which is between 0 - 3 days.​​​​​​​

• The doctor will prescribe take home medication for you and write the discharge summary confirming the operation and follow up instructions. This will be sent to your GP practice and you will be given a copy of this information.
• The ward nurse will explain how to take the medication.
• The ward nurse will give instruction about surgical wound care and explain what arrangements you need to make. Most patients will be advised to contact their GP for removal of skin closure material.​​​​​​​
• If you stay overnight, we aim to discharge you at 11am in the morning.​​​​​​​

It is well established that patients recover more quickly at home after a joint replacement and can reduce the risk of complications such as blood clots and infection. You are also more likely to get back to your previous lifestyle sooner.​​​​​​​

Managing pain at home after hip or knee replacement surgery
• Pain is a normal response to surgery; it is likely to get better over time. Pain medication will help control the pain but will not remove it completely.
• Do not wait for the pain to become severe, as mild pain is easier to control.
• Most patients will be taking pain medication for about 5 days.
• Most patients are prescribed a combination of medications, which work in different ways.

The commonly prescribed pain medications on discharge are:

Paracetamol- safe when taken correctly; it does not have any common side effects. BEWARE of other medications that also contain paracetamol like cold /flu remedies.

Weak opiods (such as dihydrocodeine or tramadol) - for moderate to severe pain. BEWARE of common side effects such as dizziness, itchiness, nausea and constipation.

Some patients in addition to the above are also prescribed:

Non-steroidal anti-inflammatories (such as Ibuprofen or Naproxen) Strong opioids (such as morphine or oxycodone).

• Before you go home the nurse will have explained how the medication works, the safest way to take them and some of the common side effects.
• Regular use of laxatives, is recommended while you are taking pain medication.
• ALL medications are labelled with instructions. It is important that you understand them. For further information on side effects-please refer to manufacturer’s information included in each box of tablets.
• Although your operated leg may feel uncomfortable, pain can be eased by doing your EXERCISES REGULARLY or by changing position. In the first few days, it can be useful to take some pain medication an hour before doing your exercises.
• You can also use an ice pack, (wrapped in a towel or pillow case to avoid skin damage) for up to 15 minutes several times a day to help reduce swelling.
• When you are home, if you are worried about the pain medication you have been given or any other medicines, please contact your GP or local pharmacist.
• Other sources of information:
How to manage my pain at home after my hip or knee replacement A Patient’s Guide to Pain Relief following your operation (Adults only) Available via www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides

Exercise following hip surgery
Please do not attempt any of these exercises until you have been advised to do so.

A member of the physiotherapy team will see you after your operation to teach you the following exercises. It is very important to start moving your hip joint and strengthen the surrounding muscles. This will aid your recovery. Try to do your exercises as instructed.

You should avoid extreme movements; a member of the physiotherapy team will explain how to move the hip safely.

If your surgeon has advised specific hip precautions, (more common after hip revision surgery), the therapy team will also provide detailed guidance.

Immediate postoperative period

Advanced exercises

Advice on sitting
Choose a firm, upright chair, preferably with arms. The ideal height of your chair depends on your height. If you do not have a suitable chair, see if you can borrow one, or use firm cushions to raise the height of the seat. Avoid low, soft sofas and armchairs since these might make it difficult for you to stand up.

Always use walking aids and if present, a rail(s) or banister(s) to support and assist you while going up or down stairs.

Going up
• Go up one step with your non-operated leg
• Take your operated leg up one step to join the other leg
• Bring your stick(s)/crutch(es) up to the step

Going down
• Take your stick(s)/crutch(es) down one step
• Place your operated leg down one step beside your walking aid(s)
• Bring your non-operated leg down one step to meet the other

Your physiotherapist may also suggest you read “A Patient’s guide to Total Hip Replacement Exercise Pack”. This can be found on the our website: www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides. Should you require a paper copy please contact the Therapy Team on 020 8909 5820.

At home after hip replacement surgery
• Rest and elevate your leg.
• Unless otherwise instructed by your surgeon continue to exercise regularly.
• Follow the exercises the physiotherapy team gave you. These will strengthen muscles, increase your confidence and improve mobility.
• Stay active and try to walk a little more each day. If you progress on to one crutch or stick, you should hold it in the opposite hand to your operated leg. Once you can walk without a limp, you may stop using your walking aid unless you are told otherwise.
• Continue to take pain relief medication as needed to help you exercise.
• Signs of dislocation: sudden extreme pain in the operated hip, shortening of the limb or rotation, inability to move hip, weight-bear or walk. This requires urgent review at your local Urgent Care Facility. Please also inform the Clinical Nurse Specialist team here on 020 8909 5279.​​​​​​​

Exercise following knee surgery​​​​​​​
Please do not attempt any of these exercises until you have been advised to do so.​​​​​​​

A member of the physiotherapy team will see you after your operation to teach you the following exercises. It is very important to start moving your knee joint and strengthen the surrounding muscles. This will aid your recovery. Try to do your exercises as instructed.

Immediate postoperative period

Advanced exercises​​​​​​​

Advice on stairs
During your hospital stay, your physiotherapy team will show you how to climb the stairs.

Always use walking aids and if present a rail(s) or banister(s) to support and assist you while going up or down stairs.

Going up
• Go up one step with your non-operated leg
• Take your operated leg up one step to join the other leg
• Bring your stick(s)/crutch(es) up to the step

Going down
• Take your stick(s)/crutch(es) down one step
• Place your operated leg down one step beside your walking aid(s)
• Bring your non-operated leg down one step to meet the other

Your physiotherapist may also suggest you read “A Patient’s guide to Total Knee Replacement Exercise Pack”. This can be found on our website: www.rnoh.nhs.uk/patients-and-visitors/ patient-information-guides. Should you require a paper copy please contact the Therapy team, details on page 2.

At home after knee replacement surgery

• Unless otherwise instructed by your surgeon, when you get home, it is essential that you continue to do all the exercises taught to you whilst in hospital. This will ensure that your knee does not become stiff.
• The exercises will enable you to work on fully straighting the knee and bending to at least 90 degrees. During the first 6 weeks you will feel stronger and the exercises will become easier to do.
• Continue to take pain relief medication as needed to help you exercise.
• Do not put a pillow behind your knee but when you sleep on your side a pillow between your knees might be more comfortable • Stay active and try to walk a little more each day.
• While your knee remains sore it is better to continue to use your walking aids as directed by the physiotherapy team.
• It is better to walk normally with an aid than develop a poor walking pattern and limp by getting rid of your walking aid too early.
• Over time you will be able to progress and aim to walk unaided if you were doing this before surgery.​​​​​​​

Advice on managing knee swelling after knee replacement surgery​​​​​​​
It is normal to experience pain, bruising and swelling at the surgical site. Over the next 6 weeks you should notice these symptoms improve as you become more mobile. Swelling can continue for up to 12 months after surgery. Swelling can be relieved by periods of resting with your feet up, using ice packs and exercising.

Advice on kneeling after knee replacement surgery
• Kneeling is not advisable for several months following your operation after which you may kneel down as you feel able.
• You may find it more comfortable to kneel on a pad or cushion.
• Many patients find they cannot kneel after their operation because it is too uncomfortable or because they are experiencing a strange sensation.
• You must consider this if you kneel a lot at work or when doing hobbies.

Return to activity

Daily tasks​​​​​​​
Unless you have been told otherwise, you can move as you feel comfortable after your surgery. You should avoid sudden or awkward movements. You should move your hip slowly and in a controlled way so that your muscles can support your hip fully as you are moving. You should also avoid forcing your leg into awkward positions that cause pain.​​​​​​​

Sleeping
Many people experience disruption to their usual sleep pattern in the first few weeks after surgery and this should improve with time. The ideal height of your bed depends on your height. If it is too low for you to get on and off the bed comfortably, you could place another mattress on top to raise the height. You can return to sleeping on your side as soon as you feel comfortable to do so. If your hip or knee feels uncomfortable when you are on your side, you can try putting a pillow between your legs to make it more comfortable. A duvet is much easier than blankets, and a walking stick is handy to pull the covers up or to push them down.

Advice on exercise
When you get home, it is very important that you continue to do all the exercises taught to you while in hospital, as advised by the physiotherapist. This will enable you to continue your recovery​​​​​​​.

Domestic tasks
You can resume household activities as soon as you feel able to do so. You might need to enlist help with tasks such as changing the bedding and vacuuming, as it may be difficult to complete these tasks.​​​​​​​

Sit for as many jobs as possible
 A high stool is useful so that you can still reach the worktops. Place items that you use frequently at a height which is easy to reach. If you are unable to carry items, a kitchen trolley or a back-pack may be helpful.

Washing
A waterproof dressing to cover the wound area will be organised by nursing staff after your surgery. You may want to make sure someone is in the house the first time you take a bath/shower in case you need assistance. You might want to purchase aids such as a long handled sponge for help with washing your lower body.

Dressing
Dress sitting on a chair or bed. Remember to dress your operative leg first, undress it last and wear good supportive shoes with low heels. If you wear lace-up shoes, you may need elastic laces; however, you may find slip-on shoes easier to manage.

Driving
Some companies will not insure a driver for a period of time after joint replacement surgery. Please check your policy or speak to your insurer. Before resuming driving you should be free from pain or any effects of pain relief medication. You should be comfortable in the driving seat and be able to safely control your car, including freely performing an ‘Emergency Stop’.

Ultimately, it is your responsibility to ensure that you are in control of your vehicle at all times and to feel confident that you would be able to demonstrate this if asked.

Keeping well. When you are feeling better, it is a good time to think about your health and wellbeing. Here are some examples of lifestyle changes you may want to discuss with your GP:

• Maintaining a healthy weight / Improving your diet
• Exercise
• Smoking cessation
• Review of your regular medication

Consent for surgery. We understand some patients may feel nervous or anxious; please do not hesitate to ask any member of the healthcare team if you have any queries or concerns. You can also find more information about consenting for treatment at www.nhs.uk/conditions/consent-to-treatment

How long will I be in hospital for?
Before your operation the Surgeon will discuss your estimated length of stay. Some patients are suitable for Daycase surgery; that means they can go home on the same day as surgery. You will be discharged when considered clinically safe. If you are staying overnight, we aim to discharge patients at 11am in the morning.

Do I need to arrange for someone to stay with me when I go home?
It is not essential to have somebody at home with you after discharge. Many elderly and frail patients have hip replacements and cope on their own without problems. The therapy staff will make sure that you are safe to look after yourself before you leave hospital. However, if you have an offer from a friend or relative it may be desirable to have them stay for a few days.

Why have I still got limb swelling?
It is normal to experience swelling and this may last for many months. Standing for long periods can aggravate it. You can alleviate some of this by doing your exercises regularly and getting mobile.

Swelling usually increases during the day and goes down overnight. If you experience swelling that does not improve after elevating the limb and / or calf pain/tenderness in either leg - please seek immediate medical advice from your GP or go to your local Urgent Care facility. Please also inform the CNS team at RNOH.

Who will take out my stitches/clips?
 You will need to make an appointment via your GP practice for the sutures/clips to be removed at 10-14 days after your operation. Some people have dissolvable stitches so that no appointment is needed.

If I am worried about my wound what should I do?
 During normal healing the wound may be slightly red and warm to touch. However if you are concerned, feel unwell, or have a fever greater than 38°C or the wound begins to discharge fluid, you need to contact the CNS team for Hip and Knee Replacement, or if urgent your local services - either the GP or Urgent Care facility.

When can I return to work?
You should be able to return to work between six and twelve weeks after the operation, but this depends upon the nature of your work and how you usually get there. It may take longer to get back to a heavy manual job. You may also need to discuss this with your GP and your employer/ occupational health advisor

When can I fly?
Flying too soon should be avoided owing to the increased risk of DVT (blood clot) and the difficulty with adhering to any joint replacement precautions. The Royal College of Surgeons recommends it is safe to travel short haul such as internal / European flights after 6-8 weeks and long haul after 12 weeks. Before surgery you should discuss your travel plans with your Surgeon. You will also need to inform the airline/tour operator / travel insurance company.

Will I be able to swim after my hip replacement?
Yes, as soon as your wound is dry and you are safe to get in/out of the pool. You can do all strokes including breaststroke.

Will I be able to participate in sports after my hip replacement?
There are no strict rules unless your surgeon advises otherwise. Hill walking, cycling and horse riding usually present no problem, although you should wait 3 months before returning to more strenuous activity. Some patients play tennis, football, cricket or badminton. Be aware there is a danger that you can break the bone around your hip replacement or dislocate the hip if you fall badly.

Is it safe to have sex after my joint replacement?
Unless you find it painful, or your surgeon advises you otherwise, it is safe to continue sexual relations with your partner. You can discuss this further with your Therapy team. If you have concerns, contact us on 020 8909 5480

Your surgeon will give instruction about when and how you will be reviewed. Most patients will receive an outpatient appointment for approximately six to eight weeks after surgery.

Clinical Nurse Specialist (CNS) for Hip and Knee Replacement work alongside your Consultant. They are involved during your hospital stay and may also review you at your follow-up appointment.

They are available for general advice in relation to your joint replacement surgery, Monday to Friday (excluding public holidays) on 020 8909 5279, or by email at rnoh.jru.cns@nhs.net.

We suggest you bring this page with you when you come to hospital and use it as a guide.

Versus Arthritis
Information about arthritis and musculoskeletal conditions, for patients and carers. Staying active when waiting for surgery “Surgery Toolkit” www.versusarthritis.org

The NHS website
Your complete guide to conditions, symptoms and treatments, including what to do and when to get help. www.nhs.uk

Royal College of Surgeons for England
www.rcseng.ac.uk

British Orthopaedic Association
www.boa.ac.uk

Authors of leaflet:C. Cassidy Lead Clinical Nurse Specialist Hip and Knee Mr E. Ali Locum Consultant, CNS specialist hip and knee team