Our skeletal system is a complex arrangement of bones and joints which both supports us and allows complicated movements to occur. The ends of the bones that form joints are covered with hyaline cartilage which protects the bone and gives a unique friction free surface which allows movement to be smooth.

Sometimes, for a variety of reasons, the hyaline cartilage in the joints can become soft, cracked or flaky - this could be after direct injury or simply degeneration which unfortunately affects us all as we get older.

The hyaline cartilage does not readily heal when damage is severe and often the only answer is to have a joint replacement. This type of surgery is now very common in the hip, knee, shoulder and hands.

The worn out surfaces of the joint are removed, and replaced by an artificial joint which may be made of plastic, stainless steel or titanium. the joint my be cemented in place, but some prostheses (artificial implants) do not need to be cemented. Weight bearing on the hip and knee helps the implant to become firmly fixed.

PRIOR TO SURGERY

You may be asked to attend the clinic for x-ray and blood tests prior to admission. At this time you are likely also to see the clinic nurse and physiotherapist, who will be happy to answer any questions you may have.

The physiotherapist will explain the importance of exercise in the post operative rehabilitation phase, and will teach you some exercises which you should practise regularly before your operation. This will make it much easier for you to mobilise afterwards and give you something positive which you can do for yourself.

IN HOSPITAL

It is usual to stay in hospital for 7 - 10 days after your operation, during which time you will gradually become more mobile and independent. Comfortable loose clothing is recommended whilst in hospital. You may prefer to get dressed during the day, in which case shorts, a tracksuit or comfortable skirts are ideal. Remember to bring a swimsuit with you in case you get the opportunity to go into the pool. Although you should be walking with crutches by the time you are discharged, you should arrange for some help at home for a short time.

THE DAY OF YOUR OPERATION

You may be issued with a pair of white (T.E.D.) stockings which you will have on when you wake up after your operation. These serve two functions:-

1. As a preventative measure to reduce the risk of thrombosis.

2. To help control swelling around the joint and in the leg.

Cuffs are sometimes fitted around your feet - these are called `foot pumps' and are also a preventative measure against thrombosis. They will be removed as soon as you are mobile. When you wake up you may also have a drip in your arm and drains coming from the operation site. Both will be removed in 1 - 2 days. Removal of the wound drain may cause some discomfort, but this should be minimal. You will be given antibiotics for a variable time after your operation.

MOBILISATION & PHYSIOTHERAPY

It is important to move about as soon as possible. The physiotherapist will get you out of bed the next day to stand and begin to take weight through the new joint. If your balance is good you may take a few steps and sit out in a chair for a short while. You will be asked to practise the exercises which you have been taught, regularly throughout the day.

Progression from now on is largely dependant on you. You will be encouraged to walk and exercise regularly to regain movement, strength and independence, but rest in between is equally necessary.

When you are ready you will be given crutches or sticks to use instead of a frame, and when confident you will find that you only need to use one. It is advisable to continue with one stick for about six weeks.

On approximately the fifth day you may be given the opportunity to go into the brine pool for physiotherapy. This is dependent on how well you are mobilising and also on the day of the week. The water is very warm and supportive, enabling you to exercise much more freely in a weightless situation. If you are unsure or apprehensive about using the pool, do talk to the physiotherapist who will explain the procedure to you fully and then let you decide what you want to do.

YOUR WOUND

Most surgery wounds are stitched with soluble thread, below the skin. The skin is then held with steristrips - this means that it is unlikely that you will have any stitches to be removed. Occasionally traditional sutures or staples are used but these remove easily. The wound usually takes eight to fourteen days to fully heal and after this time all dressings can be removed. If you are going in the brine pool a special waterproof dressing is applied until the wound is fully healed. The healing process inside, directly around the new joint will take many months to complete, but you will notice gradual improvement in strength and stability throughout the first few months. Initially you may feel "aching", particularly at night, but this again will diminish after about three months.

COMPLICATIONS

Significant complications are unusual after joint replacement surgery and the vast majority of patients are delighted with the outcome. However, as with all surgical procedures, occasional problems can arise.

• Thrombosis: Blood clots can develop in the legs following any surgical procedure. Precautions are taken against this; most patients wear elastic support stockings and in some cases, low dose heparin is prescribed. Your early mobilisation will also help to minimise risk.
• Infection: This is a serious, although fortunately very rare complication. The operating theatre features a special air flow unit to minimise the risks of infection and you will also be given antibiotics at the time of your surgery. However, if infection does occur, treatment can be difficult and often involves further surgery to revise the joint replacement.
• Wear: All joint replacements are subject to wear. This can either manifest as thinning of the plastic bearing of the joint prosthesis, or as loosening of the prosthesis within the bone. Modern joint replacements have a long life expectancy, (usually greater than 15 years) but the exact rate of wear depends on your weight and the demands you place upon your joint. If significant wear or loosening occurs, the joint replacement may require revision.

DISCHARGE

By the time you are ready for discharge you will be confidently walking with crutches or two sticks and will be able to safely negotiate stairs.

You may be required to attend physiotherapy as an outpatient. If you live a long way from Droitwich it may be advisable to see if you can find a reputable chartered physiotherapist nearby before surgery - the clinic physiotherapist will make sure that all your details are passed on when you are discharged.

Driving is usually possible as soon as you have good control of your foot on the pedals - and can transfer easily from one to the other- this is commonly between six to twelve weeks but varies from patient to patient.

THINGS TO AVOID

All surgical procedures carry a small risk but common sense will keep this to a minimum.

Movement is good - so is rest - gradually increase your daily activity, exercising "little and often" rather than for a long time, occasionally. Do not stay in one position for too long - you may feel stiff when you try to move.

When walking, try to avoid twisting on your leg - if you have to turn - step around rather than twist. If you have to go on a long journey, break at regular intervals.

If you develop an infection anywhere, (on the skin, in the mouth or the bladder etc), contact your doctor immediately - he will probably give you antibiotics - remember also to tell your dentist that you have an artificial joint if you require major dental work.

If you have a fall or repeatedly bang or twist the joint and things don't feel right, or if you have persistent pain, clicking or instability then please do contact the clinic. You will be seen quickly and examined to make sure all is well.

Excess weight does put a lot of strain through the joint - so try to avoid putting on weight and lose some if necessary.

Sport : Replacement joints are not designed for very active sports but you should be able to swim, cycle, hike, play golf and bowls, and possibly ride. If you have a uni-compartmental knee replacement you may be able to participate in slightly more activities such as leisure tennis and gentle skiing.

THE KNEE

If your new joint is a knee there are one or two points applicable only to you.

• Soon after you wake up from your operation, your leg may be placed on a "CPM" machine (continuous passive movement). This machine will slowly bend and straighten the knee and will remain in situ until the next morning. Most patients find it quite comfortable.
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• This early movement is beneficial in reducing swelling around the joint and in the leg, and also in preventing the knee becoming stiff.
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• You will be encouraged to bend the knee yourself as soon as possible but you must resist the temptation to put a pillow under your knee when relaxing - this can lead to difficulties in straightening the knee.

• If you have a uni-compartmental knee replacement the immediate post-operative recovery is slightly quicker. You may only need to stay in hospital for 4-5 days but you must be careful not to overdo things too soon.

• If you have patello-femoral resurfacing you will not need to use crutches for very long, but it may take a little longer before you can go up and down stairs normally.

THE HIP

If your new joint is a hip there are a few points which are applicable to you.

• When you wake up after your operation, you may have a foam wedge between your feet, or a foam trough under your leg. This is just to hold the joint in an optimum position for the first 24 hours.
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• With the latest methods used in surgery, the risk of dislocation is minimised. Depending on the surgical technique used, you may be advised to avoid certain movements such as bending forwards, or sitting on a very low chair in the early stages. You must try to avoid crossing your legs and when lying flat, should not allow your leg to roll out.

• If a replacement hip does dislocate, it is usually possible to manipulate it under sedation or light anaesthesia. In the rare case of recurrant dislocation, revision surgery may be required.