Practice Policy Update regarding COVID-19

Useful Info

Thank you for considering me to have surgical intervention for your hip or knee pain.

Hip and knee replacements are lifestyle operations. In other words they are about quality of life and I do not recommend that you think about surgery unless your pain is severe and it has started impacting you on day to day basis.

I have a busy practice and I perform more than 250 hip and knee replacements per year at Broomfield Hospital, Braintree Community Hospital, Springfield Hospital, Oaks Hospital and Nuffield Brentwood Hospital.

First Consultation

Majority of the patients with hip and knee pain are best managed in community with help of GP's who are more experienced than surgeons in pharmacological management and can refer you to specialist Musculo-skeletal Physiotherapists. Physiotherapy, Exercises, Steroid injections and alternate therapy like Acupuncture etc all have a role to play in management of hip or knee arthritis. Strategies like optimising pain killers, light aerobic exercises, weight loss. life style modification and use of waking aid or brace etc can be tried with allied health professionals.

www.versusarthritis.org is a good resource.

You may also find useful information about Exercises for Hip and Knee pain on Youtube.

I will not perform a hip or knee replacement until these non operative methods have been tried for minimum 3-6 months.

Once you have tried these and pain not improving, I recommend you visit

www.orthopaedicscore.com/scorepages/oxford_hip_score.html
www.orthopaedicscore.com/scorepages/oxford_knee_score.html

If you score 34 or above for hip pain you are unlikely to be a candidate for hip replacement in my practice.

If you score 32 or above for knee pain you are unlikely to be a candidate for knee replacement in my practice.

However, there is no strong criteria about Consultation with Orthopaedic surgeon and you are welcome to come for consultation irrespective of your score.

The decision about listing you for hip or knee replacement is complex and its all about shared decision making between surgeon and the patient. I will go through risk and benefit of various treatment options. Sometimes I can offer other surgical intervention like knee arthroscopy or hip injection. I typically see more than 1000 patients per year with hip or knee pain and able to offer surgical intervention in less than 30% patients.

My indications for Knee replacement will be

  1. Pain localised around knee with average Visual Pain Score 7 or more out of 10
  2. Oxford Knee Score less than 20 out of 48 (but have done up to 32/48), Lesser the  score  better is the chance of improvement in pain.
  3. Kellegren-Lawrence grade 3 or 4 changes on xrays (in other words Bone on Bone arthritis)

My indications for Hip replacement will be

  1. Pain around Groin, Buttock or Thigh with Visual Pain score 7 or more out of 10, Pain reproducing by surgeon moving your hip joint
  2. Oxford Hip Score less than 20 out of 48 (but have done up to 34/48), Lesser the score better is the chance of improvement in pain
  3. Kellegren-Lawrence grade 3 or 4 changes on xrays (in other words Bone on Bone arthritis)

Please bring your up to date Prescription or clear record of drug allergy and current medications you are taking. I would like to know what pain killers you have tried . (NSAIDS or Opioids)

If I feel that risk benefit ratio of hip or knee replacement is in favour of surgery I will put your name on the waiting list. I am looking for severe pain affecting your function and radiographs confirming bone on bone arthritis on xray.

My aim is to perform the surgery within 2-4 weeks for self pay/insured patients and within 18 weeks for NHS patients. For self pay patients a package of Hip or Knee replacement varies between 12-13000£ including post op visits. Please discuss with hospitals directly if you have any queries about financial packages. Springfield Hospital, Nuffield Brentwood HospitaL and Oaks hospital ,all 3 have a dedicated Private Patients Manager.

I recommend you go on Youtube and look at Hip /Knee exercises you can start in preoperative period.

www.youtube.com/watch?v=vR2PF-acl10
www.youtube.com/watch?v=FBqxjYvnUI8
www.youtube.com/watch?v=39e4zlYdXf0
www.youtube.com/watch?v=HzKxQciDVUE
www.youtube.com/watch?v=YpAjuHBfqfA

During preop assessment you will be reviewed by other members of the team including Physiotherapist, Occupational Therapists, Pre op nurses etc and basic blood tests and heart and lung tests eg ECG will be done. Sometimes you may require further tests like Echocardiogram and you may have to be seen by Consultant Anaesthetist during preop assessment.

During this Covid period we would prefer you to be in self-isolation for 2 weeks prior and 2 weeks after the date of surgery. We would also need a Covid swab negative test within 72 hours prior to surgery. If at any stage you develop respiratory symptoms eg Unexplained Fever, Shortness of breath, Cough, Nausea /Vomitting, Loss of sense of smell and hearing the surgery should be postponed.

Its difficult to quantify how much increased risk of Covid you are subjected to when you come for hip or knee replacement but there is definitely some increased risk. The risk of dying within 90 days after elective hip and knee replacement is less than 0.3-0.5% but with Covid prevalence this figure may be higher.

Prehabilitation

This is very important aspect of your surgery planning. I want you to continue doing your exercises while you are waiting for surgery and if possible I want you to practice crutch walking or Zimmer frame walking even prior to surgery. If you learn how to use Zimmer frame to get in and out of bed and walk up to toilet you will have best chance of getting out of bed safely on the same day of surgery and you pain and recovery will be better and quicker.

Remember Pnemonic CON (Crutch, Operated leg , Non operated leg) , sequence reverses if you are going up )

On the day of surgery you will be admitted by the nurse and you will be reviewed by Consultant Anaesthetist who will discuss various modes of anaesthtesia and perioperative pain relief strategy. Our preference is Spinal/Epidural which involves injecting local anaesthetic in the bottom of your spine. You can still drift off to sleep with sedative drungs if you elect to do so. Only difference from your point of view is that you are breathing on your own rather than a machine pumping air in your lungs. In my experience Spinal/Epidural have clear advantage over General Anaesthetic in terms of your recovery. If Spinal injection does not work or if you prefer General Anaesthetic anyways I am sure Anaesthetist will be prepared to do so.

I will also see you before surgery to seek Consent and answer any further queries. If you understand pros and cons and happy to proceed you will be asked to sign a Consent form and I will mark the operating site confirming the side and the procedure.

After surgery which lasts 60-90 minutes, you will be taken to recovery room in theatre complex where you will spend another 1-2 hours before returning to ward.

If your observations are stable and you are feeling OK we aim to get you out of bed on the same day of surgery. Transferring from bed to chair should strictly happen in presence of either a Physiotherapist or Staff Nurse. Longer you can tolerate sitting in chair better it is to expedite your recovery. To go back to your bed you must call for help to ensure you don't have a fall. Day 1 again Physiotherapist will work with you to mobilise you with help of Zimmer frame and you will progress to crutches on day 1 or day 2.

On day 2 Stairs will be practiced and if you are deemed safe with independent transfer and medically fit you will be discharged home. We aim for discharge you home on Day 1 or Day 2 after surgery.

You will stay on crutches for 2-4 weeks, Staples will be removed at 2 weeks and mostly by 6 weeks you achieve your preoperative mobility so if you were walking unaided its reasonable to aim for walking independently by 6 weeks. You can start driving at 6 weeks but I recommend you try to drive with someone on empty stretch of road and see if you are able to perform Emergency stop with your current level of pain.

Pain response and swelling varies with patient to patient but mostly knee replacements are more painful to recover from as opposed to hips.

The aim in immediate post operative period is to keep your pain under control (i.e paon level less than 7 out of 10) and its not possible to have a completely painless recovery specially with knees. To be honest, in first 2 weeks I expect the pain to be worse than preop level

It's a good idea to reduce strong Opioids painkillers as soon as practical during recovery. Typically patients do not need Oxycodone tablets for more than 3 days for knee replacement and for more than 1-2 days for hip replacement. Oxycodone as side effects like Nausea, Vomitting, Feeling unwell, Low Blood Pressure and if you feel any of these side effects sometimes we have to stop Oxycodone early on and swap it with as and when required Oromorph.

You are usually discharge home on 1 week of Opioids (Codeine, Dihydrocodeine, Co-Codamol, Tramodol, Oromorph) and you can continue your pain medications what you were using before after that for example Paracetamol, Ibuprofen, Naproxen, Meloxicam etc.

The dressings does not need to be checked or changed until 12-14 days after surgery when clips are removed. GP, Practice Nurse, Physiotherapists etc can contact me on mraghuvanshi@nhs.net if they have any concerns. Please remember that superficial wound healing problems are much more common than true deep infection. In my practice SSI (Surgical Site Infections ) are 4-5% with knee replacements and around 2 percent in hip replacement. Fortunately deep PJI Prosthetic Joint Infections requiring return to operation theatre are rare and chances are less than 1%.  Post operative physiotherapy sessions are bit variable depending on the hospital you had surgery in. Usually 2-3 group sessions are more than enough in post operative period provided you continue Home exercise programme according to leaflet. Please note its not unusual to have worsening pain, swelling ,stiffness within first 6 weeks ans as such should not be alarming but if you have any concerns you are encouraged to seek advice from healthcare professionals. (this can be either your GP or very rarely you may have to attend Emergency Dept if its out of hours). Virtual Video/Telephonic follow up with myself or my surgical care practitioner Mr Alex Bennett can be arranged in post operative period.

Knee replacements particularly are very sluggish to improve and its not unusual for a small percentage of patients to require Pain killers for up to 6 months. Some recovery in fact is expected even up to 2 years and still satisfaction are after knee replacements are around 80% as compared to hips which patients reports 90-95% outcome score.

If you develop any complication I  and my team at the hospital where you had surgery will do our best to set the things right but sometimes you may be advised to attend local Emergency Department as smaller hospitals may not be staffed with 24/7 xrays and other subspecialist availability.