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Bone surgery

Views and experiences of healthcare from people who had a knee replacement

Most people we interviewed were very happy with the care they got in hospital from doctors, nurses and physiotherapists. For some, the process of being referred to hospital was the most difficult part as it was sometimes slow. Once participants had seen a consultant and decided to have surgery, the next appointment was usually the pre-operative assessment.

The pre-operative assessment

At this appointment routine medical tests are carried out, including blood tests, a urine test and an ECG to record the electrical activity of the heart.
 

A doctor explains what happens at the pre-operative assessment.

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The pre-op assessment is a really important part of the process. It’s an opportunity where we get to impart a lot of information to patients about what will happen in their journey through hospital and after that in follow-up. 

Perhaps the easiest way to think of it is that we’re going to do an assessment of the patient to make sure that we’re making that process as safe for them as possible. There are some medical checks, blood tests, heart tracing and general assessment of ability of people to be able to mobilise and to be safe at home when we let them out after hospital. 

I think central to that process is the transfer of a lot of information to patients about what they can expect. And we’d also expect to answer a lot of your questions about the precise detail that may be very specific to you about having a joint replacement.
This video explains more about the pre-operative assessment



Many people described the pre-op assessment as very efficient and well organised. They recalled having lots of tests, one after the other, several noting that there was very little waiting around. Participants felt prepared for the appointment because they’d been sent a letter beforehand telling them the appointment date, how long the appointment would be and the tests they’d have.
 

Helene describes what happened at the pre-op assessment. She saw lots of different professionals and had lots of tests. It was ‘all very efficient’.

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Age at interview: 66
Sex: Female
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You have a letter that comes through and it does tell you, warns you, that you're going to be there for three/four hours and take a book or, you know, take something with you. I think most people would do that anyway but a friend drove me there so I didn’t have to go on public transport. And almost immediately the receptionist was really good, lovely. She said that obviously there were times when you'd be sitting still but ‘just let me know if you want to go away and have something to eat or drink and so I am aware that you’ve gone’. 
And there was almost…I was given a sample bottle to go and…to the loo. Take a plastic cup from the water dispenser with you; it's much easier ladies [laughs]. And then sort of handed it back and then almost immediately I had the nurse who was going to…introduced herself and said that, you know, I'm your main person today and went through for blood pressure, blood tests and then told me and went through sort of the other things I was seeing. Came back to the waiting area and somebody else was already asking for me. So everything was going really well. I saw a physio who talked about afterwards [after surgery]; gave me some more information - it was one after the other. Then I think we went off to have some lunch, came back and that’s when I saw the consultants and yeah…oh I forgot the nurse did the MRSA check as well. But everything sort of flowed really well.

Did you have an ECG as well?

Yes, somebody gave me, yes somewhere along the line. I don’t think it was that first nurse; it must have been another one, yeah putting all the leads on. So there was very, you do, you are seeing different, lots of different, seems to be lots of different people but it's all very efficient.
Joan said that all the health professionals she saw at the pre-operative assessment were ‘really, really nice’. Helene felt that medical staff were ‘fantastic’ and Lesley that they were friendly and ‘had time for you’.
 
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Jennifer saw the consultant, physio and various nurses at the pre-op assessment. It all went well and she felt she had excellent service.

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Age at interview: 64
Sex: Female
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I saw the anaesthetist. I saw the physiotherapist, I saw the consultant, various different nurses when I went to pre-assessment for all the…like the ECG and the blood tests; various different nurses. I think that was about it. 

And how did you feel about all your interactions with them? 

Fine, absolutely fine, yes. 

Got everything explained properly? 

Yes, yeah, really good. I didn’t… not once came away anxious about anything. I felt that everything that they said, you know, I understood and it just went well. 

And the timing, you know, when you were referred and then you got the appointment for the right knee and later the left knee, everything was fine was it? 

Fine, fine. 

Were there any situations that you were dissatisfied with at all through the whole time? 

No, no, nothing. 

Nothing. So if someone was going to say are there any improvements that could be made in terms of the care or the way anything at all was done. 

There's nothing, there's nothing. There really was…when I came out I can remember saying to people that came to see me, you know, they were…it was perfect, I couldn’t fault it, you know, I had excellent service. 
Alice said that, although she had lots of tests done, she would have liked more feedback on the results. Reassurance that everything was normal was important but she felt that she’d been told very little. A few people said that their tests highlighted a problem so surgery was postponed until the matter was resolved. Peter’s tests showed that he had high blood pressure and he had surgery two weeks later than planned:
 

Hearing that he had high blood pressure was disappointing. Peter’s GP prescribed tablets and his blood pressure went back to normal.

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Age at interview: 66
Sex: Male
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Went up for the pre-op, and a good system going. Went to see all the different people in turn, and one of the last bits was blood pressure test. And that was when it was found that I had high blood pressure, which was a bit of a bombshell really. But, you know, being self-employed and pressures of work etc., I suppose it, and my lifestyle, I don’t eat a lot of green stuff. So then it was just a case of getting the blood pressure under control, which my GP done quite well. Had a bit of a murmur on the heart, but that turned out to be, I think they said it was just hardening of the arteries, age as well. But they didn’t seem to worry too much about that.
In hospital

Most people we interviewed praised the staff who cared for them while they were in hospital. They talked positively about the different professionals they saw, including consultants, physiotherapists, nurses and anaesthetist. Like many people, Phillip felt that the nurses he saw in hospital were lovely and that he couldn’t fault the care he was given. For Nancy, aged 81, ‘everything was wonderful’ both times she had partial knee replacement surgery and Jacky, a 51-year-old, felt that all the staff were ‘fantastic’.
 

The health professionals ‘couldn’t have been better’. They were attentive and Penelope thought the hospital was excellent.

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Age at interview: 65
Sex: Female
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In terms of all the doctors, nurses, physios, anaesthetists?

They couldn’t have been better; they were excellent, really excellent. They were so attentive and that, you know, if you rang the bell for them they were there straight away and they couldn’t do enough for you. It was really good; it's an excellent hospital, excellent.

Was there anything that could have been done better in that respect, healthcare wise?

No, I don’t think so, I can't imagine, no.
Keith, aged 71, noted that some nurses were better than others and described the difference:
 

Some of the nurses said they’d do something to help but didn’t come back. The good nurses paid attention ‘to you as a person’.

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Age at interview: 71
Sex: Male
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The doctors, I didn’t see a lot of them. I guess it might have been nice to have spent a little more time with the doctors. But I recognise that, you know, the pressures on them. The physio was fine. I thought she was very helpful. Obviously one saw quite a wide range of nurses and there were some who I was a bit disappointed with. 

Some were really good and helpful and so on. But there were some who, you know, you’d ask them, “Could you do something to help me, do so and so?” And they’d say, oh, they’d come back. And they didn’t come back. And that happened two or three times. 

And I mean once, for example, you know, the ward was quite close to a road and at night, you know, one wanted the blinds down. And I asked a nurse to do that and she said, “Yes.” Walked off and never came back. And so I had to get out of bed on my crutches and go across and do it. Which seemed unfortunate. So I was a bit surprised, and particularly given the ward wasn’t that busy, that that happened. But, you know, some of the other nurses were great. And, it was mixed.

When you say the nurses, some of the nurses were great, how were they different to the ones who weren’t so good?

Well, I think they were, they seemed to know about one’s personal situation and were just sort of, I felt, better at connecting with you, me as an individual. And in terms of paying, you know, you felt they were paying attention to you as a person rather than maybe just going through the motions.
Helene and Alice felt that health professionals should focus on the whole person, not just specific problems, because patients may be living with other conditions as well. A few people were disappointed when their surgery was postponed. Alice, who had a cold, asked several professionals if her surgery would still go ahead, but it wasn’t until she saw the anaesthetist that she found out it wouldn’t. She had fasted, was in her hospital gown and had even had arrows drawn on her knee.
 

The anaesthetist advised against surgery because of Alice’s cold. She arrived at the hospital at 7am, left at 8am and went back to work.

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Age at interview: 62
Sex: Female
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I had something like a week and a half between my, or two and a half weeks, I don’t remember, between my holiday and the surgery date, and I got a cold. And you have to phone the hospital up the day before you have your surgery and I phoned them up, and I said, “Well I’m okay for it, but I’ve got a cold.” And she said, “Oh well I can’t make a decision about that, I’ll put you through to the ward.” So she put me through and I got a nurse who said, “Well take two paracetamol.” 

And I thought, “ that’s a funny bit of advice, ’cos I’m actually telling you, not for advice about what to do with a cold but does it matter whether I’ve got a cold? ’Cos they hadn’t said anything about if you’re not well, nothing at all, but I thought perhaps being unwell is significant if you’re having surgery. I don’t know. 

So I went in the next morning, you have to be there at 7 o’clock having starved yourself, and my daughter came and so we both got up at the crack of dawn. And I saw a nurse and I said, “I’ve got a cold.” And she said, “Oh right. Well tell the doctor.” So I saw the pharmacist and I said, “I’ve got a cold.” She said, “Right well tell the doctor.” So I saw the doctor and I said, “I’ve got a cold.” And he said, “Oh right. Well I think it’s important that we do the surgery today because you don’t want to put it off, but you must tell the anaesthetist.” And I finally, the anaesthetist was the last person I saw, I said, “I’ve got a cold.” And he said, “Well you’ve got to go home then.” 

And then he said, “Well did you tell anybody?” And I told everybody, and I thought, you know, if he was going to say that before, I mean they’d known he was going to say that, then why did I have to go in? But I don’t know whether it was just him that was going to say, “No, you’re not having the surgery.” Or whether it was all anaesthetists, you know, or whether a different one would have said something different. So it was a bit silly ’cos I’d even got arrows drawn on my leg by that time and I was in a gown. I was first on the list. I was all ready. And I had to go home again. So I was out again by 8 o’clock. So I had to go back to work as well having said goodbye to everybody.
 

Hugh’s surgery was postponed three times. He couldn’t understand why and contacted a patient advice service for help.

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Age at interview: 61
Sex: Male
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I called my GP and I said, “They cancelled it for the 10th.” And then they put me in for the 31st of July. And then it was cancelled as well.

Any reason?

Well, I haven’t seen any reason in a letter. These are the letters and they didn’t say any, give any reason. So I called my, I went to see my, I called the GP and I said, you know, “It’s been cancelled again. And that’s the third time.” And I don’t get any good reason why. I mean the first time, when they said they couldn’t get the letter from the, they didn’t have the letter from the [hospital name], then I could see with that. But the next two times after that, I can’t see why they cancelled it. And I was supposed to be emergency.

Did your GP call them afterwards?

Yes, my GP, well, she didn’t call them in front of me, but she said she will call them and she will talk to them. And she talked to the consultant at the Nuffield, secretary, speak to them and things like that. And every time when she called and they make an appointment, then they cancel it. 

So next time that I went back and I said, “I’m getting fed up of this thing. I’ve got to make a complaint, I shall complain.” And I said, “I’ve been cancelled three times.” The first one was because I didn’t get any letter from the [hospital name]. And I saw them cancelling as a lack of communication between my GP, the [hospital name] and the Nuffield. So I get, I get a bit cheesed off with it all. I wrote to PAL and 

You wrote to PAL, PAL? Patient Assistance? [Patient Advice and Liaison]

Yes, yes. Patient Advice Liaison, yes. And I wrote to them and I explained to them about being cancelled so many times and with one reason that they gave me. And they contacted the Nuffield, this is the letter I’ve got from them, and they contacted the Nuffield and the Nuffield put it from the 31st of July and brought it forward to the 24th of July because PAL got in touch with them.
Recovery

Most people went home the day after surgery or a few days later and had no need to contact the hospital again, only going back for a routine follow-up appointment. A telephone number was often provided in case there were problems, though people were sometimes reluctant to call the number as they didn’t want to bother busy medical staff. Peter was glad that he could phone the hospital for advice when he first came home because he was in a lot of pain. He wasn’t told that he should have been taking codeine as well as paracetamol when he left hospital. A few other people said they hadn’t been given enough painkillers when they were discharged and had to get a prescription for more. They felt that health professionals should check the medications carefully before discharging patients. Some people didn’t know who they should contact if they had any concerns at home and hadn’t been given a telephone number. Lesley was given a contact number and, when she had hip pain, she spoke to the physiotherapist who reassured her that it was nothing to worry about.

Information about the exercises to do at home was a major concern for many people (see ‘Information about exercises for knee replacement’), as was seeing a physiotherapist shortly after surgery. Although they’d been given a booklet of exercises to do at different stages, some people were unsure if they were doing them correctly. David would have liked a physiotherapy appointment three or four weeks after surgery so he could find out if he could progress to more challenging exercises or if this would damage his knee. Some people were very sporty before their knee problems and felt that a physiotherapy appointment tailored to their particular needs and goals would have been helpful. They had wanted to progress but were wary of doing so without consulting a professional first.
 
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David couldn’t tell how well he was progressing. Seeing a physio would have been reassuring. He felt wary of phoning the hospital.

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Age at interview: 57
Sex: Male
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So the physio showed you what exercises to do? 

Not really, no. She went through the book with me and said, “Well, this is what you’ve got to do. Do it as often as you can but don’t overdo it. And then as you feel more confident, progress with a few more exercises, a bit more weight on it or whatever you feel is best.” 

Was the explanation enough to know what to do or could it have been better? 

It’s difficult to say really. You just know in your own mind how much you think you can do. But then you’re thinking, “Well, should I be doing a bit more? Could I do a bit more?” You just want a little bit of reassurance on occasions. It’s difficult to say. That’s what I was saying. If you’re an older person, maybe you would think, “Well, maybe I shouldn’t be doing that” and then it will take you longer to progress. And then if it was the other way, you could do too much and then end up back in hospital again. 

So it’s hard to know how much is right for you to do? 

Yes, yes. 

What would have helped? Would going back to see the physio sooner help? 

Maybe, it [exercise booklet] gives you one to three weeks, and then three weeks to six weeks. So maybe at the end of the third week, just going back and saying, “Right, this is what I can do. Is it enough? Should it be a bit more?” There is a phone number in the back. If you are a bit uncertain, you can make an appointment to go and see them. But a lot of people might think, “Well, I don’t want to cause a problem” or “They’re busy people.” And maybe not call them. So, yes. 

So the information was there, but it would be more reassuring to go back after three weeks? 

Three weeks. Just to say, “Well, this is what I’ve been doing.” You can ask them, “The book says now go on to this; am I actually in a position to go on to doing that? And is this how it’s done?” Yes, just that little bit of reassurance I think. I don’t know, maybe it’s just me.
Keith felt strongly that people who have partial knee replacement surgery should have physiotherapy afterwards, and ended up seeing a physiotherapist privately.
 

Regular physiotherapy should be part of the recovery process. Keith feels it’s ‘wasteful’ of NHS resources to have expensive surgery and no physio afterwards.

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Age at interview: 71
Sex: Male
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One of the things I was surprised about was that I wasn’t initially offered any physiotherapy after the surgery. Which seems to me when you’re, you know, having expensive surgery, not to have physio arranged when exercise really is so important to ensuring maximum benefit from recovery. At least that’s my understanding. However I did, after sort of putting some pressure on, I was given an appointment at a local clinic, NHS clinic. I went once. And then the next appointment was a month later and I decided that was too long for me. So I went and got private physiotherapy and was able to see someone on a regular basis. And that was, I found, extremely helpful.

I would say that physio, you know, fairly regular physio appointments should be part of the process. And I’ve been someone who’s done sports and been used to exercising. So for me it was sort of natural. For people who haven’t, you know, and maybe people who are very overweight and find it difficult, they really would need a lot of help with this I think. And I think it’s wasteful of NHS resources in terms of expensive surgery if people haven’t got that back-up. Which, you know, okay, it costs quite a bit, but not that much. A tiny percentage of what the surgery would cost to ensure that they can make, get most benefits from the surgery. So I would say that would be a major recommendation.
Some people were very disappointed to learn that, despite the good information and care they’d got in hospital, there was ‘no aftercare’. Helene would have liked to see a physio about a month after surgery and had no idea how well she was progressing.
 

The hospital was ‘fabulous’ but there was a ‘black hole’ afterwards. Physio one month after surgery would have helped Helene know if she was healing well.

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Age at interview: 66
Sex: Female
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Did you feel you were given as much information as you needed?

Yeah, I think beforehand absolutely fabulous. You know, you’ve got all this information. You’ve got people that are actually talking to you that are interested and presumably. And then you have this really big fall, black hole, afterwards.

Were you told anything about what happens afterwards because you're told a bit about recovery aren't you in that video?

Yes, yeah.

But what were you…were you expecting to have more appointments and then it's a bit of a shock when you don’t?

I think it's because… yeah, there's… I asked the physio who came round on a Saturday morning and got me out of bed and, no didn’t get me out of bed, l leapt out of bed. I was so pleased that I could get up and she went through the exercises that you have to do and I'd seen they'd got a hydrotherapy pool and I said, "Is there any follow-up?" and was a smack in the face when she said no and not even locally, which happened before when I'd had the meniscectomy [surgery to remove all or part of a torn meniscus. A meniscus tear is a common knee joint injury], I'd had local follow-up on, you know, at physio. 
So yeah I didn’t realise that there was this full-stop that you came to. And friends and family would ring me or, you know, visit and say, "How are you doing?" "As far as I'm aware I'm doing OK, I don’t know. I don’t know whether I'm supposed to be doing any more than I am." 

You said that there was a big hole in terms of follow-up. So you came back home and did you go back after six weeks I suppose?

Yes.

But were you expecting at that point that maybe you might see a physio after a couple of weeks or something like that?

I think yeah, I thought that… I know when I sort of had problems with the knee that I was seeing a physio for three or four months you know, once a month. So I assumed that maybe that would happen afterwards because the physio you see, I saw was…basically it was just an examination to how, you know the sort of your angle of your knee bend and asking you questions about pain and are you doing the exercises.

That’s in the six week appointment?

That’s, yeah, the outpatients which I found out was the discharge clinic and that’s it.

Could you tell me what would be the ideal situation, what would happen if you leave the hospital, you come back home to recover; you mentioned district nurses coming if you're living on your own for the first couple of weeks because it is difficult. And what else would be good during that, you know, coming home phase?

I think actually to have like within the first month, the end of the first month, a physio appointment just so they can check on your progress and say, "OK you’ve mastered these ones; I would like you to do these ones as well, as much as you can." Obviously, you know, people have different sort of levels of pain and whether they can master the, master it. 
 

A doctor talks about the importance of exercise during recovery. It’s difficult to damage the knee unless someone has a very bad fall.

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What’s really important after joint replacement is regaining a good range of movement. And a physiotherapy [exercise] programme is critically important in doing this.

Anything which allows you to try to get your leg moving in a full arc of movement is to be encouraged. And this strengthens the muscles around your knee and in the end improves the functional recovery that you get. 

In a small number of cases, patients struggle with their range of movement. And what we’d like to do is to intervene early in that situation. And that’s one of the important checks at 6 weeks is to make sure your movement is coming back. And that’s a key part for us.

Sometimes when people were doing their exercises in the early stages of recovery, they wondered if they could damage the knee. Is there any way that they could damage it or is that highly unlikely?

If you follow the guidelines for recovery following joint replacement and specifically partial knee replacement, there are very low risks of damaging a knee replacement. 

The thing that we’d wish to avoid are falls. And falls can lead to damage or sometimes fracture around a knee replacement. But that’s very, very unusual. And most people recover very steadily and avoid those sorts of issues if they stay within the realms of the recovery programme we lay out.

If someone did accidentally fall, who should they see first?

Well, I think once you’ve had a fall, if you’re able to get up and everything seems fine, then I think you can monitor that yourself. 

If you have a fall and you feel new pain or there’s swelling in the knee and it’s clear that something more serious has happened, then I think initially the person to contact is your GP. And your GP tends to assess that situation and will refer you through the appropriate channels.
Geoff wondered if people could be offered physiotherapy locally after surgery, and Janice felt group exercise classes at the hospital might have been helpful. Like several participants, she felt that physiotherapy would have motivated her and helped her to stick to the exercises when she was mobile again.
 

Geoff would have liked physio before going back to work. He would have been happy to have it locally and pay a small fee towards the costs.

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Age at interview: 64
Sex: Male
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You came home, you did your exercises?

Yeah.

Did you feel you were doing them OK or how ...

Yeah, yeah.

But it would have been nice to…

To have some feedback really, to have someone else to tell you that you're doing OK. You know you think you're doing good, you can get around but you don’t know what anybody else has experienced so, with no feedback, you don’t know if you're doing good or you just sort of messed it up really until you go to a physio and they say, "Well your leg's doing well," and they bend it right over.

What would have been the ideal situation in that time, so if, you know, if the hospital or the GP or the physios could, you know, provide a service and they were listening to your feedback, what would you suggest?

It would be good after, let's say for… the first eight weeks really you can just do the standing on the stairs and whatever you do and the exercises they gave you. But after that and you're going back to work, I think it would be good to have half a day physio just doing knee bends or building your muscles up.

Half a day physio?

Well a couple of hours, not a whole half day, but yeah.

Just once or?

Just once a month maybe so once you get the idea of what you need to do you can carry on that for yourself, which isn’t so bad. But you're frightened to do anything for yourself because you know what damage you're going to do.

And there was no one available to give feedback. Did you ever feel like going to the GP or you felt…?

No, I was fine. I was happy to have no pain and go back to work.

But there was no physio at all?

No, no.

The physio is my sort of main…well not complaint really, it's just a theory from my point of view. You know, I think that it would have benefitted me just all the way through from the first time I met the physio guy to going back to work.

Even if that’s just someone here local rather than having to go back…?

Yeah, most surgeries or cottage hospitals have a physio department and you only need to spend an hour. I mean if you have to contribute towards that it wouldn’t be the worst thing in the world would it? You know, if you say you're going to see a physio it's ten pounds a session, I don’t think many people would complain about paying that for every week or every fortnight. And I think to make that decision on your own is, you don’t know if you're doing the right thing so that would be my only thing – physio all the time. And the physios I've had at the hospital and everywhere else have been really good; can't sort of complain about it, it's just not got the time to do it with everyone.
 

It’s a shame not to have physio after surgery. Having a specific time to exercise would help, including drop-in or group classes for knee surgery patients.

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Age at interview: 52
Sex: Female
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The only thing I think is a shame is that once you’re discharged you don’t get any physio. And I know it’s difficult because they’re busy. But I almost feel it would be easier for me because I know I’m a bit perhaps younger than people that might have it done if they’re older. But if you could go once a week even just to see a physio, it makes you feel more that you must do your exercises. Because you’re left to your own devices really. And that makes you a little bit more, “I must get on and do that or else they’ll know I’m not doing it.” But that would be my only thing as a follow-up thing. I would have liked to have seen someone rather than just be left for six weeks before you go back and see the doctor and presumably be discharged at that point.

You mentioned it would have been nice to go for physiotherapy once a week.

Yes, yes, yes. It’s like anything, isn’t it really? If you go to a fitness class and you’ve got a specific time when you’ve got, you, you go, you do make time for it. When you’re left to your own devices, you think you’ll do it, do it later. And later comes and you don’t do it. So a video would perhaps help. Or I think they did say you could go in for drop-in, you could drop in at the physio at the hospital. But I think you had to ring first. It wasn’t something you could just go and do. So I do understand though that they’re pushed up there and they can’t see everybody that has, you know, joint surgery on a weekly or daily basis at all. But actually I wondered whether it would be possible, if they could do group classes.

The physios?

Yes. So like if every day there was a group class and they could see however many people they’ve got room for that have all had knee surgery. And you can all go along at the same time.
Managing alone can be difficult for people who have had surgery. Helene, who lived on her own, said she would have liked support from a district nurse in the first couple of weeks after surgery. Such support was discussed with Hugh, aged 61, who was home alone during the day, but it never happened. Getting in and out of the bath was challenging, as was cooking, cleaning and doing the shopping. Friends and his son helped.
 

It was frightening getting into the bath to have a shower. Helene kept her phone nearby in case she fell. District nurse support would have been helpful and encouraging.

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Age at interview: 66
Sex: Female
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Going from sort of what my family have said and friends, you have the strength of character to do all the things that they’ve told you to do. It always worries me that there are people that aren't going to do that. I'm on my own. I live on my own and, if I was older and living on my own, I would be far more afraid than I had been. Because one of the things I have is an over the bath shower. It was frightening, it is frightening getting into that bath and showering when you're on your own. 

And I don’t know, I think it would have been good if they had had a ten minute/fifteen minute visit from district nurses if nothing else, nothing else… yeah in the first few weeks. As I say, I've got a good family and friends that were constantly in touch. I always make sure I was wearing clothes, or whatever clothes I had had pockets in so I could carry my mobile phone around with me and strategically place it when I was getting into the shower and things so that I could reach it if I fell. 

It was little things like that and it would have just been nice if… it's just encouraging as well; encouragement you are doing well, you are doing OK but I think you really now need to push yourself a little bit further in this direction.

Having and recovering from surgery can be particularly concerning for people who care for relatives. Keith praised medical staff at the hospital who organised his operation date around his wife’s care. She has a degenerative disease and he is her main carer. Carers looked after Keith’s wife while he recovered.
 

Keith discussed his situation with the physio and surgeon. Moving his wife from chair to wheelchair would be impossible when he’d just had surgery.

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Age at interview: 71
Sex: Male
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The physio was very good. He had a, we had a lengthy discussion. And I mean I have complicated personal circumstances. My wife’s disabled with a progressive neurological condition. And because we have carers, there was a whole discussion around how the surgery could be organised such that we could make arrangements for carers. You know, so that, because obviously we would need people in much of the time initially while I was recovering. So there was a very good discussion about that and I think that was very helpful. 

And then when I saw the surgeon in January, we had again quite a lengthy discussion about the pros and cons of the surgery. Which again was I think very helpful. And we both sort of ended up I think agreeing now was the time in terms of quality of life, that my situation had got, you know, much worse. And given my personal circumstances, with my wife’s disability, that I, you know, I was going to find it increasingly difficult to help her, because she needs to be moved from chairs to wheelchairs and so on, with a dysfunctional knee.

So, so you had those discussions. And then a date for surgery soon after?

It took a little while to get the date. Which was worrying because one wanted to make the arrangements for carers. And there was a bit of toing and froing with the surgeon’s secretary, saying, “Look, can you give us a date? We need, you know, I need it to be able to start making all the arrangements.” But then I guess I had about three weeks’ notice of the surgery.

Three weeks’ notice?

[Mhm]

And was that enough time to organise in terms of carers?

It was, yes, yeah [mhm].
The follow-up appointment 

Most people were unsure what would happen at the follow-up appointment or who they’d be seen by.
 

A doctor explains what happens at follow-up and who to contact if there are knee problems after that.

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Well, the follow-up appointment is a really important moment. When you’re discharged from hospital we might not see you until the 6 week point where you attend for follow-up. And that’s an opportunity for the majority of patients to have some feedback from our perspective about how the operation has gone, to assess the wound and check that you’re progressing in the right direction. 

It’s also a point where patients, if they are having problems, can raise that with a health care professional. And in the small number of instances where there are real problems, we can address them. And we can bring you back into hospital to make sure that you’re back on track. 

I think patients are really reassured by that follow-up appointment because it’s an opportunity for you also to ask questions that may have arisen in your rehabilitation, reinforcing the amount of activity you can do, what you can expect going forward from that 6 week point. So I think it’s a really useful meeting, the follow-up appointment.

Is it usually the physiotherapist who they’ll see at the follow-up appointment?

There are two real streams. A lot of our patients are routinely followed up by our physiotherapist practitioners, who are highly experienced in seeing patients after joint replacement. And I think patients enjoy that contact with them. 

A smaller number of patients are seen by the doctors involved in looking after the patients. And there may be reasons why you are brought back to a physiotherapy clinic or to see a doctor, which are specific to each individual. But overall everybody is seen at 6 weeks, and it’s a great check to make sure everybody is moving in the right direction.

Some people were wondering if they’d be having x-rays at the follow-up appointment. So what usually happens when they get there?

The follow-up appointment usually doesn’t involve an x-ray. X-rays are taken whilst you are in hospital, before you leave hospital. And then at the 6 week point you’ll have a meeting, an interview with a physiotherapist or a doctor, where we will check the wound, make sure the knee is moving well. And that improvement in movement is a key marker for us of how the patient is progressing. 

We’ll check that, we’ll ask you a lot of questions about how you’re doing. And we might take a score to see, so we can try to measure your progress.
Having follow-up sooner rather than later was often important and, while some people were told it would be six weeks after surgery, several had an appointment eight weeks after surgery, which they felt was too long a wait. They would have liked it at six weeks as they were concerned about how their knee was healing. David was given a follow-up appointment at twelve weeks and, when he queried this, it was changed to eight weeks. He felt anxious about waiting twelve weeks and wanted reassurance that his knee was recovering normally. Helene was disappointed that there was no follow-up until six weeks and felt that patients are ‘left on your own’ after surgery:
 

The care before and in hospital was ‘fantastic’. Helene had her dressing changed at the GP surgery so a professional could give feedback on her progress.

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Age at interview: 66
Sex: Female
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The pre-op assessment I thought was fantastic. There was no, there was a bit of waiting but not very much. I thought it was going to last much, much longer. Everybody was helpful, lots of information. I came away sort of really happy and pleased about that and went in. I had the op; was determined to come out the next day and the physio said, "Yep, OK." They were very busy. I felt sorry for the nurses. There seemed to be not enough of them. I didn’t suffer because of that but, you know, I just didn’t want to be in hospital and came out the next day, which was great and family rallied round, sort of helped with everything. I was so pleased I could walk without the pain. I knew there was dull ache from, an ache from the operation, but it was great. 

But the one thing I don’t understand was no follow-up - you're left on your own. If you don’t have the backbone, the courage, the strength, to do the exercises and get doing it yourself – there was nothing, absolutely nothing and I was so surprised that this is what it was like. I just couldn’t get over it; I really couldn’t get over that. You know sort of…I had a new dressing to put on and I thought, 'I'm going to go and ask for the surgery to do it so at least somebody professional is looking at this,' and which is what I did. They were very good, very nice and so it looked OK and I thought, 'Well thank goodness for that, somebody's told me something, it looks OK.' And then I had to go back to the surgery with… I'd be given the clip removers at the hospital to go to the GP’s. But then you're on your own, completely lost. 
David, like a few people we interviewed, didn’t know what would happen after the follow-up appointment:
 
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David would prefer to contact the surgeon if he has concerns about his knee to find out whether he needs a hospital appointment or to see the GP.

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Age at interview: 57
Sex: Male
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So you go back for the follow-up. What happens after that appointment?

I don’t know. I will find out when I go for the appointment.

What would you like to happen?

Well, I don’t know. If the surgeon says, “Right, everything’s as it should be. Unless you fall over and bang it or something, you should be okay” then that’s it I suppose. If there is a problem I expect he’ll say, “Go and see your GP” and then be referred again. But it’s difficult really, yes. If it’s all okay, that’ll be what, months / three months? So the bone’s sort of healed around the new part. So it should be okay. If he says it’s all okay, then you take his word and carry on doing what his suggestions are and gradually build it up again.

So after that, if everything’s all right, then if there are any problems then you would just go to your GP? Does that sound okay or would you like more reassurance than that?

I don’t know because the problem with going to see your GP is trying to get an appointment. And then if there is a problem, then getting another appointment for the hospital, which could then be three, four, five, six weeks down the line. Whereas if you could ring the surgeon and say, “Look, I’ve got a problem.” Or ring the hospital and say, “I’ve got this problem with the knee. Do I need to come and see you or can I go and see my GP? Which is the best way of doing it?” Explain what the problem is and they say, “Well, you need an X-ray” or whatever or, “Just go and see your GP and get some painkillers.” Then that might be different, I don’t know.
Last reviewed August 2018.

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