So you went for the pre-op. What happened there?

They, well, they sit you on the bed and try and move your leg. The phy-, the doctor said that, You, theres so much floating bone in there. We don’t know whether were going to have to give you a full knee or a half knee. Which, I’ve heard that the full knees worse, but the half knee is, I’ve had two half knees. So a lot of it was really get me to walk. And she said, Oh. She said, You’re very, very bandy. And that’s, she said, Oh, wed best get it done. Get it done straight away. And then, and she showed me the video of the actual Oxford knee, what was going to do to me, then the rehabilitation. And once I knew what was, still very apprehensive. That’s the first time I’ve had a real, well, I call it a major operation. But they made me feel at ease. Really good, really lovely people.

The first time, did you, were you shown a video the first time as well? Or only the second?

No, the first and second time, yes, yes.

Did they give you any leaflets to take away?

Yes, they give me leaflets to read on all the operation and then the physio afterwards and how long. I mean they said that every person’s an individual. But she said, Considering you were a sportsman, we hope that you will probably recover in a quick, quicker time. Which was quite amazing really, how quickly I did get about actually.

As soon as you went in, you had a sheet telling you who you would be seeing. And then they’d tick it, sign it, just to say that you’d been. So you knew that you’d got like several people to see. Didn’t know how long you would be before you went in. So if you wanted to go to the toilet or anything, I thought that I would go to the receptionist and just say, I’m popping to the loo or, I’m doing this, doing that. It would have been nice if somebody had been there so that you’ve got someone to chat to. They could have gone and got you a drink while you were waiting. They was there so that you wouldn’t, I felt as though I’d miss a time slot if I didn’t go. So it would have been nice to have someone there. So if I did pop to the loo or just, you know, just out to check the car or whatever or a phone call, thered be somebody there. That would have been, would have just been helpful.

And you mentioned at that appointment you were told about the video. That you, you know, you could go online and on a certain website and then you would see a little video about the pre-assessment, about the operation and recovery?

Yes.

You were told at that appointment? But you didn’t look at it at the hospital? You came home and looked at it? Is that right?

When I saw the physio she put it on the screen for me. She showed me how to get it and she showed me the procedure. So I did watch. But I didn’t, obviously didn’t know about that before I went for the assessment. So she did show me it. Which I thought was good. And then when I came home, that’s when I went and I looked at the second video, which was about the operation.

Would it have been helpful to see the video about the pre-op assessment appointment? Would it have been helpful to see that beforehand?

It was nice to see. And, yes, if you were able to, it probably would have been.

So if you’d been sent a letter with the appointment for the pre-op assessment —

Yes.

— and then the web address?

Yes, yes, because people that are on the computer would find that easier than reading what to expect. But I did have a sheet with it all on. I read it all, understood it all. But, yes, it probably would have been nice to see it.

Beforehand?

Yes.

In having a partial knee replacement, there are really two options in terms of the anaesthetic techniques that are used. And they’re both really safe.

General anaesthetic involves a patient going to sleep throughout the procedure, waking up afterwards. And probably that’s the commonest route that people go down, certainly in our hospital.

The second route is a spinal anaesthetic, where your legs are put to sleep so you don’t feel any pain in your legs. But the patient sleeps during the operation rather than being completely unconscious in a general anaesthetic.

And there are advantages to both techniques. And both techniques can be used in many patients, although in some patients spinal is more applicable or general anaesthetic is more applicable. And theres a conversation between a patient and the anaesthetist. It’s a shared decision in terms of which route you go down. But the key point is both are really safe techniques.

Then you came round. When you came round, how did you feel in terms of your knee? Any pain? Or could you feel your leg?

No, I can’t remember feeling any pain or anything. It was just the effects of the anaesthetic. So you’re sort of tired and groggy. Wasn’t, didn’t feel too bad. When I went up to the ward and they check things. Because I wasn’t aware that, it’s common sense that they would probably numb you, but I didn’t realise. And when they felt the bottom of my feet and the top of my feet and said, Can you feel that? And I’m thinking, Oh, its like pins and needles and, Oh, I’m not sure about that. And they prodded the rest of my leg and I couldn’t feel anything. And then I realised that I’d had an injection and then that was the reason why it was numb, yes.

Quite a few people actually haven’t been aware of that.

Yes.

So they might have told you but it wasn’t in, it wasn’t in the video, was it? This information about the anaesthetic and how your leg would be for a few hours, a bit numb.

Yes, I can’t remember reading anything like that.

Would that have been helpful?

Yes.

To have had that written down?

Yes, I think —

Sometimes you can’t remember everything on —

That’s true.

the day.

Because you did, was I was told’, was I told and I’ve forgotten? I don’t know. But, yes, I think that would be helpful if you knew. You’d expect it to be numb and you know that it’s going to come back. I mean I still have numbness now round the knee, which is taking its time to come back. If ever it does, I don’t know.

So then that was on the ward where it was numb? Did it start easing off then? Could you, you know, feel your toes and everything after a few hours?

Yes, yes. They make, they ask you to move your toes. I could move my toes. I could do everything that they asked me to do. Yes, that was fine.

My big shock for me was not being able to get up to go to the loo and that you’d have to use a bedpan. Which was quite a thought for me. I wished I’d known that before. It wouldn’t have made me not want to have it done, but I’d have been less sort of like, perhaps, because you can be a bit tearful perhaps after an operation and a bit low. That just compounded that feeling for a moment. I thought, Oh, gosh, I’ve got to go on a bedpan. But once you’ve done it once, you’re fine. And you know you can’t get up till the next day, and so that’s where you are. Then the next day you’re got up by your physio.

They [doctors] said before the surgery that you go, I think they even said, Most people go home the next day, but it’s between 1 and 4 nights and bring enough stuff to stay overnight one night, and then get other people to bring stuff in for you if you need more. And I wished they hadn’t said that because nobody that I saw went home the next day. And there was no way I could have gone home the next day, and the other person who had a knee, there was no way she could have gone home the next day. And what with all that bedpan wetting yourself, I mean with the spinal block I did wet myself cos I didn’t know what was going on down there. And I was cold and then I’d be covered in sweat, so I mean the second morning they said, Oh a shower. Oh wonderful, wonderful you know. But I really could have done with more clothes with me.

And no, I mean I went home after four nights and that seemed, and there was no way I would have gone home before that. And in fact it just changed on that fourth day that I thought, that it suddenly seemed like a possibility whereas up to that time I wouldn’t have considered it.

So I wish I’d taken more stuff in. The other thing was the shoes, they said, Bring sensible shoes so that you can do your exercises. Well I mean I don’t wear heels so I thought well what are sensible shoes? I thought ones that are going to slip off aren’t sensible so I took a pair of gym shoes, and they said, Well you can’t get those on yourself can you? And I thought well no of course I can’t. But so they got me a pair of slipper socks, they were seen to be giving out slipper socks but I think, I mean what you needed was shoes that you could slip your feet into but weren’t going to slip off your feet once you’d got them in. They wouldn’t let you walk around in bare feet and so I mean next time there are things that I have learnt from this time that I would do differently. Try and figure out some shoes that I can slip on but that are going to stay on. And take more clothes.

The big problem for me then was having to inject with the anticoagulant drug. It’s not heparin. I’ve forgotten what it’s called now. And I think all knee patients now have to have that for two weeks afterwards, which you have to do at home. Which also surprised me. On the day of my surgery the doctor said that I’d have to have that every day. And I was quite shocked. I thought it was a thing I’d have to have done once a week at the doctor’s surgery and I wouldn’t have to do it myself. But I didn’t find out until like the eleventh hour that you do that yourself. So they have to show you how to do that. Which was a bit of a pain. I didn’t enjoy doing that every day for six weeks. And I had to do it for six weeks because of my Leiden Factor V. I think generally if it’s just an ordinary situation, it’s just for two weeks. So it’s not so bad.

I hated it, I absolutely hated the thought. How people that are diabetic have to do that every day for life must be quite a thought. You take it in the e-, I was taking mine every evening. Now whether that’s relative to when you have your surgery and they give it you, I don’t know. For me, I would have preferred to have done it every morning. Because like you’d get up and you’d do it and it’s done. It was almost like once you’re, because you’ve been asleep all night and you’re not thinking about it. So you get up and you just think about it and you do it. So you haven’t got to think…

For me, I hated doing it so much that come teatime I was thinking, Oh, I’ve got to do that injection later. I hate the thought of that. And I almost sort of thought like, Oh, I’m not going to go to bed. Because if I go to bed, I’ve got to do my injection before I go to bed. Silly, it sounds silly, but I didn’t want to have to do that. And it’s not for the fact that it actually always hurt, because they show you how to do it. And you, apparently you can do it in your leg, but it’s absorbed better and quicker if you do it in your tummy.

In the immediate post-operative period, we will use some techniques to make sure that we protect you from having a blood clot. And a contemporary way of doing that is to use some injections into your tummy, which we can teach the patient how to do.

And following a partial knee replacement these injections will go on for 2 weeks on average and involves a small injection of a few mils of fluid, drug, into your tummy. And this is a routinely performed procedure and most patients find this very acceptable and something that they’re able to master.

But it’s very important as blood clot is a real issue for patients, although rare. And we really like to try and make sure that were as safe as possible in protecting patients from that.

And you will show patients how to do that?

Yes, in hospital the nursing staff, and they’re very skilled at doing this, will go through an education programme with patients in terms of their learning for how to do this. So we will make sure that patients will absolutely know how to do this before they go home.

I left hospital on the Tuesday and I had, on the Tuesday night I slept here and I had a terrible night, really, really bad night. I had, I was up in the night because I couldn’t sleep with the pain. I sat down here in this chair about from 3 o’clock onwards. Couldn’t, I think probably exhaustion got me off to sleep eventually here in the chair, just sitting in the chair with my knee up on the cushion there. And when my wife came down and we discussed the bad night that I had, we decided it was time to start talking to somebody and find out why. And that was when we found out about the problem with the pills.

Because, what had you been sent home with?

I’d been sent home with paracetamol. And that was it. That was all I was sent home with was paracetamol. I think everybody else was sent home with paracetamol plus something to go alongside it. And in most cases I think it was probably codeine. Because it wasn’t until we rung up we found out that I should have been told to be using my own painkillers alongside the paracetamol. And once we started doing, once we started sorting that out with some help from the GP, then we got the pain under control. But it still took another 24 hours before all the medication kicked in. So I’d spent really one night and one day in a lot of pain. I mean on a 1 to 10, it was 12. It was really, really bad.

Did you speak to the GP as well or he-?

Oh, yeah, yeah, yes, we spoke to the GP as well. Because I was under some medication for other things and we had to make sure that everything was okay with the GP for me to take these extra tablets. So once we got that sorted out with the hospital and the GP, things started to ease off. But, as I say, it, by that time, by the time wed got it, [clears throat] by the time wed got it sorted out, were looking at probably late afternoon on the Wednesday. And it was still painful through the Wednesday night into the Thursday. And by the, wed got halfway through the Thursday, everything was kicking in and the pain was easing off. But those first 24, 36 hours, really bad, really, really bad.

But what they, what somebody should have told me was that the pills that I had of my own would take over and do the job that the hospital should have given me. In other words they should have given me codeine, I think it was, and paracetamol. And I had co-codeine of my own, which was prescribed by my GP. And they should have said, Carry on taking your pills and we won’t need to give you ours. But they didn’t tell me that.

So until we got that sorted out, once we got that sorted out, the pain, we got the pain under control and it’s been pretty successful up to, you know, up to now. Were now three, just three weeks after the op. I’m up and about, no sticks, up and down the stairs, out for nice walks with the dog, and everything seems to be going well now.

My leg recovery was fine I didn’t have too much trouble. The only thing I had trouble with was controlling my pain relief because he said you have to control your own pain relief. They only give me a week’s worth of tablets and I thought, ‘Well is that supposed to be enough?’

And I had to phone the emergency number in [hospital name] to get some more which meant I had to go into Sainsbury’s on the Sunday to get some. And I didn’t know what to do really; I didn’t know whether to keep taking two every two hours or to gradually cut them down.

So some information on that would have been helpful?

Yeah, yeah. I wasn’t sure how long I needed to take two every four hours for.

You were given a week’s supply of taking two every?

Yeah, I think it was about eighty three/eight four I think they gave me which was two; I was sixteen a day for, or eight – two, four, six, eight a day, eight a day.

So you were originally taking eight a day for the first week?

Yeah

And then you weren’t sure what

No, I didn’t know what to do after that. They said control your own pain relief. The first week I was taking two of those and two paracetamols every day.

So when they say control your own relief they hadn’t really given you much more information other than that?

No, no

What would have been helpful to for them to say to you?

I don’t know really because everybody’s pain threshold’s different so I would imagine that would be quite a difficult thing to plan for someone. But I don’t know if he said, “If you get any problems visit your GP,” well he probably did actually. But when you’re in a hurry to get out the hospital you don’t really listen to everything. But I did eventually go to the doctor and he said, you know, “Just try and wean yourself off them if you can.”

So when you first started having pain, did you take painkillers or did you

Yes, I’ve been taking painkillers for probably the best part of that 10 years.

Painkillers that you bought over the counter?

No, no. Painkillers that were prescribed by my GP. That’s my next, probably my next big problem is, is obviously they were fairly heavy-duty painkillers and at some stage I’ve got to get off of them.

Can you remember the name of those painkillers?

Yeah, I’m on co-codamol and tramadol.

And you’ve been on that for..?

A long time.

A long time, yes.

So it’s quite possible that, to a certain extent, I suppose I’m addicted to them. So that will be the next big problem is getting off of them. Because I don’t want to be addicted to anything, not, certainly not them. So, yes, they were doing a fantastic job because they’ve kept the pain away. They’ve allowed me to carry on working up until my retirement, which was last year. And although my working day was probably shortened a little bit, at least I’ve been able to earn a living. You know, being self-employed, I need to work.

So you took, through the GP you were prescribed these. Can you remember for how long? For the whole of the 10 years or were they, was it just paracetamol to start with?

No, I think it might have been, it might have been something milder to start with. But, you know, weve progressed. And I’m not blaming the GP in any way, shape or form. It was probably me saying that I don’t want to go in for the op. Because I knew that if I’d gone in for an operation, I would have been in a situation where I would have, if both knees were done separately, one after the other, I could have been off work for, I don’t know, 8, 9 months. That’s a long time if you’re self-employed. And, you know, customers will wait a short period of time if they want you to do the work. But you can’t expect people to hang around when they’ve, when they want things done, you can’t expect them to hang around for 9 months. So I’d be losing, not only losing the work but losing the customers as well. So I made a decision there and then that I would not have new knees until such time as I got to retirement age.

How did you find it weaning yourself off, was that OK?

Quite difficult, yeah it was difficult.

Can you tell me about that because what was difficult?

Well I’d just get so hot and shaky. I’d just shake like anything when I started only taking one, I was sort of shaking like I had like, not DTs or whatever you know.

Because you’d been taking them for a while?

Yeah, yeah. I was shaky and all terrible things. Really hot, couldn’t sleep, could sleep for nearly a week, just cat-napped.

So which tabletswhich tablets were these now?

Tramadol.

Right. Did you have any idea this could happen?

No.

Nobody mentioned anything?

Hadn’t a clue. I slept in the other room. Well I didn’t sleep, I laid in the other room because I just kept my wife awake all night and luckily weve got a spare room so I just laid in there listening to my music and cat-napped in the day time.

What would have made this situation easier?

I don’t know.

Any information, would information have helped or?

I don’t know any, but I suppose if they told you how to wean yourself off a little bit better maybe or have some sort of timescale, say please don’t take these tablets after four weeks or, after four weeks if you’re still on the maximum dose try and wean yourself down to one an hour.

Would it have been helpful to know what could happen while you’re trying to wean yourself off, so you know if you were being shaky but you knew that this might happen.

Yeah, if you read the leaflet on tramadol you could have anything up to two hundred symptoms I would think. Theres so many I read the leaflet and oh I got that, you know.

Did you phone the GP at all or you carried on?

I just sort of carried on. I thought, ‘I’ve got to get off them.

And how long did it take to wean yourself off?

A week and a half. Had a week with no sleep and then gradually got better.

In hospital well give you a lot of help and assistance in trying to manage your pain. And in the first day, two days in hospital, a lot of the responsibility lies with the doctors working with the patients to get that right for each individual.

And we tend to move from painkilling drugs which are given into your bloodstream to oral tablets. And by the time you go home theres a fairly well-established protocol with the sort of tablets you should take and how often you should take them.

And over the first 2 weeks following surgery I would expect you to initially need quite a lot of support from the tablets. But that tails off over a 2 week period, such that most patients are probably needing only small amounts of tablet medication by certainly 2 to 4 weeks following surgery.

Should they just take it as they need it then after that point?

Yes. Well give you a lot of advice in hospital about how to do that. Well probably encourage people to take tablets very regularly for the first two or three days, and then to take them as you need them over the next week to two weeks.

And if pain is a problem and your knee is becoming really painful and sore, then well advise you to speak to your General Practitioner. And in those circumstances, which are unusual, we would like to see you again back in hospital to make sure all is well.

Since I’ve had the surgery and indeed, you know, one of my friends had the surgery at the same time. We were literally in the next bed to each other. I didn’t know, we didn’t know we were both having it. A chap I used to play rugby with… He had the same experience of dis-, of the pain at night, you know, waking up a lot. And I think they should warn you about that. Because that wasn’t mentioned at all. And I’ve talked to other people who’ve said exactly the same thing. I ended up having to go to the GP and ask for some sleeping tablets for ten days. Which he gave me. And then I discovered, you know, other, some other people had had the same experience as that. So I think I wasn’t, you know, wasn’t given enough warning about that.

So being prepared for that would have been helpful?

I think so. I mean I can understand that surgeons or staff may be reluctant to give warnings about, you know, these sort of negative things in case it might put people off. Or it may make them so worried about it that, you know, the experience is even worse. I don’t know. But I think it should be mentioned that You may have, you may find this. It will last for four or five weeks. Which is what happened to me. Again talking to other people, it’s what they’ve had, you know, I know they’ve experienced. And then will gradually get easier, yeah.

So it would have been helpful to know that beforehand?

Yes.

I think this is fairly well established that any intervention like this where theres surgery is a kind of general disturbance to you in your normal pattern of behaviour. And that affects sleep. It may be that your sleep was affected by your arthritis in your knee before you came into hospital. But certainly in the first few weeks after surgery, it may be because of the pain of the incision and the operation that you may find some difficulty in getting a regular night’s sleep.

I think a lot of patients will find certainly in the first week after surgery that your sleep is affected by the operation and the medications that you take. Pain is probably the biggest factor here. And so after the operation your knee will be sore.

It will gradually start to improve, but in the first two or three days it may be difficult to sleep through. And certainly we will support you in the use of tablet medications to try and make your knee more comfortable, to allow you to get as full a night’s sleep as possible.

Certainly the way forward with this is that patients become increasingly comfortable and sleep is increasingly easier for them to have. And the medications on the whole allow you to do that rather than making it more difficult. Sometimes certain medications may interfere with sleep, certainly in the initial period following surgery. But actually overall the trend should be for your sleep to improve, although it will be disturbed in that first week.

The other thing she (physio) said, “Don’t get any infections when I left hospital. How can you not get infections if you fall over and cut your leg, how can you not get them? So I didn’t know whether to keep a bandage on it, an elastic bandage sort of thing or not, that was one of the other things. And they give you these types you know the leg stocking things for deep vein thrombosis sort of thing. And they don’t tell you how long to keep wearing them for.

So more information about how long to wear that; how to look after the wound and, you know, make sure that you can prevent infections.

Yeah, yeah. Because if you’ve got hairy legs, those stockings drive you mad. So the first thing you want to do is pull them off. You know if they say, “Well you should wear them full-time for a week,” then you’ll have some information, somewhere to go instead of just putting them on when you need to or when you think you need to.

Partial knee replacement is a very effective treatment in terms of taking pain away and allowing patients their quality of life back in terms of mobility. And for the vast majority of people the knee replacement will last a long time.

If you want some simple figures to remember… Perhaps at 10 years following surgery, 90 per cent of these operations will still be functioning really well and the patients will be happy. And at 20 years, 80 per cent of patients will still find the knee replacement functions very well. So I think they probably last to a greater degree than people might imagine.

I think the discussion with patients about the timing of joint replacement is critical in the shared decision-making process. So, regardless of age, it’s very clear for some patients who are having such a difficult time with their knee arthritis that joint replacement is appropriate. And some patients who seem very young, in their 40s, will have joint replacement. But those numbers are small.

The average age of people having joint replacement in this country is in your mid to late 60s. And for those patients, the discussion is about the degree of symptoms that you have and the proposed benefits there are from having the joint replacement.

In the slightly younger age group patients, if you’re in your late 50s or early 60s, the question is whether or not you would want to invest in having a knee replacement to get rid of the pain and stiffness that you have. Weighing that up against the risks, relatively few that they are, but the risks that do exist. And that’s an individual choice that you make with your surgeon in terms of how you feel about your arthritis and how you’re coping.

Have you been given the appointment for the follow-up?

No, that’s something I need to phone up about. They said, “After three weeks, if you don’t get the letter, contact us,” because I should get a follow-upit should happen six weeks later shouldn’t it? Well it’s been four weeks now so I’d better give them a ring I suppose [laughs].

And because you’ve had the other knee done, you kind of know what’s involved with the going back?

I don’t actually, I’ve forgotten all about it. I don’t know what will happen; whether maybe they’ll do another x-ray will they?

I’m not sure.

I’m not sure, yeah. They will probably ask me questions how I’m going on, what I can do, what I can’t do and things won’t they? Things like that.

Would it be helpful like you were shown the three stages pre-op, what happens in the operation and then recovery would it be helpful to know like what happens in follow-up or, you know, when you’re discharged, that kind of information?

Yes, yes, I think so especially for the first knee you’d want that I think.

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.

Well check that, well 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.