Hip and Knee Replacement by St James

Description

Pre operatively

Once the patient has to decided to go ahead with a hip/knee replacement it will be to their advantage if they try to strengthen their leg By carrying out a programme of strengthening exercises their muscles will be in optimal condition for the surgery, and as these exercises are carried out immediately post operatively they will already be familiar with them. It will also help if the patient can manage to lose any extra weight they might have. Some medicines can complicate surgery such as HRT, Aspirin, Warfarin and even some herbal remedies and so the patient must check their prescriptions with their doctor so any adjustments can be made well in time. For example HRT should be stopped for at least one month prior to surgery
The Consultant will need to see any recent X-rays so the patient should bring them with them to their first appointment at the hospital. The X-rays may also be done at Saint James Hospital prior to consultation.

Pre-operation assessment

Prior to the operation the patient will undergo a full assessment which involves a series of blood tests (CBC, U/E's,Creatinine,INR, APTT, LFT's,RBG, cross match for 2 units of blood), ECG (heart trace) Chest X-ray and a Joint X-ray if a recent one is not available. There will also be a pre operative assessment done by the anaesthetist who will be administering the anaesthetic. This will allow the anaesthetist to decide the mode of anaesthesia and any other management required.

Operation

Usually the patient is admitted to the hospital a few hours before surgery giving them a chance to become accustomed to the room and to make the acquaintance of the staff that will be helping to take care of them.
Before the operation the Consultant will go to the room to explain again what he is going to do and the patient will sign the consent form.

After the operation the patient usually rests in bed for 24hours. They may initially have a drip and a urinary catheter. Some patients may have an abduction pillow between their legs to maintain the position of the operated leg. If there is no pillow it is imperative that the patient keeps their leg slightly apart and does not try to cross them.
A check x-ray will be taken at some point –either in the theatre or first thing next morning. Their blood will also be tested to see how their body reacted to the operation. If it results that the blood count (haemoglobin) is low then they may be transfused the two units that were cross matched prior to surgery.
The patient will be mobilised according to the Consultants instructions – usually in the morning after the operation. Some Consultants like to begin mobilising the hip as soon as possible after surgery and will refer the patient for CPM – continuous passive movement- which is a machine that bends the leg for the patient (passively) to a pre set degree and then straightens the leg out again. The patient may have none, one or two drains after the surgery depending on the surgeon and the technique used, and these will stay in for up to two days. The patient will begin to mobilise with a Zimmer frame on the first day post op and will quickly move onto crutches or sticks depending on individual progress.
Some patients will be wearing white stockings after surgery. These are another method of preventing thrombosis and should be worn for 6 weeks unless the patient is advised otherwise by the Consultant. As they are compression stockings they should be smooth all the way up and the gusset should fit over the inside of the top of the thigh. They should be firm but comfortable, and they should never be folded over. Initially they should be worn all the time, but after three weeks they can be removed at night and reapplied in the morning. They are washable but one should use warm soapy water not hot.

The Consultant will visit on a daily basis to decide patient management but the hospital doctors will be overseeing the hospital stay. It is important in the initial stages that the patient is pain free and they may have a PCA to self administer the painkiller. This is usually Morphine. It is self regulating and so the patient cannot overdose themselves with it.
When this is removed the patient will be given regular pain killing tablets which they should take, as each day they be exercising more and it is important that they are free from pain. Initially the pain they experience is the wound, as the pain of the hip disappears post operatively. Moving i.e. exercising will help to dissipate the bruising around the wound and will help with the healing. They will also be given a daily injection of a heparinoid – usually Clexane under the skin to prevent thrombosis.
The physiotherapists will visit as often as is necessary, but usually twice a day. The CPM, if used, will be done daily and the angle of bend will be gradually increased at these visits but will not exceed the safe angle at the hip (which is a right angle).
The physiotherapists will also give the patient exercise programmes and walking practice so that patients gait will be normalised as soon as possible. The patient will be encouraged to be independent and the physiotherapist will show the patient the best way to get in and out of bed.
Initially the patient will be taught to get out from the operated side and to get in with the good side first - this will help to maintain the leg in a good position. In the first three months the patient will not be able to lie onto the operated side and should never turn onto it even if asked to.
However they will be able to turn towards the good side providing that they have a large pillow between the legs to support the operated leg. This is a position which will be used by the nurses when bed bathing the patient, and they will take care to ensure that the leg is properly supported. It is imperative to maintain the position of the hip especially in the weaker initial stage. Hip stability is usually maintained by the muscles that have to be cut to perform the operation – especially if the operating technique used is exactly on the side of the hip- so special care must always be taken. However I would suggest that the patient spends the first 6 weeks lying on their back and uses a pillow between the knees at night in case they inadvertently turn onto their side whilst asleep.
Special raised seats are available for the toilet (it may be useful to buy one for use at home) and whilst the patient is recovering they may make us of special mattresses and monkey pole for the bed. When getting out of bed they should not use the monkey pole, as this does not help one to get up. The monkey pole is to help the patient maintain their position in bed and to help relieve pressure. Stairs are usually practiced on the 5th day. Most patients are discharged with crutches or 2sticks and the patient should use these for at least six weeks. If the patient makes good progress it may be safe to use one stick after 3 weeks and this should always be held in the hand opposite to the operation. However aids can only be discarded when the patient can walk normally without limping. If they stop using them too quickly they will walk with a 'dip' when they stand on the operated leg and this will then persist for a long time if not permanently. Some patients may have a discrepancy in the length of their legs. This is sometimes 'real' and sometimes 'apparent'.
If the hip joint was much damaged then the usual space of the ball from the socket would have been lost. After the operation this space would have been regained but the patient will feel the leg is longer. In time this will sort itself out. However if the unoperated hip is gone as well then the operated leg will really be shorter than the other. In this case it may be better to have a raise put onto the shoe of the unoperated leg to equal the length. Should this hip be operated at a later stage then the raise should be removed. It is usual for the operated leg to be a little swollen after the operation and it will help if the leg is elevated on a stool at intervals during the day. Painkillers should continue for as long as the patient needs them. The patients may need to continue taking the injections to prevent thrombosis for a length of time following surgery – the Consultant will decide this upon discharge.

Post discharge
Should the patient still require help from the nursing staff after discharge from the hospital to the hotel, this can be provided. Any equipment that they may require to use in the hotel such as a toilet seat or armchair will be provided from the hospital. The room should have a walk in shower cubicle to facilitate washing. It will no longer be possible for the patient to sit in a bath or on the floor and it is important when dressing that the hip/knee is protected. The operated leg should be dressed first. To apply shoes it may help to use a long handled shoehorn, but if the patient has to bend down to adjust the shoe it should always be from the middle with the legs open and never from the side. Socks / stockings can be put on using a sock aid if necessary. These small aids are available from Boots the Chemists or from a shop that sells disability aids close to where they live. Alternatively we can supply them.
The patient will continue to be monitored as necessary by the physiotherapist either in the hotel or in the hospital department which is situated next door. Post operatively the exercises are basically the same as pre operatively but with a few additions:

Move your feet up and down from the ankles
Move your feet in a circle anti- clockwise and clockwise.
Put a towel or small pillow under your knee. Pull your foot towards you and straighten your knee so that the heel comes off the bed. Hold for a count of five.
Tighten the muscles of your thigh to straighten your knee and try to lift your leg a few inches off the bed. Hold for a count of five and then lower.
Lying on your back, lift your leg slightly off the bed and then take it out to the side, hold for a few seconds and then bring it back in keeping the gap between legs. Relax.
In lying bend and straighten your leg. Putting a piece of hardboard or melamine under your leg will make this movement easier. Make sure the hip/knee, knee and ankle stay inline and that the leg does not drift inwards.
In sitting lift your leg to straighten your knee. Hold for a few seconds and then lower it down again.
Whilst standing holding onto a support in front of you:
Go up onto tip toes, lower down and rock back onto heels keeping bottom in.
Squat bending knees and hips then straighten up
Lift right knee up to touch bar and then lower. Repeat with left.
Standing straight lift right leg out to the side. Hold then lower down. Repeat with left.
Walk sideways, five steps one way the other:
When going up and down stairs the good leg always goes up first, and the operated leg goes down first. The sticks stay with the operated leg.

When the stitches or clips are removed by the outpatient nurses, the wound should be kept dry for a few days. After this it can be washed normally. However the patient is not allowed to sit in a bath and should use a shower. Should the stitch line need moisturising the best thing is E45 cream or a similar product. The stitch line may be numb for a while after surgery due to the nerves to the skin being cut- this will return to normal in time as the nerves grow back into the skin. Eventually they will be able to do most things including kneeling (if absolutely necessary), though it is better not to strain the joint if it can be avoided.
The patient will see the Consultant and the physiotherapist before they fly back to the UK. Any queries they may have can be addressed at this time. However the physiotherapist can always be contacted through the hospital or through the Personal Care Manager and will contact the Consultant on the patient's behalf if the patient has a problem that the physiotherapist cannot sort out.
Some patients may have to continue having a heparin injection for a while after the surgery- this will be prescribed in the hospital. The hospital staff will continue to administer the injection after discharge from the hospital – either by the patient coming to the hospital or the nurses will visit the hotel.

Special instructions post operatively
The patient should always be careful about the chair they are sitting in. It must not be too low – the angle of their body to their leg must never be less than 90º- normal sitting is about 120º. They must be very wary of soft sofas or chairs that sink down when you sit on them. The seat of the car may need a small cushion or towel to level it if it is not flat. A good height chair or bed would have more than 18” /46cm (when compressed) to the floor. Anything lower is not really suitable unless the patient is very short. The patient must never cross their legs as there is a strong chance of dislocation. If the hip should dislocate it would be possible for the surgeon to operate to put it back in place but the hip might then continue to give problems. If the hip dislocates more than one time it would then be necessary to wear a brace to support the hip
It is not advisable to walk without sticks until the doctor or physiotherapist says it is ok. Swimming is not allowed for six months (however the patient may do supervised exercises in the water with a trained professional). Extreme care should be taken when doing the breast stroke.

In order not to strain the joint the patient should avoid:
Repetitive heavy lifting / or pushing heavy objects
Excessive stair climbing
Putting on weight – maintain a healthy weight at all times
Inactivity – the joint should be kept mobile
Impact loading sports such as jogging, skiing and aerobics – it is better to ask the doctor or physiotherapist before starting a new sport or activity
activities that involve quick stop/start motion, twisting or impact stresses such as jumping
Excessive bending when weight bearing such as climbing steep stairs
Kneeling
Low chairs


The Hospital is MRSA free. A Cell saver is available to collect the patient's blood that is lost during surgery and to return it to the patient's blood system immediately post surgery. This option is usually preferred by patients who would not wish to have a donor transfusion after surgery.

ABOUT ST JAMES HOSPITAL
Many foreigners are choosing to travel to Malta to receive medical and surgical treatment. Malta combines a high level of medical expertise coupled with an ideal climate, best suited to enhance convalescence. Malta is no stranger to Medical Tourism, having a strong record in the field of medicine and a long tradition of care, also referred to in history as 'The hospital of the Mediterranean.'

We are registered with the Malta Tourism Authority and acts as your 24 hour, personal concierge during your stay as you undergo cosmetic surgery in Malta. We are your key interface from first enquiry to your return home and beyond. Our customer care team liaises with you during your extended convalescence back in your home country to provide support, advice and to gather your feedback on our service. We work hand in hand with the leading private hospital Group on the island, which is equipped with the latest state-of-the-art equipment and staffed by fully qualified doctors and nurses who are multilingual, being fluent in English, Maltese & Italian. The services offered are comprehensive, ranging from simple blood tests to diagnostic scans, from cosmetic surgery to dental services, from hair removal by laser to complex cardiac surgery.

The Hospital hosts ten modern and high-tech operating theatres which are equipped with advanced anaesthesia equipment. Our doctors are trained and qualified in the EU and the USA and have specialised and worked in leading hospitals and Universities in England, Scotland, Ireland, USA and other countries. We also provide for post operation physiotherapy which is backed up by a well-equipped rehabilitation gymnasium.

All private rooms are situated within comfortable and spacious wards, supervised day and night by an exceptional team of doctors and nurses. The rooms are single-bedded with an en-suite bathroom/shower, colour cable TV, telephone, air-conditioning, and a nurse call system keeping you in immediate contact with the nursing staff. Tea/coffee facilities are also available in every room. Wireless internet network for laptop computers is available in the hospitals. Overnight facilities for relative/carer are provided. Relative/Carer can also opt to sleep with the patient in the same room.

Many satisfied patients have commented on the luxurious and warm environment found in the hospital which, quoting them, 'makes you feel like you are staying in a hotel with special care and medical assistance.' The service and quality of our accommodation is in fact five star quality, forming an excellent synergy with the professional medical and nursing staff who run our wards.

Edward and Lucianne are our customer care representatives, and they will be your first point of contact with us. They handle all patients from arrival to departure, and will be in touch with you before and during your stay, providing you with support and peace of mind. We offer some of the best value for money you'll find anywhere for cosmetic surgery abroad, with no compromise on quality, service, care and convenience. Our top procedures are listed on the right, but we also offer various combinations and packages at favorable rates.