Over the last two years I have introduced an Enhanced Recovery After Surgery (ERAS) pathway for knee replacement surgery at Sportsmed Hospital. This is a patient focused evidence-based team approach to knee replacement surgery that speeds up recovery and reduces pain and complications. Every aspect of patient care has been carefully evaluated and the patient is involved as an active participant in the process.
As a surgeon the humbling thing is that surgical technique plays a relatively minor role in enhanced recovery pathways and these results are mainly achieved by assembling a dedicated multidisciplinary team focused on providing the best patient care and experience. The key factors involved are specialised anaesthetic techniques, multimodal opioid sparing pain relief, and modern nursing and physiotherapy care that reduces pain that enables early walking.
The process starts well before surgery with education. My team and I will discuss your expectations and ensure you are fully informed and prepared for surgery. Consultations are arranged with the anaesthetist and physician to assess and discuss any anaesthetic or medical issues. This helps with education and also makes the surgery safer.
On the day of surgery you will be advised to remain hydrated continuing clear fluids until 2 hours before the procedure. Most patients will have a spinal anaesthetic and light sedation, supplemented by a muscle sparing nerve block as well as infiltration of local anaesthetic and medicine to reduce inflammation around the knee. Tourniquet use is minimised and drains are avoided. Patients should wake up with no pain. Oral pain relief is commenced early, with minimal opioids to reduce nausea and sedation. After a few hours the spinal anaesthetic wears off and patients are assisted to walk, with the aim of walking twenty metres using a frame on the day of surgery. This helps prevent the joint becoming stiff and sore. Pain is usually manageable with oral pain relief and is often less than patients had before the surgery. Strong narcotics are not usually required.
Using this approach most patients choose to spend only one to three nights in hospital and are able return to independence and activity more quickly. This can of course be adjusted based on a patient’s individual circumstances and recovery. There will always be some individual variation.
An example of what can be achieved is shown in this video:
Many other factors contribute to the success of enhanced recovery pathways. Every member of the team is involved including the patient, family, surgeon, anaesthetist, physician, physiotherapist, nurses and admin staff. We have carefully evaluated every aspect of the patient journey from the time of booking until full recovery to provide the best patient care and experience. A full list of these factors is detailed below.
If you would like to discuss knee replacement surgery with Dr Bauze then send us an email using the form on this page or call 81301259
For more information on knee replacement surgery click here
ENHANCED RECOVERY KNEE REPLACEMENT SURGERY PATHWAY
Education Before Surgery
- Dr Bauze will explain the process and discuss your expectations
- Anaesthetist will discuss the recommended anaesthetic and pain relief options
- Nurse led education session is offered
- Dr Bauze’s personal assistant will be a single point of contact to help with all the administrative details, investigations and appointments
Medical Optimisation
- Physician assessment to identify and manage any medical issues before surgery and provide ongoing care in hospital after surgery
- Key factors in reducing complications are ceasing smoking (every day counts), moderating alcohol intake and correction of anaemia
- Antibiotic nasal ointment will be provided and should be used twice daily for the 5 days before the day of surgery to reduce infection risk
- 2 Antiseptic sponges are been provided for you to use, one the night before and the other the morning of surgery. Wash the operative site first, then the remainder of the limb followed by the rest of your body, then rinse off
- Cease aspirin, anti-inflammatories, herbal supplements and any specific other medications as directed by your surgeon, physician or anaesthetist
Admission Day
- Admission time to be confirmed the business day before surgery
- Take regular medications unless advised otherwise by physician or anaesthetist
- Present to the hospital reception desk on admission
- Bring ring the following:
- Relevant X-Rays
- Your medications in their original packages not in dosettes
- Loose fitting daytime clothing, sleepwear, flat footwear and toiletries
- Cease solid food (including milk/custard/yoghurt) 6 hours before surgery time
- Keep drinking clear fluids up until 2 hours before the scheduled surgery time to remain hydrated
Anaesthetic
- Usually this will be a single injection spinal anaesthetic with some sedation so you sleep lightly through the surgery. This means you should wake up with no pain.
- A muscle sparing nerve block and infiltration of local anaesthetic and anti-inflammatory around the knee to further reduce pain
- Medications are given to prevent nausea and vomiting.
- Medication to reduce bleeding
Surgery
- Takes approximately one and a half hours.
- Drains are not used routinely but may occasionally be required.
- Tourniquet use is minimized to reduce pain
- Dr Bauze will discuss his recommended techniques with you before the surgery.
After Surgery
- Approximately one hour in recovery before returning to ward
- Early oral intake especially fluid is encouraged
- A few hours after surgery when the spinal anaesthetic has worn off you will be assisted to get out of bed and walk. The aim is to walk twenty metres, get to the toilet with minimal assistance and sit out of bed for meals.
Pain Relief
- The key to early walking and recovery is good multimodal pain management.
- Minimal use of opiates
- Regular paracetamol and anti-inflammatory medication
- Oral mid strength pain relief for moderate pain
- If you do experience severe pain then stronger painkillers are available but these are often not required
- The aim is for any pain to be manageable and allow early walking and independence
Deep Vein Thrombosis Prevention
- Early mobilization the same day
- Injection of medication to thin the blood while in hospital
- Compression stockings for 6 weeks
- Aspirin 300mg daily after discharge for 6 weeks is standard unless otherwise directed
Discharge From Hospital
- Planning for this will start before admission to hospital
- If you live alone you will be able to go home safely when you can walk 20m, get dressed and go to the toilet independently. If you have someone who can help at home then you may go home when you can do these things with minimal assistance.
- Most people can expect this to be possible from one to three days after surgery.
- Some patients may require longer in hospital or some time in rehabilitation and this can be arranged if needed.
- You may resume driving once you can perform an "emergency stop" and are no longer taking regular strong analgesia. For most patients this is 4 to 6 weeks after a right leg hip or knee replacement.
- Maintaining good oral health is recommended. Many surgeons advise avoiding routine dental procedures for three months after having a hip or knee replacement and to have antibiotics if a higher risk dental procedure is required.
After Discharge
- Depending on your needs, where you live, when you go home and your health fund a home visit from a nurse and physiotherapist may be arranged
- 24-hour phone support is available and if you experience any problems, we encourage you to contact us so that we can assist.
- An early appointment one to two weeks after surgery will be arranged with Dr Bauze to assess wound healing and provide any further advice, prescriptions and treatment.
- Ongoing physiotherapy is recommended and can be arranged for the same time
- Dr Bauze will see you again at 6 weeks by which stage most patients have fully recovered, and provide ongoing follow up as needed.
Reference:
- Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020 Feb;91(1):3-19.
