It is now possible to do the vast majority of my operations arthroscopically, that is, with a minimally invasive “keyhole” approach. This means that the scarring is reduced, it is less painful and often actually gives me a better, well-lit & magnified view of what I am doing than by making a big cut in the skin. Obviously the most important thing is that the operation is done properly not that it is done through a small incision, but more and more, we are moving towards minimally invasive techniques.
The majority of operations are done as a “day case” procedure - that is you go home the same day. If it is a more major reconstruction or if you have significant medical problems, then you will be asked to come up for an assessment of your fitness for the anaesthetic. This sometimes means some blood tests, heart tracings and further x-rays. This is an attempt to make the operation as safe as we possibly can for you. There are always small risks to any operation, even quite a small one, and for planned surgery which is not done as an emergency, we need to get everything as safe as we possibly can before going ahead.
Almost all the operations are done under general anaesthetic. By this I mean you are “asleep”. The anaesthetist will talk to you about whether or not he will add a nerve block to this. The advantages of the nerve block are that it means you could have quite a light general anaesthetic with less “hang-over” after it from the powerful drugs, and also that the nerve block will make the area rather numb following the operation so that it is less uncomfortable. The disadvantages are that it does mean having an injection of local anaesthetic around the nerves and this can occasionally cause problems such as nerve irritation.
The complications you need to be aware of do depend on exactly what operation you are having, but the very small risks of infection and DVT as well as probems with the anaesthetic are common to all. I always tell patients that one of the risks of the operation is that it is not 100% effective. The success depends on a number of factors including how serious the injury is, and the post operative rehabilitation as well as the skill with which the operation is done. With some operations, there is a small risk to the nerves and vessels which run close to the operative site, and after operations like ACL reconstruction, patients aften have a patch of altered feeling over the front of the shin, which improves with time. If there is any significant risk of nerve injury during the operation then I will warn you explicitly.
One of the complications of any operation is deep venous thrombosis. This has been in the news in recent years because it is associated with long haul air travel. As the blood pools in the veins when you are immobile, particularly of the legs, it can stagnate and clot and this can give you a swollen, painful leg. The clot can also break off and travel along a vein into your chest and make you very ill indeed. It is for this reason that we usually insist that any oral contraceptive pill which contain oestrogen are stopped for at least a month before routine lower limb surgery. The pill is thought to increase the risk of DVT by about three times. You do not need to stop the progesterone-only pill. The other precaution we take against clots in the veins, is to get you up & about as quickly as possible. I usually do not use a tourniquet during most surgery in order to help minimise the pooling of the blood in the leg, and therefore the risk of DVT. There is a balance between the risks and benefits of thinning the blood with drugs as preventive treatment. Following joint replacement surgery, the risk of clots in the veins is quite high and my colleagues often recommend taking drugs to thin the blood for a period around the operation. My experience which is agrees exactly with nationally published guidelines from the British Association for Surgery of the Knee and the British Orthopaedic Association, is that the risk of clots in the veins following keyhole surgery (including ligament reconstruction) is so low that the risks actually outweigh the benefits of this kind of drug treatment. Unfortunately, this conflicts with the NICE guidelines published in April 2007 which recommend anticoagulation with drugs for “all inpatient orthopaedic surgery”. NICE does accept that their guidelines were NOT intended to apply to minimally invasive surgery, especially in fit young mobile patients. I therefore do not recommend routine pharmacological DVT prophylaxis for almost all of my patients.Relevant NICE guidelines are here (2010)
With any cut in the skin, even for keyhole surgery, there is a small risk of infection. All the operating theatres which I use have special “clean air” environments which reduces the risk of germs getting into the would and causing infection. Following routine keyhole surgery, the risk of joint infection is well under one in a thousand. If for any reason there is more risk of infection, such as if an implant is being inserted, then I give preventive routine antibiotic cover. Patients often ask about the “superbug” MRSA. This is not a significant problem for the sort of work I do in the environments in which I work, which are “over-engineered” for joint replacement work where the risks are much higher. For example, in Oswestry NO patient in any department acquired MRSA last year.
The Day of the Operation
You will come into hospital on the day of surgery and be seen by me as well as the anaesthetic doctor. Most surgery is done as a “day case” procedure – this means you don’t have to stay in hospital overnight. Depending on the size and nature of the operation, you may need to stay in hospital for up to a couple of days. If the operation involves something being repaired or stitched together, then the joint needs to be protected and rested while the repair heals, but if it is simply a matter of removing some torn or damaged tissue (for example cartilage), then we can get you going pretty quickly and get you back to full activities within a few weeks. The key hole incisions are usually too small to need stitches and they heal up very well without
This is individualised, but we do have some standard evidence-based protocols for the common procedures. We are adding these to the rehabilitation page on this site & are progressively publishing them via the Oswestry Institute of Orthopaedics site at: www.keele.ac.uk/depts/rjah/ - go to “Departments”, then “Physiotherapy”.
Driving after Surgery
The decision of when you are fit to drive after surgery is yours. You must be able to sit at the wheel of the car & “do an emergency stop” without any concern over whether your operated area will be hurt or damaged. If you cannot do this in simulation, then you cannot drive safely. This is regardless of whether you drive to the corner shop or long distance. Prolonged sitting & driving , moving from accelerator to clutch may make you sore & swollen, & delay your recovery. I suggest a few days after any general anaesthetic, but usually one to to weeks after knee arthroscopy - more like 3-4 weeks after ligament reconstruction
Travel after Surgery
I usually explain to patients that there are three separate issues with (especially air) travel after surgery:
1. Will you be able to get the treatment you need (the physiotherapy & rehabilitation is usually a very important part of recovery)?.
2. What if something goes wrong? Will you be somewhere “civilized” & will your insurance cover you, whether for a post operative complication such as infection, or if you are simply unlucky and fall, or have another injury?
3. Deep venous thrombosis & pulmonary embolism (“Venous thromboembolic disease”). There is a small risk of this with any operation even on the upper limb as there is with immobilisation & especially air travel. These risk add up. There is widely accepted advice not to travel longhaul (over 3 hours) for at least 3 months after joint replacement, the risks are MUCH lower in the relatively younger & fitter group of patients I usually see & the operations are shorter & less invasive.
The advice after more or less any operation is to hang around for 1-2 weeks, just to make sure the area is healing as expected. When travelling after that, it is worth doing the airline’s exercises to keep the blood flowing, keeping well hydrated (NO alcohol!), & walk up & down the aisle every half hour or so. There is a bit of evidence for DVT stockings & it may be worthwhile “turning left” for more legroom on the plane.