Day knee surgery could become the norm for healthy patients

A surgical team at Barlborough NHS Treatment Centre is offering day surgery knee replacements to patients, who otherwise are healthy, after spending months researching techniques and interviewing experts in America.

Medical director and consultant anaesthetist Marco La Malfa and lead orthopaedic surgeon Gyorgy Lovasz have followed the work of teams in America, who perfected a technique that allows patients up on their feet quickly after surgery and go home the same day. The two highly experienced international clinicians attended conferences and talked to experts in the States to gain first-hand experience of the techniques.

They perfected the technique and launched a regular programme of one-day hip replacements. More than 20 one-day hip replacements have been carried out so far with excellent results and very high levels of patient satisfaction.

Mr Lovasz explained: “Quick mobilization after joint replacement and safely limiting time in hospital has a number of patient benefits. The risk of developing potentially fatal deep vein thrombosis is radically reduced by having the patient mobile quickly and the risk of hospital-acquired infection is also dramatically reduced. Patient satisfaction is greater and recovery is quicker in their home environment.”

Mr La Malfa said: “Whilst much of the operation remains the same, there are significant changes in the anaesthetic used. For some time, we have been using an enhanced pathway that sees us using a spinal aesthetic, rather than the traditional general anaesthetic: the patient is awake and/or slightly sedated, but pain-free. The patient then begins work with a physiotherapist within hours of returning to the ward.

“The knee surgery is a progression from the hip surgery, as pain control with knees is more complex than with the larger hip joint.

“This technique has enabled us to reduce the average stay for a knee replacement from average four days in 2014 to an average of 2.3 days in 2017. The new pathway uses the same spinal anaesthesia this time with a short acting local anaesthetic drug, but no opiate-based drugs are used, meaning that while the operation is totally pain-free, the patient is able to get up and working with our physiotherapy team very quickly after returning to the ward.”

The team say the key is planning, as well as choosing the right patients to go through the day surgery process. Mr Lovasz said: “Age is not a critical factor when selecting suitable patients. What is important is that their general health is good, have proper family support and are motivated to work at their recovery.”

The decision to select patients for the list takes place at the pre-operative assessment. If selected, the patients are included within the day case knee pathway. If for any reason on the day of surgery they will be not ready for discharge on the same day, they will always be given the option of following the normal in-patient pathway. Those patients who are suitable are given the equipment they need to take home after the assessment. This can include a raised toilet set, toilet frame and chair raisers. Patients will also be taught how to use crutches, a skill which is tricky to master.

Post-surgery, they will return home accompanied by a relative or friend, who will have to stay with them. Marco said: “The people who are suitable for surgery must live relatively close to the centre, as long car journeys are not advisable, and they must have someone at home to support them.

“A nurse calls the patient the next morning to see how they slept and to discuss pain control. Patients also have a 24/7 helpline number that goes directly onto the ward, giving them instant access to medical support.”

Hospital director Steve Booker said: “This is a fantastic development that has come about from exhaustive research and preparation to ensure patient safety and comfort. All the surgeries went smoothly, with outcome similar or better to overnight cases and the satisfaction levels for patients was very high.”

“It supports the NHS in delivering surgery to more people and it supports patients by taking them away from the excruciating pain caused by joint degeneration and back to their families and pain-free futures.”