Practice A Patient’s Journey

Two hip replacements

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1502 (Published 29 April 2010) Cite this as: BMJ 2010;340:c1502
  1. Pat Tomlinson, patient1,
  2. Geoffrey J Stranks, trauma and orthopaedic consultant2
  1. 126 Church Lane, Holybourne, Alton GU34 4HD
  2. 2Basingstoke and North Hampshire Hospital, Basingstoke RG24 9NA
  1. Correspondence to: Pat Tomlinson pat{at}jptomlinson.com
  • Accepted 19 February 2010

A retired general practitioner had hip replacements in 1997 and 2009. Here she describes the improvements made in surgical techniques and case management between her two operations

In 2009 I had a left hip replacement, having had a new right hip in 1997. Both operations took place in the same hospital and were carried out by different surgeons, and both have been very successful.

I have nothing but praise for the surgeons and staff who cared for me on both occasions. However, the 12 years between the operations saw substantial improvements in surgical techniques and postoperative case management, making the second operation a much more pleasant experience. This was partly because the orthopaedic technique had been improved and refined and is now less invasive and so reduces damage to the surrounding muscles. After the first operation it was more than a week before I could raise the operated leg from the bed, whereas in 2009 I could do so on the same day as the operation. For the second operation I had a spinal anaesthetic, which made the immediate pain control and recovery much better.

However, the most important difference was that in 2009 the preparation and recovery of hip replacement patients were in the hands of a multidisciplinary team of specialist orthopaedic nurses, physiotherapists, and occupational therapists, rather than only in the hands of the surgeon. Specialist orthopaedic nurses had initiated the team approach, and the consultant surgeons had agreed to such delegation and compromised on a uniform policy of postoperative management. The team members shared their different expertise to achieve a united aim of quality of care and rapid recovery for patients.

The team approach

After the first consultation with the surgeon I attended a “hip school” with several other patients. It lasted about an hour, and one of the hip team members explained what to expect when coming in to hospital. We were shown x ray films of damaged hips and were able to handle examples of the different types of hip prosthesis. We were each measured for crutches and a stick and shown how to use them. We were able to borrow the crutches and sticks from the hospital, returning them postoperatively when the team deemed they were no longer needed. They also lent each of us a DVD demonstrating advised exercises for before and after the operation. The same information was provided in booklet form, along with an invaluable list of “dos” and “don’ts” for after the operation. My fellow patients and I found the knowledge offered by the hip school empowering. It raised our morale and confidence and increased our determination to cooperate with each other and with the team.

The road to recovery

After the operation we were all treated in the same way by the hip team, with confidence, encouragement, and infectious enthusiasm. The different consultants’ consistency in management and treatment meant that the patients did not make comparisons or feel that their treatment had been poorer than that of other patients. Every patient was encouraged to become mobile immediately. If all went well, as it did in my case, we were ready to go home in two to three days, able to walk safely with crutches, manage stairs, and get into a car. We could contact the hip team by phone if we had any problems—it is usually impossible to talk to the surgeon, unless you are a private patient. Knowing that I could phone someone who knew me and my progress in hospital was important to me. I developed an unexpected symptom from my new hip, but this was recognised by the physiotherapist I spoke to, and I was reassured and advised which exercises to concentrate on.

After two weeks and again at six weeks postoperatively, each patient was seen in the hip clinic by the team. All team members were able to assess the recovery process. They emphasised the importance of various exercises to strengthen the appropriate muscles and increase joint stability, and advised avoidance of certain positions and movements to prevent loosening or dislocation of the new hip. I found this very helpful. It increased my confidence and encouraged me to persevere with boring exercises to improve my rate of recovery.

In comparison with the ease of this rapid recovery programme, memories of my first hip replacement were of immobility and pain. I stayed in bed for three days, initially with an indwelling catheter, using patient controlled analgesics intravenously, and went home after a week. The immobile operated leg caused painful heels and miserable nights. When a nurse unexpectedly got me out of bed to stand, to my surprise this caused me great anxiety and distress. This, together with my difficulty in negotiating crutches, left me feeling utterly humiliated.

The multidisciplinary team approach undoubtedly brings great benefit to patients, to the atmosphere on the ward, and to the working satisfaction of the team members. By specialising in joint replacement recovery, they gain considerable personal experience, provide continuity of care, and give authoritative advice. For surgeons to agree to a uniform policy and to allow the follow-up care of their patients to be delegated to the hip team calls for both courage and generosity. It was quite obvious to me as a patient that this is an effective way of working, satisfying to staff, and highly beneficial to patients. I wonder why this method of postoperative case management is not used by all orthopaedic units, and the development of similar systems might be possible for other procedures too.

A doctor’s perspective

Osteoarthritis of the hip is a common problem, and its symptoms and signs are well known. Groin and thigh pain and stiffness lead to reduced mobility, night pain, loss of function, and reliance on analgesia. Joint replacement is one of the medical triumphs of the past 50 years. According to the National Joint Registry, more than 75 000 primary hip replacements were undertaken in the UK in 2008-9.

Over the years, patients’ expectations have increased. They want to return to all their pre-arthritis activities, which has led to advances in prosthetic materials, different methods of fixation, and different bearing surfaces. Orthopaedic surgeons have tended to concentrate research on prosthetic longevity, avoiding infection and dislocation. What has been forgotten perhaps in all this technology is that patients are people with needs and concerns.

The National Audit Office reported in 2000 that the average length of stay after a hip replacement was 11 days. Such stays were not financially sustainable and have had to be reduced. But today, people tend to live more independently, often alone with no close family support, which makes it more difficult to find help after the operation. Rapid discharge from hospital without support risks an increase in complications and leads to poor patient satisfaction.

When Pat Tomlinson had her first hip replacement in 1997, little was discussed before the operation, and the arrangements for discharge—aftercare and help with crutches, for example—were made postoperatively. Trying to make such arrangements immediately after surgery when patients were in pain was unsatisfactory. Patients were often confused about what they should do.

We realised that a multidisciplinary team approach was needed. The cooperation of all consultant orthopaedic surgeons was needed—no mean feat. Lack of money was a problem, but by transferring the resources that we used postoperatively to preoperative care, we incurred no extra costs.

We felt that patient education was essential, so we wrote information booklets, created a website, and raised funds to produce “A Patient’s Story”, a professionally made DVD, which also showed the exercises they needed.

All this information is given to patients in the clinic when they are placed on the waiting list. At the preassessment clinic their discharge is organised, involving the occupational therapy department, social services, friends, and family.

Patients attend a “hip school” run by trained nurses and physiotherapists who work closely with the wards and other teams. The school reinforces what patients need to know and acts as a point of contact after discharge. Somebody is always available to help with any concerns or problems. Follow-up occurs at the school after two and six weeks. No formal physiotherapy takes place; patients are expected to do their own exercises, but the hip school does provide long term follow-up.

Everybody has helped to make our rapid recovery programme a success. We have notably reduced the length of hospital stays and the number of complications at almost no extra cost, and importantly, as Pat Tomlinson describes, we have greatly improved the patients’ experience.

Geoffrey Stranks, trauma and orthopaedic consultant, gjswork{at}googlemail.com

Useful resources

  • Rapid Recovery Hip Replacement Programme (www.hampshire-hip.co.uk)—A video guide to rapid recovery after the operation, provided by Basingstoke and North Hampshire NHS Foundation Trust

  • The British Orthopaedic Association (www.boa.ac.uk/en/patient-liaison/elderlyhip)—Guidance for elderly patients with hip fractures

  • National Joint Registry (www.njrcentre.org.uk)—Information on hip and knee replacement operations

  • British Hip Society (www.britishhipsociety.com)—Homepage of the British Hip Society, including a link to download the BHS Hip Replacement Booklet - A Guide For Patients

Notes

Cite this as: BMJ 2010;340:c1502

Footnotes

  • This is one of a series of occasional articles by patients about their experiences that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley (plapsley{at}bmj.com) for guidance.

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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