Introduction to case study

Scenario

Giani is now 68 years old and has been a dancer and professional performer for 25 years. Over the last 10 years, he has had several injuries and has been experiencing increasing arthritic pain in his left knee. After multiple visits to his GP for ongoing treatment and monitoring, as well as regular acupuncture and massage, the pain has become unbearable. As a result, 2 years ago he was referred to an orthopaedic surgeon, Dr Kim, who placed him on a waiting list for knee surgery. The pain was beginning to affect his fitness and activity levels as well as his mental health. The doctor said that if knee pain is preventing him from undertaking adequate regular exercise, then the benefit of total knee replacement (TKR) is substantially increased. Furthermore, the procedure would prevent him from being in a high-risk group. Giani and Jay both know how dangerous it is to be immobile and neither wants a sedentary lifestyle.

Prior to admission, Dr Kim took a medical history and blood tests to gather information about Giani’s general health and the extent of his knee pain and ability to function. He undertook a physical examination to assess the range of motion in Giani’s knee, as well as stability, strength, and overall leg alignment. Giani also had x-rays and a magnetic resonance imaging (MRI) scan to determine the extent of damage and deformity in his knee. Jay and Giani had to drive one hour to Lismore or Tweed Heads for most of these appointments.

Giani and Jay talked to some of their friends who had had this operation. They wanted to learn about what was involved the procedure, the pros and cons and risks. Their friend Murphy told them how he had a rapid reduction in swelling in the knee about 6-8 weeks post-op but needed to have quite a lot of rehab to work on his strength and bending. Their friend Carla had swelling in her knee for nearly 6 months, which improved with ice and elevation at the end of the day, and was able to get back into swimming 6 weeks post-op. At 12 weeks Carla added in bicycle riding around town and found that was an excellent way for her to build mobility and range of movement in her knee. Ted, Jay’s brother-in-law, said it was the best thing he had ever done, after his knee was hurt during a motorcycle accident; now he is driving, walking, swimming, and playing golf again, all within 3 months of the operation. He had his knee replaced 15 years ago and will probably be looking at another replacement in the next few years. The average replacement lasts 10-20 years, and Ted is hopeful he will be a candidate for the minimally invasive procedure next time.

After considering all the positives and negatives of the procedure, Giani decides to proceed with the surgery. He is worried about the recovery and the scarring, but ultimately, he and Jay want Giani to return to his previously levels of mobility. Monty loves to dance! Giani and his surgeon discuss using a minimally invasive technique, which allows for a shorter incision, hopefully less pain during his recovery and a speedier recovery overall. Given Giani is fit, younger in terms of knee replacements, and very willing to complete an extensive rehabilitation regime, his surgeon feels he is a good candidate for the minimally invasive procedure. They are aware, as always, of the risk of blood clots, bleeding and infection, but hope that Giani should have an uneventful recovery.

Giani is admitted to the hospital on the day of his surgery. The nurse greets him and goes through the admission process, saying ’you will be soon seen by a member of the anaesthetics team. After surgery, you will wake up in the recovery room, where you may remain for several hours. After you properly wake up, you will be moved to your hospital room’. Giani’s TKR is performed and the surgery takes 1.5 hours. After surgery, he is monitored in recovery for 3 hours until the effects of the anaesthesia wear off. He is transferred to the ward, visited by the surgeon and told that all went smoothly. If all continues to go well, he will stay in the hospital for 2 nights.

Giani has a nerve block in place on return to the ward, which leaves the area feeling numb to start with. He is told about his patient-controlled analgesia (PCA) to help with pain after the block wears off. He is also told he has had a peri-articular injection (PAI) of local anaesthesia that will control much of his pain post-op. The PCA allows Giani to control his pain relief, with regular paracetamol and anti-inflammatory medications to augment it.

Giani’s postoperative orders stated:

• Complete vital signs every 30 minutes for 2 hours, then hourly while the PCA was in situ, then per pathway.
• Provide oxygen via nasal prongs to keep SpO2 > 95%. Encourage deep breathing and coughing, and use of triflow.
• Assess foot for temperature, pulse, capillary refill, movement, swelling and pain.
• Encourage ankle pumps and static contractions as able with pain relief.
• Monitor drainage from site and output into drains – document same.
• Indwelling catheter in situ for 24 hours, remove once mobile, and commence trial of void – monitor output on fluid balance chart.
• Physiotherapy to commence on day one with mobilisation to chair and to shower.
• Start ice on knee day one.
• Patient controlled analgesia (PCA) in situ with morphine for 24 hours. Monitor use and supplement with regular paracetamol and anti-inflammatories.
• DVT prophylaxis and regular IV antibiotics as charted.
• X-ray of knee for alignment 24 hours postoperative.
• Haemoglobin and clotting levels check day one.

Giani’s initial recovery is uneventful. He finds the PCA and regular oral analgesia are adequate to control his pain. He has TED (thrombo-embolus deterrent) stockings on his legs to help avoid clotting. He has inflatable sleeves called sequential compression devices (SCDs), that intermittently compress his legs to help move the blood out of the calves. Giani’s wound is closed with staples on the surface and covered with a waterproof dressing. He has a small bellovac drain in his knee that drains blood and other fluids from the surgical site.

Giani’s PCA is stopped and removed 24 hours after the procedure and Giani commences oral analgesia. He requires some opioid medications (codeine) for a week, as well paracetamol and anti-inflammatories to minimise pain before physio and sleep. Giani experiences some nausea with his oral analgesia. His medical team reassures him it is common for people to experience some nausea and loss of appetite several weeks after surgery and give him an antiemetic medication to help. The nursing team explain that a balanced diet with protein is important to help wound healing and restore muscle strength and that regular small meals can help with the nausea.

Giani starts his physiotherapy exercises within the first 24 hours to help develop movement and function. The physio team help him learn exercises to do several times a day to improve mobility and strengthen the knee. A graduated walking program slowly increases his mobility.

After the drain is removed on day one of Giani’s recovery, he has an x-ray of his knee to check the alignment of the joint and ensure it is straight.

The physiotherapist and occupational therapist meet with Giani again on day 2 of his recovery. They discuss his plans for discharge home and his care in the community. They make suggestions for home modifications including safety rails in the shower, handrails on the stairs, stable chairs for resting and securing all loose carpets and surfaces.

Giani is discharged home, where Jay will care for him, 72 hours after his procedure.

Key information and links to other resources

 Case study 1 summary

After 5 months Giani is walking daily and able to climb stairs without any pain or stiffness. He hopes to be back on stage soon, doing his weekly drag bingo as Monty Carlo.

Giani and Jay are extremely happy with the outcome. They have returned to volunteering at the local youth centre and attended Mardi Gras.