What Happens on the Day — An Hour-by-Hour Guide

Part of The Joint Replacement Guide — Phase 4: The Operation · Article 28 of 44 · Hip & Knee

Key Points

  • Knowing the general sequence of events can reduce anxiety, although exact times vary considerably.
  • Your admission time is not necessarily the time of your operation, and waiting is a normal part of the day.
  • Several team members will repeat important questions. This deliberate repetition forms part of the safety process.
  • Most patients are encouraged to drink, eat and begin moving as soon as it is safe.
  • Many patients stand or walk on the day of surgery, but waiting until the following day can also be appropriate.
  • Instructions from your own hospital take priority over this general guide.

Before You Leave Home

Your hospital should provide individual instructions covering:

  • when to stop eating;
  • which fluids you may drink and until what time;
  • which regular medicines to take or omit;
  • when and where to arrive;
  • what to bring; and
  • whether you are expected to go home on the same day or stay overnight.

Follow these instructions precisely. Do not apply a fasting timetable found online or given to another patient, because instructions can differ according to the anaesthetic, medical conditions and hospital protocol.

In particular, medicines used for diabetes or to reduce blood clotting may require an individual plan. Do not stop or change them unless your clinical team has instructed you to do so.

Bring an up-to-date list of your medicines and doses. If you accidentally eat, drink or take a medicine outside the instructions, tell the team honestly. This does not always mean the operation must be cancelled, but the anaesthetist needs accurate information to make a safe decision.[1]

Arrival: Approximately the First Hour

You will usually check in at a surgical admissions area, day unit or ward. An admission time is chosen to allow the necessary preparation and does not necessarily show where you are on the operating list.

A nurse or healthcare assistant will usually:

  • confirm your identity and contact details;
  • check your blood pressure, pulse, temperature and oxygen level;
  • confirm when you last ate and drank;
  • review medicines and allergies;
  • check that preoperative tests have been completed;
  • ask about any change in your health;
  • help you change into appropriate clothing; and
  • apply any measures required by the hospital’s pathway.

You may have an identification wristband applied and a small intravenous cannula placed in a vein. Further blood tests are sometimes required, but they are not necessary for every patient.

Tell the team if you have recently developed a cough, fever, skin problem, dental infection, urinary symptoms, vomiting or another significant change in health.

Meeting the Surgical Team

Before the operation, the surgeon or an appropriate member of the surgical team will confirm:

  • which joint is being replaced;
  • which side is being operated on;
  • the planned procedure;
  • that the consent process has been completed;
  • whether anything has changed since your previous assessment; and
  • whether you have any final questions.

The correct limb will ordinarily be marked while you are awake. You may be asked to identify the operation and side yourself. This is a deliberate safety check, not evidence that the team has forgotten.

Consent should be an ongoing process rather than a signature obtained without discussion. You remain entitled to ask questions and may withdraw consent before the operation if you no longer wish to proceed.

Meeting the Anaesthetist

Your anaesthetist will review your health, medications, previous anaesthetic experiences and the results of relevant tests.

They will discuss the proposed anaesthetic, which may include:

  • spinal anaesthesia;
  • general anaesthesia;
  • sedation;
  • local anaesthetic infiltration;
  • a nerve block; or
  • a combination of techniques.

The final plan may differ from an earlier provisional plan if new information emerges or if the anaesthetist considers another option safer. If you have a spinal anaesthetic, you may remain awake or receive sedation so that you are relaxed and drowsy.

The anaesthetist will also discuss pain relief, sickness prevention and any individual monitoring requirements.

Waiting for Theatre

There may be a wait after the checks are complete. Operating lists are arranged according to several clinical and practical considerations rather than simply admission order.

Timing can change because:

  • an earlier operation takes longer than expected;
  • an emergency requires priority;
  • further tests or equipment are needed;
  • a bed or recovery space is temporarily unavailable; or
  • your own team needs additional time to make the operation safe.

Staff should keep you informed, but exact predictions are not always possible. A delay does not necessarily mean that there is a problem with your operation.

Going to Theatre

When theatre is ready, you will be taken to the operating department by walking, on a trolley or in a wheelchair, depending on hospital policy and your mobility.

Further identity and safety checks will occur. Repeated questions about your name, date of birth, allergies, operation and surgical side are intentional safeguards.

The WHO Surgical Safety Checklist has three principal stages:

  1. Sign in before anaesthesia;
  2. Time out before the operation begins; and
  3. Sign out before leaving the operating theatre.[2]

The team confirms matters including identity, consent, surgical site, allergies, anticipated difficulties, antibiotic administration and equipment requirements. At sign out, matters such as instrument counts, specimens and the postoperative plan are checked.

Anaesthetic Preparation: Often 20–45 Minutes

The time required varies. Monitoring equipment will be attached, usually including:

  • a blood-pressure cuff;
  • heart-monitoring stickers; and
  • an oxygen sensor on a finger.

The anaesthetic team may insert or use an intravenous cannula and administer fluids and medicines.

A spinal anaesthetic or nerve block requires positioning, preparation and time to confirm that it is working. If you receive a general anaesthetic, you will be unconscious and continuously monitored throughout.

Anaesthetic preparation is part of your total theatre time but is separate from the duration of the operation itself.

The Operation: Commonly Around One to Two Hours

A straightforward primary hip or knee replacement commonly takes approximately one to two hours. This is only a general estimate.

The operation may take longer because of:

  • unusual anatomy;
  • substantial deformity or stiffness;
  • previous surgery or retained metalwork;
  • poor bone quality;
  • the need for additional reconstruction;
  • difficulties obtaining appropriate stability; or
  • other unexpected findings.

A longer operation does not necessarily indicate that something has gone wrong. It may mean that the team is taking the additional time required to manage the findings safely.

Your total time away from the ward will be longer because it includes transfer, anaesthesia, positioning, safety checks and recovery.

Recovery Room: Commonly One to Several Hours

After the operation, you will usually be transferred to a post-anaesthetic recovery area. A recovery nurse will monitor:

  • breathing and oxygen levels;
  • blood pressure and pulse;
  • alertness;
  • pain and nausea;
  • the wound and dressing;
  • circulation and movement in the operated leg; and
  • recovery from spinal or regional anaesthesia.

You may receive oxygen, intravenous fluids, anti-sickness treatment or additional pain relief.

Pain after joint replacement is expected. The objective is to make it sufficiently controlled for rest, breathing, drinking and safe movement—not necessarily to remove every sensation of pain.

Tell the recovery team if you feel pain, nausea, itching, dizziness, shortness of breath or anything else concerning. You will return to the ward or day-surgery area when the team is satisfied that it is safe.

Returning to the Ward

On return, the nursing team will continue monitoring you and review the wound, circulation and pain relief.

Depending on local practice and your recovery, you may:

  • begin drinking and eating;
  • receive regular pain medicines;
  • start blood-clot prevention;
  • perform ankle and breathing exercises;
  • have a postoperative X-ray;
  • change into your own clothes; and
  • prepare for the first mobilisation.

Not every patient requires a urinary catheter, surgical drain or immediate postoperative X-ray. Practices vary according to the operation, anaesthetic and hospital pathway.

If you have had a spinal anaesthetic, your legs may initially feel heavy, numb or weak. Staff will wait until movement, sensation and blood pressure have recovered sufficiently before attempting to stand.

Later the Same Day

Enhanced-recovery pathways encourage patients to drink, eat and move as soon as they are safely able.[3]

A nurse or physiotherapist may help you to:

  • sit upright;
  • move to the edge of the bed;
  • stand using an appropriate walking aid;
  • take a few supported steps; and
  • begin the exercises provided for your hip or knee.

You should not attempt the first mobilisation alone. Temporary dizziness, nausea, low blood pressure, pain or residual weakness from the anaesthetic can make assistance necessary.

Many patients stand or walk on the day of surgery. If your operation finishes late, the spinal anaesthetic has not worn off, or you are not yet clinically ready, mobilisation may take place the next morning. This is not a failure and does not by itself indicate a poorer recovery.

The Evening and Overnight

The team will continue to assess:

  • pain and nausea;
  • eating and drinking;
  • passing urine;
  • wound drainage;
  • blood pressure and oxygen levels;
  • circulation and nerve function in the leg; and
  • your ability to move safely.

Sleep may be interrupted by observations, medication and the unfamiliar ward environment. Some pain and swelling are expected, particularly as the anaesthetic and local pain relief begin to wear off.

Tell staff promptly if pain changes suddenly, the dressing becomes heavily soaked, you feel short of breath or unwell, or you notice new numbness or weakness.

Going Home the Same Day

Selected patients may go home on the day of surgery. This is based on meeting clinical and functional criteria, not on reaching a particular time.

Before discharge, the team will usually need to be satisfied that you:

  • are medically stable;
  • can eat or drink sufficiently;
  • have manageable pain and nausea;
  • can pass urine where required by local policy;
  • can mobilise safely with the advised walking aid;
  • can manage any necessary steps or stairs;
  • have appropriate medication and blood-clot prevention;
  • understand wound care and warning signs; and
  • have suitable support and transport.

Remaining in hospital overnight is not a setback. Discharge should occur when it is safe for the individual patient.

In More Depth

Early mobilisation is a central part of enhanced recovery. It helps limit the effects of prolonged bed rest and is associated with earlier achievement of functional discharge criteria and a shorter hospital stay.[3]

It works alongside—not instead of—other precautions such as appropriate blood-clot prevention, pain control, hydration and clinical monitoring. Standing once on the day of surgery does not remove the need for continued regular movement and the prescribed preventive treatment.

The safest principle is mobilisation as early as you are able, rather than mobilisation according to an inflexible clock. Your own hospital’s instructions and the judgement of the team caring for you should always take priority.

This article provides general information and does not replace individual clinical advice. Timings, fasting instructions, medication plans and discharge pathways vary, so follow the instructions provided by your own hospital.

References

  1. NHS. Having an operation: preparation and before surgery. NHS guidance.
  2. World Health Organization. WHO Surgical Safety Checklist and implementation resources. WHO safe-surgery resources.
  3. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery Society recommendations. Acta Orthop. 2020;91(1):3–19. doi: 10.1080/17453674.2019.1683790.
  4. ERAS Society. Orthopaedic enhanced-recovery guidance. ERAS Society orthopaedics.

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