Inside Britain's biggest orthopaedic centre: Epsom Guardian observes knee operation at Epsom Hospital's EOC
To mark the tenth anniversary of the acclaimed South-West London Elective Orthopaedic Centre (EOC), based at Epsom Hospital, I had the rare privilege of being invited to spend an afternoon in one of its operating theatres observing a knee replacement operation.
As one of the fortunate few never to have been inside an operating theatre as a patient, let alone as an observer, I had a few worries beforehand.
Will there be lots of blood everywhere, what will it smell like, will it be stressful, will I have to rush out because being I can't stomach seeing the inside of another human being?
Arriving at the EOC in the afternoon, I met with the surgeon who would be carrying out the operation, Philip Mitchell, a consultant orthopaedic surgeon at St George’s Hospital, in Tooting, and director of surgery at the EOC, who carried out the centre's very first operation a decade ago.
Philip Mitchell, director of surgery at the EOC, speaking to Epsom Guardian reporter Hardeep Matharu
Chatting informally to me barefoot and in scrubs, he reasssured me that this was not going to be a stressful afternoon - either for the experienced staff involved, or for me.
He explained that the two-hour operation was necessary as the patient, a 55-year-old man from Wandsworth, was experiencing problems with a partial replacement which had been done previously. This time round, a whole replacement knee was to be fitted.
This would involve removing the existing metal implant, cutting away some of the bone to create a flat surface above and below the knee joint for two metal implants, with a plastic top fitted to the lower one.
Amazingly, Mr Mitchell knew he wanted to be an orthopaedic surgeon at the age of four. Born to working-class and non-medical parents, his secondary school had never sent anyone to study medicine at university.
But after winning a place at Epsom College’s sixth form, he took his A Levels and went on to train at St Mary’s Hospital Medical School in London, qualifying in 1991.
Insistent that my article should not be about him, Mr Mitchell spoke passionately about the work at the EOC.
He said: "This is the most efficient unit in the NHS. Our volume of work is bigger than anywhere else in the NHS. We are very well benchmarked against others in the country as it’s a very high-quality service.
"The teams at the EOC are like a family and there is consistency in expertise so we can make the procedure the same each time."
Mr Mitchell said advances in anaesthetic procedures have really made a difference to orthopaedic surgery in the last 15 years as it helps speed up a patient’s recovery time.
So instead of spending the two weeks in hospital of 20 years ago, patients are now ready to go home within four days.
A clever cocktail of anaesthetics means patients are in much less pain when they come round and are therefore more likely to start using the joint more quickly - which is good for both their peace of mind and their physical recovery.
"Fifteen years ago, you walked into the recovery ward and everyone would be screaming. It was like a torture chamber. The patients would be in terrible pain from the moment the anaesthetic wore off," Mr Mitchell said.
"The surgical technology is also more advanced now - the instruments used can be more accurate, and the implants have changed. The manufacture of them is more sophisticated and the plastic is more likely to last."
Mr Mitchell said the approach to joint replacement is now about "incremental change", rather than any all-in-one, ‘quick fix’ solutions which have proven unsuccessful in the field in the past. Knee replacements now last between 15 and 20 years.
The surgeon reassured me that today’s operation would be a fairly blood-less affair as a tourniquet around the patient’s thigh would prevent blood flowing into his leg for two hours - the longest time the human leg can go without it.
I popped in and said hello to the patient, who seemed calm and relaxed as he had been operated on by the same team at the EOC before, and then changed into scrubs.
Epsom Guardian reporter Hardeep Matharu ready in scrubs
Adding the finishing touches of a surgical hat and mask, I entered the operating room and met the team.
The patient was anaesthetised and surgical drapes were placed over his body, covering everything except the knee to be operated on.
Anaesthetic was injected into the base of the spine, targeting it at the lower part of the body, with further injections into the knee itself.
Mr Mitchell and his assistants wore protective body suits and head masks and conducted the operation within a yellow square in the centre of the room, free from germs and bacteria.
Only the surgeon, his assistants and a surgical nurse were allowed inside this area during the procedure.
With Moby playing in the background, the atmosphere in the room - chilly to ensure a hygienic environment - was calm and relaxed throughout.
Once the incision had been made and the skin on the patient’s knee came apart, the existing metal implant could be seen glistening - much like a gold tooth inside a mouth of pearly whites, I thought.
I stayed for the entire two hours and sat fascinated, marvelling at the resilience of the human body and the skill of the surgical team who hammered, sawed and drilled at various points during the operation.
The knee replacement took two hours for Mr Mitchell to complete
It is extremely precise work, orthopaedics. The angles and mechanics of the joint have to be just right. There are no second chances. Mr Mitchell’s face was a picture of complete concentration throughout. It was clear that he loves the craft of his work.
At the end of the operation, he sat down with me for a de-brief.
"It went very well - I stuck to my Plan A. You always have a Plan A, B and C," he said.
I asked him if he still found the procedure mentally stimulating work, given the number of times he has performed it.
Mr Mitchell said: "It is stimulating The day you stop finding it stimulating is the day you need to start worrying."
Speaking about why the EOC has been such a success for a decade, he said said efficiency was at the core of its mantra.
He said: "The patients are very privileged to get this level of service. It is a very relaxing environment and everyone pulls together as a team. The people who work here have a reputation.
"It is the biggest unit in the NHS in terms of volume - we see 3,200 patients a year.
"We get economies of scale - we buy so much that we can get it cheaper. We are financially attractive to the Government as we actually make a profit.
"We are one of the few units which does everything to a very, very high standard and still makes a profit."
Mr Mitchell said that it is not only the pooling of expertise from across South West London which is an advantage, but also the ease and efficacy of conducting all orthopaedic surgery together in one location.
Prior to the operation, patients are kept in a ward which is very close to the operating theatre and are then transported to a recovery ward close by afterwards.
"It was set up to do this. It was designed with the patient in mind," Mr Mitchell said.
"We don’t cherry-pick cases either."
Mr Mitchell said that the EOC has its own corporate identity, which comes with a familiarity and stability in terms of its work and staff.
"From a clinical point of view, this is not Epsom Hospital. The EOC has its own identity. So if there are a lack of beds in Epsom, it doesn’t spill over into here.
"We are constantly monitoring how well we are doing," he said.
Mr Mitchell said that a surgeon has to be consistent in their surgical technique, while always be willing to assess how well they are doing.
Mr Mitchell used saws, drills and hammers to perform the operation
The surgeon said: "You learn all the time. You have to have a personal desire to keep learning and there is a statutory requirement to prove that you are doing continued professional development.
"The EOC should be supported. The way healthcare is going, the busy acute hospitals are less able to run elective services.
"The landscape is changing. St George’s will become a level one trauma centre.
"It’s a very busy, very acute hospital and will be looking to provide elective surgery in a different way."
During the operation, Mr Mitchell said how difficult it was to read so many negative news reports about the NHS and its staff.
"We come in here, work hard each day and love what we do, so it is difficult."
The EOC is operated by Epsom and St Helier hospitals, in conjunction with St George’s, Croydon and Kingston hospitals.
Since opening in 2004, the EOC has grown to become the largest hip and knee replacement centre in the UK and one of the largest in Europe.
It conducts 95 per cent of the area’s spine, foot, ankle, hip, knee and shoulder work.
It has 65 beds and four state-of-the-art orthopaedic operating theatres.
In the last year, it performed more than 3,000 hip and knee replacements - more than any other hospital in the UK; had no incidents of MRSA cross-contamination; and achieved fifth place in the Healthcare 100 list, which is compiled by the Health Service Journal and Nursing Times.
The centre treats patients from the boroughs of Wandsworth, Merton, Sutton, Kingston, Richmond, and Epsom.