Total Knee Replacement

Patient Information

TABLE OF CONTENTS

allaboutarthritis.com - View actual surgical procedures and complete information about knee surgery and recovery

Introduction
  • Why replace your knee?
  • How is the surgery performed?
  • Life after surgery
Preparation For Surgery
  • Office visit
  • Medical clearance
  • Donating blood
  • Exercising before surgery
  • Financial considerations
  • Hospital orientation
  • Clothing
In The Hospital
  • Admission
  • Surgery
  • Recovery
After The Hospital
  • Living with your new knee
  • Office visits after surgery
Common Questions

Preoperative and Postoperative Exercises
INTRODUCTION  table of contents

This guide was prepared for our patients who are having knee replacement surgery. It is intended to give you an overview of the surgery, answer common questions and discuss important items you will need to be familiar with before and after surgery. Remember that every patient is different and you may have specific questions or concerns not covered in this guide. We will be happy to answer any questions that you may have.

WHY REPLACE YOUR KNEE?

The most common reason to replace a knee is arthritis resulting in pain, stiffness, deformity or instability which interferes with your lifestyle and is not controlled with simpler measures such as medication, using a cane, or less extensive surgery such as arthroscopy. A normal knee joint has smooth cartilage surfaces which glide across one another with almost no friction. In an arthritic knee the joint surfaces are rough and irregular causing pain as the uneven surfaces grind across each other. As the arthritis worsens, deterioration of the bone may occur causing deformity and stiffness. In a knee replacement operation, the rough surfaces are replaced with smooth, gliding components and the deformities and stiffness are corrected.






Figure 1: Diagram on the left depicts changes seen in an arthritic knee. These changes involve the joint surfaces between the femur, tibia, and the patella. After joint replacement surgery, new joint surfaces replace the old worn ones as shown in the diagram on the right.


HOW IS THE SURGERY PERFORMED?

Most commonly, the surgeon enters the knee through an incision centered over the front of the joint. It is common for people who need knee replacement surgery to have had previous operations on the knee so that the selection of the incision may be modified. Your surgeon will discuss this with you before the operation. The capsule of the knee is opened generally on the inside edge of the kneecap. The muscles and tendons are then pulled out of the way and the knee is bent to expose the arthritic bone ends. Two to three millimeters of bone are removed from the ends of both the tibia and the femur which are shaped to accept the implants. The metal implants are anchored to the tibia and femur using bone cement or a press fit technique (biologic fixation). The technique of fixation depends on many factors such as the strength and quality of your bone. A plastic implant is attached to the tibial implant to form a firm, stable, low friction articulation between metal and plastic. It is common to find considerable damage to the joint surface of the kneecap requiring it to be resurfaced as well. At surgery great care is taken to restore the overall alignment of the knee and the position and function of the kneecap.

LIFE AFTER SURGERY

The debilitating pain you experience with daily activities will be drastically reduced. Most patients become virtually pain free. Some patients still have discomfort but the pain in no way compares to the pain prior to surgery. You can probably reduce or eliminate the anti-inflammatory medication you took before surgery. Your activity level will also increase. Walking, biking, dancing, gardening and playing golf will be fun again. You can probably even play doubles tennis, bowl and swim. Because a total knee replacement has man-made components and cannot continually repair itself, your doctor will probably advise against activities which can cause wear and tear of your new joint. Running, downhill skiing, water skiing or racquetball are probably activities you will be advised to avoid. Your new knee does not have the potential to fight off infection that may form near it. After your surgery you should remember your knee replacement when you have other surgery or dental work so that a short course of prophylactic antibiotics can be prescribed to reduce the risk of infection.

PREPARATION FOR SURGERY  table of contents


OFFICE VISIT

During the office visit, your doctor will take a careful history, examine you and review x-rays of your knees. He will discuss your general condition, allergies and the medications you are taking. Our surgical assistant will schedule a date for your operation and will obtain any necessary preauthorization required by your insurance company. If you have any questions about these arrangements please call the office to speak with one of the surgical assistants.

MEDICAL CLEARANCE

Before proceeding with surgery we want to be sure that any medical problems you have are under control. Please be sure to bring any medical problems you have to our attention. This includes medications you take and any allergies you may have. Prior to surgery you should correct any dental problems. If you are under the care of a family doctor, internist, or other specialist, we may consult with the other doctors to make sure they are aware of the surgery and can address any special needs or adjust medication as necessary.

You should continue to take blood pressure, heart and other medication right up until the time of your surgery. Take any heart or blood pressure medication with a small sip of water on the morning of surgery before coming to the hospital. If you are taking arthritis medications or any blood thinning medications such as Coumadin please ask your doctor for guidance about when to stop taking these medicines. If you are diabetic and take insulin every morning you must discuss this with your doctor also.

Approximately two weeks prior to surgery all of your laboratory studies should have been completed and the results returned to your doctor. This allows time for any problems, such as a bladder infection, to be evaluated and treated. It is important that this laboratory evaluation be completed on time so that your surgery will not be delayed or postponed.

DONATING BLOOD

Approximately one-half of patients receiving knee replacement surgery require blood transfusions afterwards. In order to prevent possible complications from blood transfusions such as fever, hepatitis or HIV infection, we recommend all patients be evaluated for donating their own blood (autologous blood donation). This is arranged through the Red Cross and usually involves donating one pint of blood per week for two or three consecutive weeks. If you are anemic, have a medical condition limiting your ability to give blood or have any other reason preventing blood donation, there is a program called directed donor in which family and friends with your blood type can donate blood for you. If necessary, bank blood from our area is available. This blood is well tested and very safe.

To prevent you from becoming anemic and to allow your body to replace blood loss from donation, we suggest you take a multiple vitamin with iron three times a day until you are admitted for surgery. Iron may cause your stools to become darker but this is nothing to become concerned about. If, however, you develop diarrhea or constipation from the iron you should discontinue it.

Your donated blood will be tested for diseases including HIV, hepatitis and syphilis. If any abnormalities are found you will be notified. All of the blood you donated may not be needed. Donated blood not needed will be used by the hospital in accordance with Red Cross policies.

EXERCISING BEFORE SURGERY

It is important for you to improve your general medical condition prior to surgery. With this in mind you should continue to eat nutritious well-balanced meals. Make every effort to stop smoking one week prior to surgery. It is important for you to be as strong and as fit as possible. While your knee pain will make it difficult, we would like you to work on those muscles which will be used right after surgery to stand and walk. These exercises are shown in a section at the back of this pamphlet. Performing these exercises two times a day will improve your progress after surgery. Exercises to strengthen your arms will make it easier to use a walker or crutches. Any other exercises you can do before surgery such as swimming, biking or walking will help you recover faster.

FINANCIAL CONSIDERATIONS

Financial arrangements will depend on the type of insurance (Medicare, Blue Cross/Blue Shield, etc.) you have and if there is a supplemental insurance policy. Our staff will help you to understand your insurance and we will file forms and obtain preauthorization as required. It is important that you understand the requirements of your policy. Although we will do all we can to assist you in meeting the requirements of your plan, it is your responsibility to follow the procedures specified in your policy. If you have any questions please call our accounting department and ask for Penny or Karen.

HOSPITAL ORIENTATION

Both Riverside and Mary Immaculate Hospitals offer orientation classes during which you visit the hospital, meet some of the staff responsible for helping you in the hospital, listen to presentations and ask questions. We strongly urge your participation in these programs. You will also be contacted by the hospital for a home visit from a physical therapist. The purpose of this visit is to help you to prepare for surgery and it is free of charge.

If you still have questions after these orientations, you may wish to speak to another patient who has had a knee replacement procedure. This can be arranged by calling the office and we can put you in touch with one of our patients who has volunteered to speak with patients like yourself.

CLOTHING

Hospital gowns are suggested for the first two days after surgery. You may wear your own nightgown or pajamas. Jogging clothes, T-shirts, sweat pants or shorts are also comfortable in the hospital. Slippers, tennis shoes, loafers or other comfortable shoes should also be available.

IN THE HOSPITAL  table of contents


ADMISSION

You will be admitted to the hospital the morning of surgery. It is important to remember not to eat or drink anything after midnight the evening before surgery. You should take any heart or blood pressure medicine with a small sip of water the morning of surgery before coming to the hospital. After admission you will go to your room and change into a hospital gown. An IV (intravenous) line will be started in your arm and you will receive a dose of antibiotic. This antibiotic is administered for one to two days after surgery to help prevent infection. A preliminary antiseptic scrub of your knee will be performed which is repeated again in the operating room after anesthesia has been induced. After being prepared in your room you will be transported to the preoperative holding area where nurses again will ask many questions to be certain that all preparation for surgery has been completed. Your knee may also be shaved at this time. The anesthesiologist will talk with you to review your condition, medications and allergies. The time spent in the preoperative holding area is generally about 30 minutes.

We would like to talk with friends and family members immediately after surgery to reassure them and to provide information about your condition. Please let us know before surgery where your family members can be contacted.

SURGERY

Once in the operating room things proceed more swiftly. Most patients are given a general anesthetic but a spinal or epidural anesthetic technique is also very satisfactory. During surgery the joint surfaces are resurfaced and the joint is realigned. The decision whether to resurface the kneecap is made during surgery. The entire operation lasts about an hour and a half after which you are taken to the recovery room to be monitored while coming out of anesthesia. After about an hour you will be taken to your room.

The day of surgery is generally a day of rest and careful monitoring. You will receive antibiotics to prevent infection and receive a blood thinner to decrease the chance of blood clots or phlebitis.

Pain following knee replacement surgery can be managed in a variety of ways. Most commonly an intravenous infusion of pain medication is provided which is under your control. Some patients receive intramuscular injections of pain medicine. You will be educated carefully by the nursing staff in the use of this pump. After surgery you can begin eating and drinking. Generally patients begin with sips of water and other clear liquids and progress gradually to their customary diet.

Most knee replacement patients will have a tube similar to an IV line coming from their knee to drain excess blood. If used, this drain is generally discontinued the day after surgery.

You and your surgeon may decide that a catheter should be placed in your bladder to assist in monitoring urine flow. If this catheter has been placed, it is usually removed in a couple of days when you become more active.

RECOVERY

The day after surgery the nurses and physical therapists will begin to help you get up and around. Exercises will begin to help you bend your knee. To help bend the knee, most patients use a continuous passive motion (CPM) machine which gradually and slowly increases the flexibility of the joint. You will have a cut off switch to stop the machine if you need a rest. It is important to consider the CPM machine one of your best friends, since it works under your control to help you regain flexibility in your knee. The CPM machine should be used at least two hours twice a day but many patients are able to use it many more hours a day and even sleep in it at night.

One of the most common problems after any surgery is a slight fever which lasts for several days. This is the result of the stress from surgery and congestion in the lungs. You will be asked to perform specific breathing exercises every 15 minutes or so to prevent this congestion.

You will be continually reminded to perform exercises with your ankles to help keep the blood flowing in your leg to help prevent phlebitis and swelling. Some patients are given compression hose to help keep swelling under control.

Almost every patient develops an area of numbness on the outer side of the knee following knee replacement. This is due to the position of the incision and the nerves in the skin. This numbness is permanent but becomes less noticeable with time and causes no disability.

An occupational therapist will visit you to provide you with devices which make it easier to put on shoes and socks. The occupational therapist will also review how to perform activities of daily living while you recover from your knee operation.

No two patients recover from surgery exactly the same way. Generally speaking, patients are ready to leave the hospital in three to six days. There are specially trained personnel available to help make arrangements so that the transition to home goes smoothly. If necessary, temporary transfer to a rehabilitation center may be necessary for one or two weeks. This is generally the case if you do not have sufficient help at home or you have disabilities in your other leg or arm. Most people are able to be transported in the family car.

Your emotional approach to the operation is very important. A positive attitude will help you through the first couple of days with all the new experiences, people and places. It is common to get a little discouraged after 4 or 5 days because the excitement of the operation is past and the reality of using crutches and relying on others for several weeks is sinking in. Once again, a confident, positive attitude will help you get over this period of time which lasts 1 or 2 days. Once you are out of the hospital, the future looks rosy again.

Mild swelling is common in the operated leg after going home. This usually improves with elevation and the ankle exercises and compression hose you used in the hospital. If it does not resolve or it is excessive you should call the office.

We strongly recommend that you purchase, borrow, or rent a stationary bicycle. This can be very helpful to maintain the muscle tone and flexibility in the joint before surgery as well as being extremely important in the recovery period to regain the muscle tone and flexibility in your hip and knee.

AFTER THE HOSPITAL  table of contents


LIVING WITH YOUR NEW KNEE

After discharge from the hospital you will be encouraged to perform your exercises and to walk at home. It is common for patients to take a CPM machine home for one or two weeks. Your sutures will still be in place and this area should be kept clean and dry. If there are any problems with your incision such as redness or drainage please notify the office. You should take your temperature twice a day and for any temperature elevation above 100.5 degrees F contact the office. When you come to the office two weeks after surgery, sutures will be removed and new x-rays of the knee obtained. We will monitor your progress on a regular basis until you have resumed normal activities. Most patients usually walk on crutches for about four weeks after surgery and are able to resume most normal activities such as driving a car by about six weeks after surgery.

Sleeping on your back, on either side, or on your stomach is permissible. Sexual relations can be safely resumed approximately four weeks after surgery.

All patients are different but generally most patients resume their normal routines and activities 6-8 weeks after surgery. Generally speaking patients are 90% improved in six months but full recovery can take up to one year.

OFFICE VISITS AFTER SURGERY

Once you have recovered from surgery it is important that your knee is checked on a yearly basis. If you experience any problems you should come to the office earlier. The sooner problems can be evaluated and treated the quicker your recovery will be.

Call our office if you have increased knee pain, swelling, incision drainage, chest pain, shortness of breath, temperature greater than 100.5 degrees F or any other symptoms you do not fully understand.

Remember to mention your knee operation to other physicians or dentists if you have any medical or dental procedures performed. Prophylactic antibiotics can then be recommended to decrease the likelihood of infection spreading to your knee replacement.

COMMON QUESTIONS  table of contents


1. What are the risks involved with this surgery? Every surgical procedure, no matter how minor it may seen, carries with it certain risks. Total joint replacement is no exception. There are general risks such as heart problems, lung problems, infection and blood clots which can occur with any operation. With the knee replacement the most serious problem is developing infection. This risk is less than 1%. Infections can be treated with antibiotics but at times require additional surgery to remove infected material. There are several risks specific to knee replacement surgery such as loosening, nerve injury or blood vessel injury. The risk of injuries to nerves and blood vessels is much less than 1% but may require further surgery and result in temporary or permanent numbness and weakness in the leg.

2. Should I delay the surgery and wait until the symptoms are worse? We will not recommend knee replacement surgery unless we feel the surgery is indicated and that by having the procedure your lifestyle will be greatly improved. Delaying surgery can lead to the development of other problems brought on by the inability to remain active. It is possible that the worsening condition of the bones may make the surgery more difficult to perform. There is good rationale for having the surgery while you're healthy so that after surgery you can resume an active healthy lifestyle and avoid problems related to inactivity.

3. How long can I expect the new knee to last? Current studies show that 5% of knee replacement patients are reoperated after 10 years for a variety of reasons, such as infection, loosening or fracture. With current technology it is extremely rare for a knee replacement to "wear out". We would expect you to have a 95% chance of being satisfied with your knee in 10 years and a 90% chance of being satisfied in 20 years.

4. What happens if I develop pain in my knee again? A careful evaluation will be performed to decide whether there is a problem with the knee replacement or some other problem such as a back condition or tendinitis. If the problem resides in the knee prosthesis the operation can be redone. Revision surgery is more difficult and carries more risk than the original surgery. The best way to prevent the need for revision surgery is to avoid overstressing the new joint, maintaining a satisfactory body weight and reporting any problems to your doctor as soon as possible.

5. How long will it be before I can take a shower or bath? Your incision must be kept clean and dry while the skin staples are still in place. You may shower or bathe after the staples have been removed and there is no seepage from the incision. This is usually 2-3 days after the staples have been removed. A clean light dressing should be placed over the incision daily until it is healed.

6. Will I be able to kneel? It is permissible to kneel on the operated knee although many patients find it uncomfortable due to the location of the incision. There is no risk of doing damage to your knee by kneeling.

7. What is the prosthesis made of and how heavy is it? Most knee replacement prostheses are made from a cobalt chrome alloy which weighs 1-2 pounds. Some knee prostheses are made of titanium and are much lighter. You will not notice the weight of the prosthesis although it is possible that metal detectors such as at airports may be sensitive enough to detect the implant.

THANK YOU

We'll do everything we can to insure that you are happy with your new knee. Remember that no two patients are exactly alike. If you have questions or special requests please ask us about them. We want your knee replacement surgery to be a good experience. If you have any comments or suggestions for this pamphlet or any of our services please let us know so we can continue to improve our treatment.

PREOPERATIVE AND POSTOPERATIVE EXCERCISES  table of contents


Because of the many months of pain and decreased activity, your muscles are probably a little weak. The following exercises are designed to make the muscles stronger and improve muscle tone so that you will recover faster and rehabilitate more quickly following surgery. You should work on these exercises 2-3 times daily at home once your surgery has been scheduled. You may perform these exercises while lying down in bed or on a padded floor.

1. Ankle Pumps: Move the foot/ankle up and down, make circular movements with the foot. Repeat on both feet 50 times per session.


2. Isometric Adduction/Abduction: Sitting in a chair, place hands along the outside of the thigh. Try to push the legs apart, while resisting with the hands for 10 seconds. Place the hands on the inside of the thighs. Try to bring the knees together, while resisting with your hands for 10 seconds. Repeat 25 times per session.


3. Quadriceps Exercise(Knee Tighteners): Lying on your back with your legs straight, push down with the back of the knee against the floor. Maintain the muscle contraction in the thigh for 10 seconds. Relax. Alternate sides. Repeat 25 times per session.

4. Gluteal Isometric Contraction(Buttock Tighteners): This exercise can be done lying down , sitting or standing. Squeeze the buttocks muscles together and hold for 10 seconds. Repeat 25 times per session.

5. Short Arc Quads: Lie down on your back with a pillow, rolled towel or blanket under the knee( 6-10 inches high). Rest the weight of the thigh on the roll. Lift the heel off the floor while straightening the knee. Hold the knee straight for 10 seconds and slowly lower the heel to the floor. Perform on each side 15 times per session.


6. Shoulder Push-Ups: Sitting in a chair with armrests, push yourself up using your arms. Begin by using your feet to assist you, then progress to putting more weight onto your arms to lift yourself up. Hold 3 seconds. Repeat 10 times per session.




Two other exercises which you will be asked to perform after surgery, during the first 6 weeks at home, are shown. You should become familiar with them.

1. Hip and Knee Flexion: Lying on your back, slowly bend the knee, sliding the heel along the floor up to the buttocks as far as possible. Then lift the heel off the floor, bending the hip and knee. Do not exceed 70 degree angle at the hip.


2. Hip Abduction: Lying on your back with the bolster between your knees, lift you heel just off the floor and bring your leg out to the side 6-12 inches. Try to keep the kneecap pointed toward the ceiling. Place your leg inward back against the bolster.


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