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Total Knee Replacement

A total knee replacement resurfaces your knee joint by removing the diseased bone and cartilage. This includes the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the backside of the kneecap (patella). These surfaces are replaced with a metal and plastic implant, which mimics natural knee motion and function. Total knee replacement can help put an end to arthritic pain in your knee and enable you to resume a functional and active lifestyle.

Preparing for Surgery

The decisions you make and the actions you take before knee replacement surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.
  • You should discuss with your physician and his support staff what devices will be needed when you are discharged from the hospital following surgery. If your hospital has a pre-operative total knee class, where you can speak with nurses and therapists, it is recommended that you attend. These classes provide valuable information.
  • Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.
  • Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.
  • In the weeks prior to surgery, your physician may recommend that you donate some of your own blood to be used for transfusion after surgery. Your physician will instruct you about where and when you can donate blood.
  • Discontinue the use of any anti-inflammatory medicine at least one week prior to surgery, to prevent excessive bleeding during the surgical procedure. All decisions regarding your medications should be discussed with your physician.
  • To reduce the risk of infection or wound healing problems, smoking should be stopped at least one week prior to surgery and not resumed following surgery.
  • Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is often recommended.
  • Make sure the orthopedist performing the surgery is board-certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.
Seven to ten days before surgery, you may be instructed to go to the hospital for pre-admission testing. A nurse will review your medical history and provide you with all the preoperative instructions you need. You will be given a complete physical exam, have blood and urine tests done, and undergo X-rays and a cardiogram (EKG).

If you are taking any medication, you will receive instructions about safe doses to take in the days leading up to surgery.

Day Of Surgery

At most medical centers, you will go to "patient admissions" to check in for your inpatient total knee replacement procedure.

After you have checked in to the hospital or clinic, you will go to a holding area where the final preparations are made. The paperwork is completed and your knee area may be shaved (this is not always necessary). You will wear a hospital gown and remove all of your jewelry.

You will meet your surgeon, his operating room nurse and staff, along with the anesthesiologist or anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room.

Here are some important steps to remember for the day of your surgery:
  • You will be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under anesthesia.
  • Arrange for someone to drive you home when you are released, usually within three to six days after surgery.
  • Wear loose fitting clothing for your arrival to the hospital.
  • Bring only what you will need for the first 24 hours, like a toothbrush, glasses, or dentures.
  • Pack a bag for someone to bring you the day after surgery that contains a full length robe, toiletries, underwear, personal phone numbers you may need, and any other items you would like to have around during your hospital stay. Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.
Surgery

During a total knee replacement, surgeons reshape your knee joint. The metal and plastic implant is attached to the thighbone (femur), shinbone (tibia), and kneecap (patella).

The procedure usually takes about two hours to perform.

Surgery
  • The choices of anesthesia include epidural, spinal, or general, and will be decided upon by your surgeon and anesthesiologist, who will review with you the advantages and disadvantages. Once entering the operating room, you will be placed on the operating table and anesthesia will be administered. The surgical team washes and prepares the leg with an antibacterial solution. IV (intravenous) antibiotics will also be administered.
  • The surgery is performed through an approximately seven to ten inch incision in the front of the knee. The front (anterior) muscles are incised and the joint is exposed. The thighbone, shinbone, and kneecap are seen.
    Step 1

  • After opening the joint, the surgeon uses precision instruments to cut and reshape the knee joint in order to accomodate the prosthetic components.
    Step 2

  • The final components may be either cemented in place or press fit in a cementless manner.
    Step 3

  • During the operation, surgeons check the alignment of the knee as well as test function and stability of the knee joint. The knee is stitched closed, a sterile dressing is applied, and you are taken to the recovery room.
Recovery Room

Following a total knee replacement, you usually stay in the recovery room where there may be several other patients for at least two hours while the anesthetic wears off. If you were given spinal anesthesia, you may not have any sensation in your legs when you wake up after surgery.

You will be given adequate pain medicine, either orally or through an IV (intravenous) line. IVs will deliver fluids, blood, and medication as needed. Oxygen may need to be delivered through a nasal tube or facemask.

A Foley catheter may be inserted into your bladder in the operating room to drain urine. The catheter is usually removed by the second day following surgery. Your knee will be bandaged and may have ice on it. You may have significant pain early on and you should take the pain medicine as directed. Remember that it is easier to keep pain suppressed than it is to treat pain once it becomes present, so ask the nurse for medication when you feel pain coming on. Blood tests and an x-ray of your knee may be performed while you are in the recovery room.

You should try to move your feet and ankles while you are in the recovery room to improve circulation.

Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, along with the doctor, will determine when you are ready to be transfered to your hospital room. Most patients remain in the hospital for three to five nights following surgery.

If you have a previous heart condition or a significant past medical condition, you may be taken to the intensive care unit (ICU) for routine cardiac monitoring for a day or two. Following the monitoring, you will be transferred to your hospital room and begin your formal physiotherapy program.

Post-Op In Hospital

After total knee replacement, you are usually taken to a hospital room where doctors, nurses, and therapists will regularly monitor your recovery. Most patients feel sleepy and fatigued the day after surgery.

Following surgery you may be placed in a CPM (continuous passive motion) machine, which will mocve your knee while you are in bed. This flexion and extension of your knee will help reduce knee stiffness. You will also start daily physical therapy, which includes active and passive range of motion exercises, walking, getting yourself out of bed, and getting up from a chair.

You can expect to be given pain medication as needed. Ice also helps control pain and swelling. You may become nauseated after surgery and you should inform a nurse immediately so your medication can be changed to relieve nausea. To help keep your lungs clear, you will receive instructions about deep breathing and using a device called an incentive spirometer.

For two or three days after surgery, you may experience an elevated temperature. This is common and should not alarm you. Your doctor may suggest acetaminophen, deep breathing exercises, and spending more time out of bed. The medical staff will evaluate prolonged fevers.

It is important to move your bowels before the third day after surgery, even if you have not been eating. Ask for a laxative if you need assistance.

While in the hospital, you will wear tight-fitting, anti-embolism stockings that help control swelling in your legs. They are removed daily for bathing and then reapplied. Physicians usually prescribe wearing the stockings day and night for up to six weeks after surgery.

By the third or fourth day after surgery, you can usually walk freely around the hospital.

The incision usually starts to close within six days and the bandage can be removed.

You will be ready to leave the hospital when you can get in and out of bed and a chair, go up and down a few stairs, bend your knee between 70 and 90 degrees, and manage your pain with oral medication.

You should be able to fully bear weight on your leg when released from the hospital, but most patients may need to use crutches, a cane, or a walker for a few weeks until they are comfortable walking on their new knee. You will be given a prescription for pain medication and schedule a series of follow-up visits starting sometime around three and six weeks after surgery.

Recovery at Home

You may feel pain or discomfort for the first few weeks at home after a total knee replacement, and you should take your prescribed pain medication as needed. A prescription-strength painkiller is usually prescribed and should be taken as directed on the bottle. Taking one every four to six hours as directed is a good idea during the first few days to suppress pain.

Swelling in your knee usually slowly decreases over the weeks following surgery. The surgical incision should be dry, but there may be occasional slight spotty bleeding along the wound. A light dressing may cover the incision and the compression stockings should be worn, as prescribed by your doctor. If you notice increased swelling, redness, or wound bleeding, you should call your physician. Arrangements for a visiting nurse and home physical therapist will be made at the time of discharge from the hospital. Their role is to help you with your transition into the home environment and monitor your progress.

Physicians generally recommend that you focus on your therapy program and avoid strenuous activities that may irritate your knee for about six weeks following surgery. The goal is to restore your motion and improve your strength. Progressively walking longer distances each day is helpful. Riiding a stationary bicycle can also help restore motion and strength to your knee.

Here is what you can expect and how you can cope after a total knee replacement:
  • Try to arrange for someone to visit you at home to help you for up to six weeks. You may need help putting on the elastic stockings, cooking, doing laundry, cleaning, and getting around town. You may be qualified to receive personal care services from a home health aid if you do not have family members who can provide all the help you need.
  • Icing your knee for 20 to 30 minutes a few times a day during the first few weeks after surgery will help reduce pain and swelling.
  • Whenever possible during the first few weeks after surgery, you should periodically elevate your leg to help reduce the swelling. Most patients may shower when they get home. Whether or not the incision can get wet needs to be discussed with your surgeon.
Rehabilitation

Most patients can begin physical therapy immediately after surgery. This will be initially performed at your home with a home physical therapist. Once you are strong enough, arrangements will be made for your physical therapy at an outside physical therapy center that is convenient for you.

Crutches or a cane may be needed for up to six weeks, depending on the pain. Older patients may have to continue using a walking aide for a longer period of time.

In the first few weeks of rehabilitation, your physical therapist will help you stretch and strengthen the muscles about your knee. The goal is to restore your knee motion and resume comfortable walking.

As your strength and motion improves, you may be instructed on endurance exercises such as long distance walking, cycling, and swimming. These exercises should restore your feeling of wellness.

You may take up to six weeks off from work, depending on the type of job you perform and how you get to work. It is useful to discuss this with the doctor before surgery so that you can make appropriate arrangements.

Following total knee replacement, patients are encouraged to resume an active lifestyle. However, they are strongly advised against doing activities that produce high impact loads such as running and jumping. Sports such as golf, cycling, swimming, and walking are permissible. You should discuss with your physician the exact level of sport participation recommended for you.

Prevention

Total knee replacement is a predictable and durable procedure. How you treat your new knee will influence its longevity. Therefore, it is important to know which activities are permissible and which are not following total knee replacement.

The pain relief achieved by total knee replacement, combined with the correct regimen of exercise and sports, should improve the patientís overall health and quality of life.

The benefits of an active lifestyle have been well documented. Following total knee replacement, you should be instructed about limitations and have good self-control and self-awareness when returning to recreational sports.

After surgery, most activities require some reflection and often some modification. Your level of expertise in your particular activity needs to be considered. Sports and fitness regimens must be individualized. Participation in sports and recreational activities should be discussed with your surgeon.

Recommended Activities

Cycling is an excellent aerobic workout.Calisthenics, swimming, low-resistance rowing, stationary skiing machines, walking, hiking, and low-resistance weight lifting all are excellent ways to maintain fitness without overstressing the implant.

Suitable activities include bowling, croquet, golf, doubles tennis, table tennis, ballroom dancing and square dancing.

Other activities that are suitable but slightly more risky include downhill skiing, scuba diving, in-line skating, ice skating, softball, volleyball, speed walking, horseback riding, hunting and low-impact aerobics.

Discouraged Activities

In general, patients who have undergone total knee replacement should avoid high-impact activities that cause high stress loads on the implant and therefore may increase the risk of early failure.

Activities to avoid include baseball, basketball, football, hockey, soccer, high-impact aerobics, gymnastics, jogging, power lifting , rock climbing, hang gliding, and parachuting.



The Knee Society Office:
6300 N. River Road, Suite 727, Rosemont, IL 60018-4226
Telephone: (847) 698-1632 Fax: (847) 823-0536
Email: knee@aaos.org