Your Procedure

What is it?
Total knee replacement surgery involves removing the surface of the knee joint and replacing it with metal and plastic surfaces. This is most commonly performed for arthritis of the knee in which the smooth surface cartilage has worn away and bone is rubbing against bone, causing significant pain and deformity.

The procedure is performed by separating the muscles and ligaments around the knee to expose the knee capsule (the tough, gristlelike tissue surrounding the knee joint). The capsule is opened, exposing the inside of the joint. The ends of the thighbone (femur) and the shinbone (tibia) are removed and often the underside of the kneecap (patella) is removed. The artificial parts are cemented into place. Your new knee will consist of a metal shell on the end of the femur, a metal and plastic trough on the tibia, and if needed, a plastic button in the kneecap.

When is total knee replacement considered?
Knee replacement works best in patients who have severe arthritis throughout the entire knee. This is most commonly seen in older patients, but can occur in younger patients after infection, or significant injury.

The circumstances vary somewhat, but generally, you will be considered for a total knee replacement if:

You have daily pain.
Your pain is severe enough to restrict work, recreation, and the ordinary activities of daily living.
You have significant stiffness in your knee.
You have significant instability (constant giving way) of your knee.
You have significant deformity (knock-knees or bowlegs).
You have failed to respond to other forms of treatment, including activity modification, anti-inflammatory medications, and cortisone injections into the knee.

What can I expect from an artificial knee?
An artificial knee is not a normal knee, nor is it as good as a normal knee. However, the operation will provide pain relief for at least ten years and may allow you to return to active sports or heavy labor under your physician's instructions.

If you don't have other health problems, you should be able to carry out many normal activities of daily living. About 90 percent of patients with stiff knees before surgery will have better motion after a total knee replacement. However, activities that overload the artificial knee must be avoided.

What are the risks of total knee replacement?
Total knee replacement is a major operation. Complications usually result in a longer hospital stay.

The most common complications are not directly related to the knee and usually do not affect the result of the operations. These complications include:

urinary tract infection
blood clots in a leg
blood clots in a lung
pnuemonia

Complications affecting the knee are less common, but in these cases, the operation may not be as successful. These complications include:

some knee pain
loosening of the prosthesis
stiffness
infection in the knee

A few complications such as infection, loosening of prosthesis, and stiffness may require re-operation and you would be able to walk with the aid of a cane or crutches, and a shoe lift.

Can I have both knees operated on at the same time?
The surgeons at MHP are highly trained in knee replacement surgery and can replace both knees at the same time, if the degree of arthritis in both is severe. This obviously involves a slower period of recovery, but most patients who undergo bilateral replacements are glad that they did this, following recovery.

How long will I be in the hospital after surgery?
The hospital stay usually ranges from three to four days. Patients who live with a person who can assist them, are usually able to go home without much problem. Patients who live alone need to find another person to stay with them after they return home to assist with every day activities.

How long will I be on crutches or a walker?
Most patients use crutches or a walker for about 4-6 weeks or until instructed otherwise by their physician.

What activities can I do following knee replacement?
It takes about three months for the knee to recover to a point where you are back to full activity. Obviously, some patients recover faster and others slower, depending upon age, health status, personal motivation, and response to rehabilitation.

The purpose of knee replacement surgery is to relieve pain, allowing you to return to a high level of function. This means that most activities are okay once you have completely healed. However, most surgeons recommend that you avoid "impact" type of activities, such as running, aerobics, cutting or pivoting sports, or other activities that place a high degree of stress on the knee. Walking, bicycling, cross-country skiing, and bowling are often approved.

How successful is total knee replacement surgery?
Results are generally very good; most people are relieved of nearly all of their knee pain and the replaced joint will usually last ten years, depending on patient use and activity levels. This may vary from person to person.

The major long-term problem is loosening. This occurs because either the cement crumbles (as old mortar in a brick building) or the bone melts away (resorbs) from the cement.

Loosening is in part related to your weight and activity. A loose, painful artificial knee can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complication are higher.

Preparing for Surgery
Preparing for a total knee replacement begins several weeks before the actual surgery. Maintaining good physical health before your operation is important and activities that increase upper body strength will improve your ability to use a walker or crutches after the operation.

The physician may order blood tests and urinalysis before surgery to make sure that a urinary tract infection is not present. Urinary tract infections are common, especially in older women, and often go undetected. Your orthopaedic physician may ask you to see a medical doctor, especially if medical problems have been present in the past.

It is important that your teeth be in good condition. An infected tooth or gum may be a possible source of infection for the new knee. In addition, any blisters, cuts, or boils should be reported. If infection is found, surgery is generally delayed until the infection is cleared.

Will I need anything special at home?
You will need crutches and/or a walker and handrails for the stairs leading to your house. Optional things include a raises toilet seat, handrails around the toilet, bath areas, and stairwells. Any scatter rugs should be removed and torn areas in the carpet or tile tacked down to prevent falling. In addition, watch out pets that may get underfoot!

When preparing for surgery, you should begin thinking about the recovery period after you leave the hospital. Discharge from the hospital is usually in about three to four days and a patient with a new total knee replacement is strongly encouraged to have someone at home to assist with dressing, getting meals, etc. for the first couple of weeks.

If assistance from someone at home is not possible, please discuss this with your discharge planner. It may be necessary to think about arranging to stay a few weeks in a skilled extended care facility, an acute rehab unit, or receive therapy at home with in-home care. To qualify for these options, you must meet certain criteria as directed by Medicare and/or your insurance carrier. If needed, outpatient therapy can be arranged in a facility near your home.

Pre-op Visit
Due to changes in insurance coverage, it is necessary for most patients to visit the hospital before their actual surgery date. This visit usually lasts several hours, so plan to spend most of the day.

The day begins in the clinic, where an interview by the nursing staff concerning past medical history and current medications will be taken, as well as a chest x-ray. You may be instructed to stop taking your anti-inflammatory medications (Ibuprofen, Naprosyn, Relafen, DayPro, Aspirin) one week before surgery. You will be attending a teaching session, which will provide you with information about your surgery. There will also be time for discussion and questions. Bring a written list of past surgeries and of the medications and dosages that you normally take at home.

During your pre-op visit, blood will be drawn and lab tests done to insure that you are in good general health. X-rays are taken if necessary. Chest x-rays and an EKG are obtained if you have not had one taken for six months or if otherwise indicated. After all of these tests and exams are completed, a nurse will talk with you to determine the type of anesthesia that is best suited for you. Before you leave the hospital, make sure your questions are answered.

If at any time you become ill, such as with a cold or flu, you need to call your physician. You need to be in the best of health before surgery!

Pre-op Exercises
Deep Breathing Exercises: You should exercise your lungs every day before surgery by inhaling deeply through your nose, then slowly exhaling through your mouth. Repeat this three times and then cough two times, every 30 minutes. These exercises are necessary to remove any excess secretions that may settle in your lungs while you are asleep during surgery.

Ankle Pumps: You should pump your ankles back and forth 1,000 times every day before your surgery. This is your best defense against blood clots.

You need to practice all exercises given to you (on paper) during the pre-op visit.

Crutches/Walker
Please bring crutches or a walker with you to the hospital, so we can make sure that the equipment is in good working order and set at the right height.

Surgical Checklist

Are there any special instructions I should know about?
A shower, bath, or sponge bath should be taken the evening before and the morning of surgery with the medicated liquid soap that was given to you at the time of your pre-admission testing. Nail polish and make up should be removed.

Unless instructed otherwise, do not eat or drink anything after midnight.

What should I bring to the hospital?

Crutches or walker
Good walking shoes (crepe or rubber soles)
Pair of shorts or sweatpants and a t-shirt
Pajamas and robe
Toothbrush, toothpaste, deodorant and other personal items
Electric razors only!
Only two family members or friends may accompany and stay with you before surgery in the prep holding area.

What happens after I arrive at the hospital?
You should arrive at the hospital at the instructed time and go to the Surgery Prep Area. The nurse will spend a few minutes making sure that you are still in good health and ready for surgery. The nurses will try to give you a good estimation of when you will be going into surgery. However, it is hard to predict how long every surgery is going to take, so expect some waiting time and bring something like a book, magazine or other quiet activity to help pass the time.

You will be taken to a presurgical care unit where you will be asked to change into a hospital gown. An intravenous (IV) will be started to administer fluids and medications during and after the surgical procedure. From there, you will be transported to the operating room. Your family and/ or friends may accompany you part of the way and then will be instructed to wait in the Surgery Waiting Area. Your doctor will talk to your family after the surgery to report your progress.

How long does the surgery take?
It depends upon how complicated your particular knee problem is, but usually a total knee replacement takes about 60 to 90 minutes.

What should I expect after surgery?
After surgery, you will be taken to the Recovery Room for approximately 2 hours for close observation. Your blood pressure, pulse, respiration, and temperature will be checked frequently. Attention will be paid to the circulation and sensation in your legs and feet. It is important to tell your nurse if you experience numbness, tingling, or pain in your legs or feet. When you awaken and your condition is stabilized, you will be transferred to your room.

Although circumstances vary from patient to patient, you will probably have some or all of the following after surgery:

You will find that a large dressing has been applied to the surgical area to maintain cleanliness and absorb any fluid. This dressing will be removed within 24 - 48 hours after surgery.
An IV, started before surgery, will continue until you are taking adequate amounts of fluid by mouth. When you are taking fluids well, the IV may be changed to a Heparin lock, a small sterile tube that will keep a vein accessible for antibiotics and allow for easier movement. Antibiotics are frequently administered every eight hours, for two to three days, to reduce the risk of infection.
One side effect of anesthesia is often a difficulty in urinating after surgery. For this reason, a sterile tube called a foley catheter may be inserted into your bladder to insure a passageway for urine. It will be removed 24 hours after surgery.
You will have on intermittent passive compression (IPC) stocking sleeves that are connected to a machine that circulates air in the plastic and around your legs. These stockings are worn on your legs to prevent blood clots from forming after surgery. You will also be given medications and exercise instructions (moving your ankles up and down), which help to prevent clots.
Post-operatively you may have temporary nausea and vomiting due to anesthesia or medications. Anti-nausea medication may be given to minimize this condition.
Your diet will progress as your condition permits, starting with ice chips and clear liquids.
To help prevent complications, such as congestion or pneumonia, deep breathing and coughing exercises are important. After surgery, these exercises are to be done every one or two hours. Inhale deeply through your nose; then slowly exhale through your mouth. Repeat this three times and then cough two times. You will be encouraged to use your inspirex, blowing the ball up the tube by taking deep breaths.
A metal triangle called a trapeze maybe placed in the overhead bed frame to assist you in moving around the bed. You are encouraged to move in bed without using the trapeze. This will prepare your for independence at home.

Pain Control
Most patients have a moderate degree of discomfort in the knee that is effectively treated with pain medications. The pain decreases over the next week or so, and by about two or three weeks after the surgery, patients are feeling much better.

An epidural or a patient controlled analgesia (PCA) is used for the first two to three days after your surgery. When the epidural or PCA is discontinued, your doctor will prescribe pain medication to be taken by mouth. It is important to continue taking them because preventing pain is easier than chasing it. If you continue to experience pain after taking the medication, we encourage you to notify your doctor or nurse so alternate methods of pain control can be started.

Some patients experience back discomfort after surgery. This is caused by partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown.

Patients are usually given blood thinners to prevent blood clots in the leg following the knee replacement. This continues for about three weeks following surgery.

Exercise Therapy and Rehabilitation Program

When muscles are not used, they become weak and do not perform well in supporting and moving the body. Your leg muscles are probably weak because you haven't used them much due to your knee problems. The surgery can correct the knee problem, but the muscles will remain weak and will only be strengthened through regular exercise. You will be assisted and advised how to do this, but the responsibility for exercising is yours.

Physical therapy is started the day after surgery provided there are no complications. You will walk and be assisted into a chair the first day after surgery Some physicians recommend that patients use a continuous passive motion (CPM) machine. This is a device that is fit to your leg and is placed in bed with you. It slowly and smoothly bends and straightens your knee. You will use the machine periodically during the day, and it will be adjusted to increase the bend in your knee. However, this is not a substitute for your exercises.

In your physical therapy sessions you will walk, using crutches or a walker, bearing as much weight as indicated by your doctor. You will also work on an exercise program designed to strengthen your leg and increase the motion of your knee.

Your overall progress, amount of pain, and condition of the incision will determine when you will start going to physical therapy. You will work with physical therapy until you meet the following goals:

Independent in getting in and out of bed.
Independent in walking with crutches or walker on a level surface.
Independent in walking up and down three stairs.
Independent in your home exercise program.
Able to bend your knee 90 degrees.
Able to straighten your knee.

Your doctor and therapist may modify these goals somewhat to fit your particular condition.

How well you regain strength and motion is, in part, dependent upon how well you follow your physical therapy. This part of your rehabilitation is something that you must do for yourself, and not something someone else does for you. It takes about three months for the knee to recover to a point where patients are back to full activities. Obviously, some patients recover faster and others slower, depending upon age, health status, personal motivation, and response to rehabilitation.

Guidelines at Home

What happens after I go home?
Upon discharge from the hospital, you will have achieved some degree of independence in walking with crutches or a walker, climbing a few stairs, and getting into and out of bed and chairs. However, someone is needed at home to assist you for the next two weeks or until your energy level and mobility has improved.

Medication
You may be sent home on prescribed medications to prevent blood clots. Your doctor will determine whether you will take a pill (Coumadin or coated aspirin) or give yourself a shot (Enoxaparin). If an injection is necessary, your doctor will discuss it with you. The nursing staff will teach you or a family member what is necessary to receive this medication.

You will also be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises. Remember that preventing pain is easier than chasing it. If pain control continues to be a problem, call your doctor.

Exercises
You will be instructed in a home exercise program designed by your physical therapist. Remember that walking is not a substitute for your exercises.

If an exercise is causing long-lasting pain, you should cut back on your exercises. If it continues to cause pain, contact your physical therapist or physician.

Activity
Continue to walk with crutches or a walker as directed by the doctor or physical therapist. Your physician will determine how much weight you can place on your operated leg.

Walking is one of the better forms of physical therapy and for muscle strengthening. However, walking does not replace the exercise program that you are taught in the hospital. The success of the operation depends largely on how well you do the exercises and strengthen weakened muscles.

Are there certain things I need to avoid after my total knee replacement?
Yes, there are a number of things you need to be aware of. Your new knee is designed to eliminate pain and increase function. Certain movements place undue stress on your new knee. For your safety, these should be avoided. This is especially true during the first few months after your surgery.

The following is an outline of the precautions you should follow after surgery.

Riding in a car is permitted as long as you make hourly stops to get out and walk around.
Generally, you will be able to resume driving in three to four weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/out of the car.
Sexual activity can be resumed per your physician's instructions.
You can usually return to work within three to six months or as instructed by your doctor.
No tub baths, only showers, until staples are removed.

In addition, when visiting physicians and dentists it is important that you inform them that you have a total joint replacement. You will need antibiotics for certain dental and medical procedures, ask your doctor for a medical alert card, if you don't already have one.

This precaution is permanent.

Your Incision
Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. When using heat or ice, remember not to get your incision wet before your staples are removed. Generally, the staples are removed in 1-2 weeks.

Prevention of Infection
If at any time (even years after the surgery) an infection develops such as strep throat or pneumonia, notify your physician. Antibiotics should be administered promptly to prevent the occasional complication of distant infection localizing in the knee area.

This also applies if any teeth are pulled or dental work is performed. Inform the general physician or dentist that you have had a joint replacement.

When do I return to the clinic?
Your first return appointment is 1-3 weeks after discharge, at which time you will be examined and have x-rays. Subsequent appointments are then at one month, three months, six months, one year, and two years after surgery. Thereafter, you should return every three years.

Once you return home, if you have any questions or concerns regarding your total knee replacement, please do not hesitate to call. Between the hours of 8:00 a.m. and 5:00 p.m., Monday through Friday, please phone your surgeon's office.

After 5:00 p.m. and on the weekends and holidays, please phone (231) 672-3916 and ask to speak to the doctor on call.

Remember: Your physician, physical therapist, and nurses are striving to make a painless, functional knee possible for you. The real success of your knee replacement, however, depends partly on you - especially how conscientiously you exercise and take care of yourself.

Good luck and good health.

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