Patient's Guide To Knee Replacement

What is Knee Replacement Surgery? Preparation to be Made Before Surgery Getting Ready for Surgery Personal Preparations For Surgery Finalizing Arrangements Before Surgery

Hospital Stay After Surgery: Day by Day Leaving the Hospital General Care Dos and Don'ts After Knee Replacement Surgery

What Is Knee Replacement Surgery?

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Your knee joint is composed of three parts: the end of the femur (thigh) bone, the top of the tibia (leg) bone, and the patella (knee cap). In a normal knee, these three bones are coated with smooth cartilage that allows them to move against each other without friction or pain. In the arthritic knee, the cartilage layers are destroyed. Bone rubs against bone in the arthritic knee joint, causing pain and limitation of motion. An arthritic knee may also develop a bow-leg or knock-knee deformity.

Knee replacement surgery involves resurfacing your knee joint with three artificial components: a metal component fixed to the end of the femur, a metal and plastic or all plastic component fixed to the top of the tibia, and a plastic component fixed to the patella. These three components move together to allow near normal knee function. Knee replacement surgery will also correct deformity in the knee.

Preparations to Be Made Before Surgery

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In consultation with your orthopaedic surgeon, you have decided that knee replacement surgery is appropriate treatment for your knee condition. It is important to understand that this is elective surgery. Knee replacement surgery is not something that you must do. Other treatment options are available for arthritic knees that do not involve surgery. Nonoperative treatment for your knee includes medicine for pain and inflammation, the use of a cane or crutches, weight loss, and restricting your activities. Many patients try these nonsurgical measures before choosing surgery.

Generally, knee replacement surgery is very successful. Knee pain is relieved, deformity is corrected, and patients can resume many activities. It is not clear how long a knee replacement will last. The long-term success rate will vary, depending on your age, your weight, and your activity level.

Knee replacement is considered major surgery. When making the choice for knee replacement surgery, it is important that you are aware that there are potential risks and complications. These include problems from anesthesia, infection, surgical bleeding, blood clots, damage to nerves or blood vessels, and, very rarely, death. With time, an artificial knee can become loose or wear out, requiring further surgery. These and other potential problems are uncommon but possible. Whenever possible, precautions are taken to avoid complications.

Getting Ready for Surgery

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Once you have decided to have your knee replaced, there is much to do to prepare for the day of surgery. Lahey clinic provides a team approach to your care. You will have a chance to meet many of the team members before surgery. They will answer your questions and help make necessary arrangements so that your surgery and hospital stay go as smoothly as possible.

Physical Examination/Tests

Generally, a physical examination by an internal medicine doctor is recommended to ensure that you ware well enough to undergo major surgery. Consultation with other medical specialists may also be necessary. Several diagnostic tests, including chest x-ray, EKG, and blood and urine tests will be scheduled for you.

Autologous Blood Donation

The next step is to consider whether you wish to donate blood for your surgery. Knee replacement generally requires blood transfusion. Usually, your surgeon will ask you to donate two or three units of blood. This blood is refrigerated and stored until the time of your surgery. If transfusion is necessary, you will be transfused with you own blood. This helps avoid some of the risks involved in receiving blood from anonymous donors, such as transfusion reactions and transmission of viral diseases. There are certain instances when it may be impossible for you to donate your own blood. When this is the case, it will likely be necessary for you to be transfused with blood-bank blood, which in general is very safe.

Meeting Your Physical Therapist

It is helpful if you can see a physical therapist before surgery. Your therapist can give you a preview of the kind of physical therapy you will receive in the hospital after your surgery. You will learn about the exercises you will be asked to perform after your surgery, and you may get a chance to practice walking with crutches. Successful knee replacement requires successful surgery and successful rehabilitation.

Your Social Service Worker

It is also helpful for you to visit with a member of the Lahey Clinic Social Service team before surgery. The social service person can help you plan your discharge from the hospital. He or she can tell you about options for physical therapy and nursing support when you return home. He or she can also discuss with you whether you should be transferred to a rehabilitation hospital at the time of discharge from Lahey Clinic. This kind of advance planning helps alleviate concerns you and your family may have about what will happen after you leave the hospital with you new knee.

Meeting the Anesthesiologist

Usually, you will have a chance to visit with an anesthesiologist or a nurse representative before surgery. He or she will review your medical records and answer any questions you have about anesthesia.

Personal Preparations for Surgery

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Prepare Yourself:

• Eat well-balanced meals. This is not the time for serious weight loss.
• Get plenty of rest.
• Cut back or eliminate alcohol.
• Exercise to improve and maintain muscle tone and joint motion.
• Cut back or eliminate smoking.
• Have fun and develop a positive attitude for knee replacement

Prepare Your Home:

• Obtain a cordless phone.
• Stock freezer and pantry.
• Obtain an apron with pockets or a back-pack. Your hands will be using crutches.
• Remove scatter rugs.
• Make sure all doorknobs are clear and accessible.

Prepare For Hospital Discharge:

• Discuss hospital and discharge plans with relations and friends.
• Evaluate the options of home discharge or rehabilitation facility discharge.
• Review insurance coverage as it pertains to discharge.

Prepare a Hospital Bag:

• Low-heeled supportive shoes or sneakers.
• "Walkman" type tape player if you like music.
• Loose, comfortable clothing.
• Shorts, T-shirts.
• Cash for newspaper, TV, etc.
• Personal care items.

Finalizing Arrangements Before Surgery

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An appointment will be arranged for you to see a member of the Orthopaedic Surgery team, who may be your attending physician, a resident or intern, or the orthopaedic surgery physician's assistant. He or she will check to be sure that all the necessary preparations for surgery have been made and will answer any final questions that you may have. You will be asked to sign an informed consent document.

A week before surgery, you should stop taking all anti-inflammatory medications, including such medications as aspirin, Advil, Motrin (or ibuprofen), Feldene, Naprosyn (Aleve), Clinoril, Voltaren, Relafen, Tolectin, Ansaid, or Indocin, to name but a few. If you are uncertain if your pain medication is a kind of anti-inflammatory drug, contact your doctor. It is permissible to take acetaminophen (Tylenol - regular or extra strength) for pain up until the night before surgery. Also, If you get a cold or the flu in the week or two before surgery, be sure to notify your doctor.

You can eat or drink anything you wish up until midnight before the day of surgery. After that you must not eat or drink anything unless directed otherwise by your doctor.

Hospital Stay

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On the morning of surgery, you will be admitted to the hospital and you will be asked to dress in hospital clothes. A name band will be placed on your wrist. Rings may be kept on your fingers. They will be taped in place. All other jewelry must be removed until after the operation. Perhaps the safest choice is to place your valuables in the Lahey Clinic Security Department for safekeeping. You may also wish to leave jewelry and valuables at home. Your nurse will go over a preoperative checklist with you.

Your nurse will record your temperature, blood pressure, pulse rate and respiratory rate. You will be asked to empty your bladder. An intravenous line will be started. The anesthesiologist may order medications to calm you and make you drowsy.

When the operating room is ready and the operating team is assembled, you will be escorted into the operating room on a stretcher. In the operating room, you will be transferred onto the operating table, where anesthesia will be induced. At this point, your knee replacement operation is ready to begin.

Family members who wish to wait in the hospital during your surgery may do so in the family waiting room across from the operating rooms. Your surgeon will report to them after your surgery, if you request it. Otherwise, you can request your surgeon to call a family member of friend after surgery.

After Surgery: Day-by-Day

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To help you know what to expect during your hospital stay, we have developed the following schedule. This schedule details the sequence of events that usually follow knee replacement surgery. The sequence may vary from patient to patient.

Day of Surgery

• When surgery is finished, you will be taken to the recovery room. You will be quite drowsy at this time, and you may not recall much about the recovery room experience. When you are ready, you will be transferred from the recovery room to your hospital room. Family members or friends may visit you in your hospital room. Sometimes it may be necessary for your to stay overnight in the recovery room. If so, family members may visit you briefly in the recovery room after 7:00 pm.
• After surgery, you will be given liquids to drink. If you tolerate liquids, your diet will be advanced to regular foods.
• To control the pain you feel after surgery, you will be given strong medication through an injection or through the intravenous line. Later, you will be given pills to take for pain.
• After surgery, some patients will find that their operated leg has been placed in a continuous passive motion (CPM) machine. This machine will slowly and continually flex and extend the knee. It helps you gain motion in your artificial knee as quickly as possible.
• The nurses will give you an incentive spirometer. This device will help you fully expand your lungs. It is important that you do this as often as you think of it - at least every hour when you are awake.
• You may discover that when you were anesthetized, a catheter was passed into your bladder to monitor your urine output.
• You will receive antibiotics to prevent infection and a blood thinner to prevent blood clots.

Postoperative Day 1

• Safety precautions for patients with artificial knees will be discussed.
• Several blood tests are drawn to monitor your recovery.
• Physical therapy begins:
• You will be instructed in hip and knee exercises.
• The therapists will check the range of motion of your knee. They will chart your progress on the wall. Your goal is to maximize flexion (bending) and extension (straightening).
• The therapists and the nurses will help you out of bed and into a chair. Hopefully, you can do this two or three times on postoperative day one. During transfers (getting in and out of your bed or chair) you can ordinarily put as much weight on your operated leg as you wish.
• A representative from the Social Services Department will visit with you and your family. Planning for your discharge from the hospital begins now in earnest.

Postoperative Day 2

• The dressing over your wound will be changed.
• If a drain was placed in your wound, it is removed.
• If a catheter was placed in your bladder, it is usually removed.
• A blood test will be drawn to measure the effectiveness of the blood thinner (coumadin) you are given while in the hospital. This blood test will be drawn daily during the rest of your hospital stay. Other tests will be added as necessary.
• The CPM machine will be advanced.
• Physical therapy continues:
• Hip and Knee exercises.
• Your knee range of motion will be tested and charted.
• Practice with transfers continues. You should be getting into a chair at least three times a day.
• You will begin walking with a walker.
• The social service representative, in discussions with you, your family, your physicians and your therapists, will finalize discharge planning. Transfer to a rehabilitation hospital may be as early as postoperative day three. Discharge to home may be as early as postoperative day four or five.

Postoperative Day 3

• The dressing on your wound will be changed.
• The CPM will be advanced.
• If you have been unable to have a bowel movement (pain medicine commonly causes constipation), the nurses may offer you a suppository or an enema.
• Physical therapy continues:
• Your knee range of motion will be tested and charted.
• You should learn to perform the hip and knee exercises on you own.
• You should practice to become independent with transfers.
• If it is possible, you will practice ambulating with crutches instead of a walker. Your goal should be to walk independently as soon as possible.
• The Occupational Therapist will visit to assist you with the performance of everyday living tasks.

Postoperative Day 4

• The dressing on your would will be changed. If your wound is dry, it may not be necessary to cover it any more.
• The CPM will be advanced.
• Physical therapy continues:
• Your knee range of motion is tested and charted.
• Practice independent exercises.
• Practice independent transfers.
• Practice independent ambulation with crutches/walker.
• Practice stair climbing.
• Safety precautions reviewed prior to discharge.
• An ultrasound test is performed on your legs to ascertain whether you have developed any blood clots in your calf or thigh veins.

Leaving the Hospital

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When you are medically stable, independent with crutches or a walker, and knowledgeable in total knee precautions, or may be discharged to home. Arrangements may be made for home or outpatient physical therapy. If you still need more physical therapy, you may be transferred to a rehabilitation hospital. The social team will assist you with these arrangements.

Before you leave the hospital, you will be given prescriptions for any medications that you need, including pain medication. Usually, you will resume taking all of the medications that you were taking before you came into the hospital. These medications should be reviewed with you regular doctor.

General Care

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Here is some general information of interest to you as you plan to leave the hospital:

Follow-Up Visit
Usually, your surgeon will want to see you in the outpatient clinic to remove skin staples or sutures two weeks after your surgery. If you go to a rehabilitation hospital, they may remove your staples or sutures. You will see your surgeon at the Lahey Clinic four to six weeks following surgery. An x-ray of your knee will be ordered during your 4-6 week follow-up visit.

Wound Care
You should keep a dressing over your wound if there is any drainage. If the wound is cleaned and dry, you can either leave it open to air or cover it with a dressing - whichever you wish. If you see increasing redness around your knee wound, or drainage that persists or looks like pus, or if the wound becomes increasingly tender or warm, call your surgeon immediately.

Toileting
Because most toilet seats are low, a commode or raised toilet seat may be recommended. Grab bars may also be recommended to ensure safety at home.

Bathing
You may shower after your skin sutures are removed. Bathing is best done in the shower - getting in and out of a tub can be difficult and dangerous when recovering from knee surgery. A long-handled sponge, can be helpful for bathing your lower body. Some patients find a tub seat in the shower to be helpful. Be cautious when walking on slippery bathroom floors.

Dressing
Some patients will need assistive devices in order to dress independently. A stocking aid may enable you to put on your socks without bending over too far. A dressing stick or long-handled shoehorn may assist you in taking socks off. Long-handled reachers may assist you in putting on and pulling up your pants. You will be evaluated at the time of discharge for your particular needs.

TEDS Stockings
The white TEDS stockings should be worn on both legs when you are up during the day. They help keep down the swelling in your legs (especially in your operated leg). At night, you can remove them and launder them, if necessary. Usually, you will be asked to wear these stockings for the first six weeks after surgery.

Driving
You should not drive until you can safely control your vehicle. This is your decision, not your doctor's.

Sexual Relations
You may resume sexual relations whenever you wish. Usually, this is most successful if you wait a few weeks for your surgical discomfort to subside. A general rule for sex after surgery is to do what seems comfortable and enjoyable.

Dental Work
Anytime you arrange an appointment with your dentist, tell him or her that you have an artificial knee. We recommend that you take an antibiotic both before and after any kind of dental work, including simple teeth cleaning. The antibiotic we prefer is amoxicillin or, If you are allergic to that drug, erythromycin. Either we or your dentist can provide you with the prescription for this medication.

Infections
Rarely, infections from other sites of the body can travel through the blood and settle in the artificial knee, causing an infection. Anytime you suspect you may have an infection of any kind - of your skin, your throat, your urine, your teeth, etc., see your family doctor sooner rather than later. Let your doctor know that you have an artificial knee. He or she will decide whether it is appropriate to begin treating the infection with antibiotics.

Dos and Don'ts After Knee Replacement Surgery

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For the safety of your artificial knee replacement, you should adhere to the following precautions.

If is especially important that you comply with these precautions during the first eight weeks after surgery.

• Avoid low chairs.
• Avoid slippery surfaces which may caused your leg to give way.
• Avoid twisting you r new knee for six to eight weeks.
• Do not sit longer than 45 minutes at a time. During the daytime get up every half-hour or so and take a brief walk. Prolonged sitting may make the muscles around your knee stiffen.
• Push to gain maximum range of motion during the first six to eight weeks following surgery.
• Do stay active. Walking is your most important physical therapy. You should take daily walks, each time lengthening your walking distances as your strength improves.

For the rest of your life, you should protect your artificial knee from undue stress by being careful about your activity. High-impact rhythmic activities, such as jumping, running, jogging, and sports, such as basketball, racquetball, volleyball, tennis, etc., should be avoided. Heavy lifting should be avoided. Low-impact rhythmic activities such as walking, cycling, swimming, and golf are suitable activities for recreation and exercise after knee replacement.

Enjoy you new knee!