Contents
Introduction
This booklet provides information for you and your family regarding
total knee replacement surgery. The surgical procedure, pre-operative
and post-operative care, the risks and benefits of surgery, as well as
rehabilitation, are explained. Please read and discuss this booklet with
your family before your total knee replacement surgery. The Orthopaedic
Health Care Staff's goals are to restore your knee to a painless,
functional status, and to make your hospital stay as beneficial,
informative and comfortable as possible. Please feel free to ask
questions or share concerns with the staff.
Total Knee Replacement
Total knee replacement is a surgical procedure in which injured or
damaged parts of the knee joint are replaced with artificial parts. 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 thigh bone (femur) and the shin bone
(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.
 
Who is a candidate for a total replacement?
Total knee replacements are usually performed on people suffering
from severe arthritic conditions. Most patients who have artificial
knees are over age 55, but the procedure is performed in younger
people.
The circumstances vary somewhat, but generally you would be
considered for a total knee replacement if:
- You have daily pain.
- Your pain is severe enough
to restrict not only work and recreation but also the ordinary
activities of daily living.
- You have significant stiffness of
your knee.
- You have significant instability (constant giving
way) of your knee.
- You have significant deformity
(lock-knees or bowlegs).
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. The operation will provide pain relief for at least ten
years.
If replacement provides you with pain relief and if you do not have
other health problems, you should be able to carry out many normal
activities of daily living. The artificial knee may allow you to return
to active sports or heavy labor under your physician's instructions.
Activities that overload the artificial knee must be avoided. About 90
percent of patients with stiff knees before surgery will have better
motion after a total knee replacement.
What are the risks of total knee replacement?
Total knee replacement is a major operation. About one patient in
four develops one or more complications. The effect of most
complications is that you must stay in the hospital longer.
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, or
blood clots in a lung.
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 reoperation. Infected artificial knees sometimes
have to be removed. This would leave a stiff leg about one to three
inches shorter than normal. However, your leg would usually be
reasonably comfortable, and you would be able to walk with the aid of a
cane or crutches, and a shoe lift. After a course of antibiotics the
surgery can often be repeated.
How long do artificial knees last?
About 85 to 90 percent of total knee replacements are successful up
to ten years. 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. By ten years, 25
percent of total knee replacements may look loose on x-ray, and about 10
percent will be painful and require reoperation. By ten years, possibly
20 percent may require reoperation.
Loosening is in part related to your weight and activity. For that
reason, total knee replacement usually is not performed on very obese or
young patients. 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 ahead of
the actual surgery date. Sometimes this can be done at your local
community hospital. Maintaining good physical health before your
operation is important. Activities which will increase upper body
strength will improve your ability to use a walker or crutches after the
operation.
A blood transfusion is sometimes necessary after knee surgery. You may
wish to donate several pints of blood prior to your surgery. Then if you
require a transfusion you will receive your own blood. This is called
autologous blood donation. The first donation must be given within 42
days of the surgery and the last, no less than seven days before your
surgery. The usual amount of donation is two units, which may
require separate visits to the blood center.
When donating blood, you must be healthy, without a cold, flu or
infection, as you could get this same illness when your blood is
transferred at the time of surgery. Eat a nourishing meal two to four
hours prior to donation, and avoid strenuous exercise for twelve hours
following the procedure.
The blood donor center will check the blood count before drawing
additional units. A prescription for iron will be given. Iron may be
constipating for some people, so sometimes a stool softener is
prescribed. Stool softeners can also be purchased over the counter.
You may be a candidate for autotransfusion after your surgery. Blood
collected from the wound drain is filtered and transfused back to the
patient early in the post-operative period. The physician will assist
you in deciding whether this procedure will be done.
The physician may order blood tests and urinalysis two weeks 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. Teeth need to be in good condition. An infected
tooth or gum may also be a possible source of infection for the new
knee. The orthopaedic physician may ask you to see a medical doctor,
especially if medical problems have been present in the past.
When making preparations for surgery, you should begin thinking about
the recovery period following surgery. A patient with a new total knee
replacement will need help at home for the first several weeks.
Assistance with dressing, getting meals, etc. may be necessary. Most
often discharge from the hospital is anticipated in about 3-4 days. Your
energy level will not have returned. If assistance from someone at home
is not possible, it may be necessary to think about making arrangements
to stay a few weeks in an extended care facility. A social worker is
available at the hospital to plan an extended period of recovery if
necessary.
Pre-op Visit
Due to changes in insurance coverage, it is necessary for most
patients to make a visit to the hospital a few days 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. 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 include the following topics and other
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.
Diet
You should follow your regular diet on the day before your surgery.
DO NOT EAT OR DRINK AFTER MIDNIGHT. The day of surgery you may
brush your teeth and rinse your mouth without swallowing any water.
Bathing
A shower, bath or sponge bath should be taken the evening before and
morning of surgery. You will be given antiseptic scrub brushes to use.
Using the spongy side, scrub your knee for a period of five minutes.
This may require assistance from a family member. The brushes contain a
special soap which will reduce the risk of infection. If you are
allergic to iodine or soap, please inform the nurse. If possible, you
should shampoo your hair. Nail polish and make-up should be removed.
Deep Breathing Exercises
You will be instructed in deep breathing exercises to minimize the risk
of lung complications after surgery. These exercises are necessary to
remove any excess secretions that may settle in your lungs while you are
asleep during surgery. These exercises are to be done every one-to-two
hours after surgery. An incentive spirometer may be demonstrated. This
bedside device assists you in deep breathing exercises.
Blood Clot Prevention
You may be fitted with elastic support stockings (TEDS). These
stockings aid the circulation of your legs and feet to reduce the risk
of blood clots.
Anesthesia
You may be scheduled for an appointment with the anesthesiologist to
discuss how you will be put to sleep. The anesthesiologist will advise
you about taking routine medications on the day of your surgery.
Pain Control
Please read the booklet on "Patient Controlled Analgesia" (PCA) which may be used for pain control for the first day after your
surgery. When the 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.
The physician will also review your medical history and the
medications that you take. He will listen to your heart and lungs, and
do a general physical exam. He will check for any type of infection. Any
blisters, cuts, or boils should be reported. If infection is found,
surgery is generally delayed until the infection is cleared.
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. An EKG is obtained if you have not had one
taken for six months or if otherwise indicated. After all of these tests
and exams are completed, an anesthesiologist will talk with you to
determine the type of anesthesia that is best suited for you. After you
see the anesthesiologist, your pre-op evaluation is usually over. 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. Remember, we want you to be in your best possible health!
Surgical Checklist
Night Before Surgery
- Shower (with 5 minute scrub to surgical area with brush
provided)
- Nothing to eat or drink after midnight
- Review booklet, exercises
Day of Surgery
- Routine medications with sip of water (as instructed by your
anesthesiologist)
- Second shower and scrub
Day of Surgery
You should arrive at Day of Surgery Admissions (DOSA) at the instructed time, with your knee scrubbed. The nurse will spend a few minutes again making sure that you are still in good health and ready for surgery. The nurses try to give you a good estimation of when you need to be at the hospital. However, it is hard to predict how long every surgery is going to take, so expect some waiting time. Bring something to do to help pass the time.
You will be asked to change into a hospital gown. You will be
transported to the operating room on a stretcher. Your family may
accompany you on the elevator and then will be instructed to wait in the
Day of Surgery Lounge on 6th floor, John Pappajohn Pavilion. Your
doctors will talk to your family after the surgery to report your
progress.
You will be taken to a presurgical care unit where an intravenous
(IV) is started for the administration of fluids and medications during
and after the surgical procedure. From there you will be transported to
the operating room by your anesthesiologist.
The actual surgical procedure may take two to four hours. However,
preoperative preparation as well as wake-up time may make your operating
room and recovery room stay longer.
After Surgery
After surgery you will be taken to the Recovery Room for a period of
close observation, usually one to three hours. Your blood, pressure,
pulse, respiration and temperature will be checked frequently. Close
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 likely
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 is usually changed 2 days after surgery by the surgeon.
- A hemovac suction container with tubes leading directly into the
surgical area enables the nursing staff to measure and record the
amount of drainage being lost from the wound following surgery. The
hemovac is usually removed by your doctor one day after
surgery.
- An IV, started prior to 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 saline-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, until all drains are removed, to reduce the risk of
infection.
- Elimination: One side effect of anesthesia is
often a difficulty in urinating after surgery. For this reason, a
sterile tube called a catheter may be inserted into your bladder to
insure a passageway for urine. This may remain in place for one to
two days.
- Besides the elastic hose (TEDS), you will also
have a compression foot pump. This is a wrap that is connected to a machine which puts pressure on the bottom of the foot. This is another method of promoting blood flow and
decreasing the chances of blood clots. You will also be given
medications and exercise instructions (moving your ankles up and
down), which also help to prevent clots.
- Post-operatively
you may have temporary nausea and vomiting due to anesthesia or
medications, i.e. PCA. Anti-nausea medication may be given to
minimize the nausea and vomiting.
- Diet: You will be allowed
to progress your diet as your condition permits; starting with ice
chips and clear liquids to diet as tolerated.
- A knee
immobilizer will be worn as directed by your physician.
- Coughing and Deep Breathing: To help prevent complications, such
as congestion or pneumonia, deep breathing and coughing exercises are
important. 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 incentive spirometer.
- In order to speed your rehabilitation, you may be using a
continuous passive motion (CPM) machine. It 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.
- You will be assisted into the chair the
first day after surgery provided there are no complications. Physical
therapy is started the morning after surgery. It is very important for
you to have pain medication 30 minutes before going to physical
therapy to help you fully participate in exercises. Please discuss
this with your nurse.
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. If there are no complications after
surgery, most patients stay in the hospital approximately 3-4 days.
Exercise Program and Physical Therapy
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.
Your overall progress, amount of pain, and condition of the incision
will determine when you will start going to physical therapy. If no
problems arise, your doctor will have you start the morning after
surgery. 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 3 stairs.
- Independent in your home exercise program.
Your doctor and therapist may modify these goals somewhat to fit your
particular condition.
In your physical therapy sessions you will walk, using crutches or a
walker, bearing as much weight as indicated by your doctor or physical
therapist. You will also work on an exercise program designed to
strengthen your leg and increase the motion of your knee.
Your exercise program will include the following exercises:
Quadriceps Setting
The quadriceps is a set of four muscles located on the front of the
thigh and is important in stabilizing and moving your knee. These
muscles must be strong if you are to walk after surgery. A "quad set" is
one of the simplest exercises that will help strengthen them.
Lie on your back with legs straight, together, and flat on the bed,
arms by your side. Perform this exercise one leg at a time. Tighten the
muscles on the top of one of your thighs. At the same time, push the
back of your knee downward into the bed. The result should be
straightening of your leg. Hold for 5 seconds, relax 5 seconds; repeat
10 times for each leg.
You may start doing this exercise with both legs the day after
surgery before you go to physical therapy. The amount of pain will
determine how many you can do, but you should strive to do several every
hour. The more you can do, the faster your progress will be. Your nurses
can assist you to get started. The following diagram can be used for
review.
Terminal Knee Extension
This exercise helps strengthen the quadriceps muscle. It is done by
straightening your knee joint.
Lie on your back with a blanket roll under your involved knee so that
the knee bends about 30-40 degrees. Tighten your quadriceps and
straighten your knee by lifting your heel off the bed. Hold 5 seconds,
then slowly your heel to the bed. You may repeat 10-20 times.
Knee Flexion
Each day you will bend your knee. The physical therapist will help
you find the best method to increase the bending (flexion) of your knee.
Every day you should be able to flex it a little further. Your therapist
will measure the amount of bending and send a daily report to your
doctor.
In addition, your therapist may add other exercises as he or she
deems necessary for your rehabilitation.
Straight Leg Raising
This exercise helps strengthen the quadriceps muscle also.
Bend the uninvolved leg by raising the knee and keeping the foot flat
on the bed. Keeping your involved leg straight, raise the straight leg
about 6 to 10 inches. Hold for 5 seconds. Lower the leg slowly to the
bed and repeat 10-20 times.
Once you can do 20 repetitions without any problems, you can add
resistance (ie. sand bags) at the ankle to further strengthen the
muscles. The amount of weight is increased in one pound increments.
Use of heat and ice
Ice: Ice may be used during your hospital stay and at home to
help reduce the pain and swelling in your knee. Pain and swelling will
slow your progress with your exercises. A bag of crushed ice may be
placed in a towel over your knee for 15-20 minutes. Your sensation may
be decreased after surgery, so use extra care.
Heat: If your knee is not swollen, hot or painful, you may use
heat before exercising to assist with gaining range of motion. A moist
heating pad or warm damp towels may be used for 15-20 minutes. Your
sensation may be decreased after surgery so use extra care.
Guidelines at Home
What happens after I go home?
Medication
- You will continue to take medications as prescribed by your
doctor.
- You will be sent home on prescribed medications to
prevent blood clots. Your doctor will determine whether you will take
a pill (Warfarin or coated aspirin) or give yourself a shot
(Enoxaparin). If an injection is necessary, your doctor will discuss
it with you, and the nursing staff will teach you or a family member
what is necessary to receive this medication.
- You will be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises. Preventing pain is easier than chasing pain. If pain control continues to be a problem, call your doctor.
Activity
- Continue to walk with crutches/walker.
- Bear weight and walk on the leg as much as is comfortable.
- Walking
is one of the better kinds of physical therapy and for muscle
strengthening.
- However, walking does not replace the exercise program which you are taught in the hospital. The success of the operation depends to a great extent on how well you do the exercises and strengthen weakened muscles.
- If excess muscle aching occurs, you should cut back on your exercises.
Other Considerations
- For the next 4-6 weeks avoid sexual intercourse. Sexual
activity can usually be resumed after your 6-week follow-up
appointment.
- You can usually return to work within two to three months, or as instructed by your doctor.
- You should
not drive a car until after the 6-week follow-up appointment.
- Continue to wear elastic stockings (TEDS) until your return
appointment.
- No shower or tub bath until after staples are
removed.
- When using heat or ice, remember not to get your
incision wet before your staples are removed.
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. Generally, the staples
are removed in three 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. You will be
given a medical alert card. This should be carried in your billfold or
wallet. It will give information on antibiotics that are needed during
dental or oral surgery, or if a bacterial infection develops.
When do I return to the clinic?
Your first return appointment is 6 weeks after discharge, at which
time you will be examined and have x-rays. Subsequent appointments are
then at 6 months, one year, and two years after surgery. You should
return every three years after this.
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 a.m. and 5 p.m., Monday through Friday, please phone
the Orthopaedics Clinic 319-356-2377. After 5 p.m. and on the
weekends and holidays, please phone 319-356-1616 and ask to speak to the
orthopaedic resident on call or to the orthopaedic nurse supervisor.
Should I have a total knee replacement?
Total knee replacement is an elective operation. The decision to have
the operation is not made by the doctor, it is made by you.
The physician may recommend the operation, but your decision must be
based upon your weighing the benefits of the operation against the
risks.
All your questions should be answered before you decide to have the
operation. If you have any questions, please feel free to ask the health
professionals at University Hospitals' Orthopaedic Clinic.
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