Total Knee Replacement - Brief Summary of Care Before and After Surgery

Joint Reconstruction Center
Department of Orthopaedics
Georgetown University Medical Center

Joint replacement surgery requires that you take an active role in your preoperative and postoperative care as well as rehabilitation. This booklet will provide useful and important information about your surgery and serve as a reminder and reference after surgery. If you have any questions, please feel free to ask your surgeon, nurse or therapist. 

Total knee replacement (TKR) is a common operation today. Approximately 200,000 replacements are performed each year. A wide variety of disorders result in knee disease. They all result in pain, limitation of motion and restriction of a person's ability to participate in the activities of daily living. The primary goal of knee replacement surgery is to relieve pain. This can be accomplished in more than 95% of patients. The results of TKR can last approximately ?? years. In fact, one study found that more than ??% of TKRs lasted a minimum of ?? years. 

Total knee replacements are very successful at relieving the pain and limitations resulting from knee disease. However, you must actively participate in the care of your knee replacement after surgery. Some activities will need to be modified and some may not be appropriate after knee replacement.

The knee joint is composed of the femur (thigh bone), the tibia (shin bone) and the patella (knee cap). In total knee replacement, the surfaces of these bones are cut and resurfaced with metal and plastic parts. The components are attached to your bones with a special cement. A plastic liner is inserted between the femur and tibia to help the parts move smoothly.

Several important steps need to be taken before joint replacement surgery. First, we are committed to providing you with the highest quality of care. In order to do that, we need information about you, your health and how pain and limited mobility has affected your daily life. You will receive several questionnaires in the mail. Please take time to complete and return them. All information is strictly confidential and will be used to track your progress throughout each stage of recovery and rehabilitation.

In addition, blood and urine tests will be taken as well as an EKG and, possibly, a chest x-ray. These will be reviewed by your primary care physician to ensure that you are in good medical condition and can tolerate anesthesia safely. If you have had any recent dental surgery or infections, you should inform your surgeon before admission. Any planned dental work should be carried out before joint replacement surgery. In addition, you should stop taking aspirin or aspirin-like products ten days before the day of surgery.

Most patients will be asked to donate two units of their own blood before surgery. This blood will then be available for use during or after surgery. One unit of blood is donated at a time. The second unit will be donated one week after the first. Then two weeks are allowed for your blood to rebuild before proceeding with surgery. Some patients may not be able to donate their own blood or may require more units than they donate. This blood will come from the Blood Bank. All of the blood in the Blood Bank, including the units you donate, is screened for Hepatitis C and HIV (the virus that causes AIDS) according to Red Cross guidelines. However, there is still a small risk of disease transmission by transfusion. If you have any questions, please ask your physician for a further explanation. 

Physical and occupational therapists will meet with you before the surgery. They will introduce themselves and begin instruction on exercises to increase your range of motion. The physical therapist will review some exercises, which will be helpful postoperatively, such as quad sets, dangles, leg extensions and straight-let raises. These exercises will also help you maintain muscle tone and good blood circulation in your legs. The occupational therapist will show you how to do some of the basic activities of daily living after TKR.

Your surgeon will provide an estimate of your expected length of stay in the hospital and your functional level at the time of discharge. This will provide a basis for you to plan for your home care. You may wish to have someone stay with you for several weeks after surgery until you are independent in your daily activities. 

Before you come to the hospital, you should prepare several things. It will be very helpful for you to provide a list of all the medications you take, including the dose and number of times you take them per day and a list of any allergies you have to medications, foods, tape or latex products. You should bring in a knee-length bathrobe, a pair of shorts or sweat pants and a pair of sturdy shoes with non-skid soles (tennis shoes or sneakers are ideal) to use for therapy and for walking in the hall post-operatively. The night before surgery do not eat or drink anything after midnight. Prepare your home by removing loose rugs and making sure your carpeting is secure. You might want to set up a room on one level of your home where you stay comfortably for a majority of the day.

On the day of surgery, you will meet one of the orthopaedic surgery residents who will perform a history and physical examination and review your medications, allergies and your laboratory studies. The anesthesiologist will also meet with you to discuss your anesthesia and answer any questions you have about it. The anesthesiologist will start an intravenous line and may begin the anesthesia before you enter the operating room if you have decided to have an epidural or spinal anesthesia. 

You will then be taken to the operating room, where you will be sedated or anesthetized and positioned for the surgery. After the surgery, you will be transported to the recovery room in your hospital bed. You will be in a knee immobilizer. Your incision will be covered with a bulky dressing, and you will have a drainage tube from the dressing to prevent blood from accumulating at the site. 

 In the recovery room the nurses will frequently check your blood pressure, temperature and heart rate. The circulation to your feet will also be monitored. If you have an epidural or spinal anesthesia you may not be able to move your toes or legs for several hours after surgery. This is normal and the function will return after the anesthesia wears off. If appropriate, you may receive a patient-controlled analgesia (PCA) device that will allow you to control your own pain medication. Limits are set in the device to prevent you from overmedicating yourself. The amount of medication you receive can also be adjusted to maintain your comfort. 

After you have recovered from the anesthesia, you will be taken to your room on the orthopaedic surgery floor located on the sixth floor of the Main hospital building. A nurse will continue to monitor your vital signs, circulation and pain. You should try to cough, take deep breaths and pump your feet. These activities will help to improve your breathing and maintain the circulation in your legs while in bed.

 

You will remain in bed until the evening or the first day after surgery. While you are in the hospital bed, you should continue deep breathing and coughing to prevent congestion in your lungs. These exercises should be performed every hour while you are awake. 

After surgery, we do several things to reduce the risk of blood clots forming in the veins of your legs. If they do form, this can lead to increased swelling in your legs. If the clots break loose they may travel to your lungs and interfere with breathing. To avoid such complications, we will apply elastic stockings to help prevent blood from pooling in your legs. We may place you on either aspirin or Coumadin to thin your blood to reduce the risk of clot formation. In addition, you should continue the exercises in bed to maintain the blood flow in your legs and to keep your heart and muscles strong.  Pump your feet up and down 20 times each hour while awake. Do not put a pillow under your knee.

Your bed will have an overhead trapeze bar for you to use to reposition yourself. You may use this to lift your buttocks off the bed and shift your position. The nurses will also assist by turning you from side to side and placing pillows behind you for support. You may move in bed within the limits of your comfort. This activity will help to prevent your skin from becoming irritated and improve your comfort. If an area of your skin feels hot or sore and cannot be relieved by shifting, notify your nurse.

After you have recovered from anesthesia, you will be able to drink and eat. However, because of the medication you have received for pain control and anesthesia, your stomach will not be able to tolerate more than a small amount. Initially, you should start with small amounts of fluids and then slowly progress to solid food over the first 24 to 36 hours after surgery.

Pain Medication

After surgery the operative site will be significantly painful for the first one or two days.  You will be able to control your pain with the PCA. More traditional methods of pain management, such as intermittent injections of medication, can be provided instead of a PCA.

After two days, the PCA or injections should no longer be necessary and oral medications will provide satisfactory pain relief. The oral pain medication can cause nausea, constipation and a light-headed sensation. If these occur, inform your surgeon or nurse and the medication can be changed. You will be given a prescription for pain medication when you are discharged from the hospital. This is helpful as some people are more active at home than in the hospital before discharge.

Dressings & Sutures

The postoperative dressing will remain in place for two or three days unless it becomes soiled. After the initial dressing is removed, it will be replaced with a dry gauze dressing daily until all drainage stops (approximately three to six days after). The staples will be removed approximately 10 to 20 days after the surgery. This may require you to return to the surgeon's office for staple removal after discharge from the hospital. It is common to feel some superficial numbness on the outside part of the knee, and this may persist for several months.

Swelling

Swelling in the operative leg is normal after knee replacement. Normal swelling is reduced in the morning when awakening, and gradually accumulates Throughout the day as you are active and on your feet. This can be reduced by elevating your legs or lying down for 30 to 60 minutes during the day. Any activity that leaves your feet on the floor, such as sitting in a chair or walking can lead to swelling. If the swelling is severe in the morning when you first arise, contact your surgeon. Swelling and a little warmth are normal and may persist for 3-4 months after surgery. Your replace knee may always be a little larger than your other knee.

The primary objective of knee replacement is to eliminate your knee pain in order to allow you improved mobility. Physical and occupational therapy will begin on the first day after surgery. The physical therapist will review some exercises (quad sets, dangles, leg extension and straight leg raises). It is important to follow the instructions carefully while you are in the hospital and after you are discharged.

The continuous passive motion (CPM) machine is an important piece of equipment for your rehabilitation. Use the CPM four hours every day. This may be split into two 2-hour sessions. Increase the degrees of flexion by 10° until you can easily reach 90°. Once you have reached 90°, you no longer need to use the CPM. However, it is important to continue with the other exercises the physical therapist has shown you. For knee flexion, perform leg dangles over the edge of your bed twice a day. Use a pillow or rolled towel under the ankle of the operative leg to achieve full extension. When you can perform a straight leg raise on your own, you may discontinue use of the knee immobilizer. You may bear your full weight on the operative leg, as tolerated. The use of a walker or cane is helpful while you regain strength in the leg. A bag can be attached to your walker or crutches to assist you in carrying items. Remember, walking is the best exercise for your rehabilitation.

Getting out of Bed or a Chair

Getting out of bed begins the day after surgery.  First, you will dangle your legs over the edge of the bed and transfer to a chair. If you tolerate this well, you will take a brief walk in the room with a walker and the help of a nurse or therapist. When you first get up, you may become dizzy. Please inform the therapist or nurse if this happens. This is normal and usually passes as you become more accustomed to getting up. The therapist will instruct you on the correct way to get into and out of bed. At home, use chairs with arms to help you get in and out of the chair.

Walking & Stairs

You will begin walking with a walker. You may bear as much weight on the knee as you can tolerate. The therapist will teach you how to use the walker and how to safely turn. Stair climbing will also be part of your instruction while in the hospital. Your therapist will review and practice these techniques with you. When going up or down stairs, use a handrail or banister for stability. Lead off with you good knee to go up stairs, and lead with your operative leg to go down stairs. Go up or down stairs on at a time.

 

The occupational therapist will review important information about how to safely perform your activities of daily living. The therapist will discuss how to safely bathe, dress, prepare food and function independently at home after surgery.

 The Bath & Toilet

Plan to use a shower or sponge bath at home after surgery. A walk-in stall shower with a support rail is ideal. A shower seat may also be useful if applicable to your bathroom. If you cannot safely get in and out of the shower, you may sponge bathe at a sink. You will not be able to take a bath for eight weeks after surgery.  Traction strips for the shower are helpful to prevent slipping.

Use of the Car

If you drove on a regular basis without restrictions before surgery, you may be able to resume driving six weeks after surgery. Before venturing on the road, take time to practice in a secluded area. You may notice that your reaction time is longer, particularly if your right knee is replaced. You should discuss this with your doctor. If you will require handicapped parking permit during rehabilitation, please obtain the necessary forms from your state department of motor vehicles. Bring these forms to the office  and we will complete the forms for you.

 

A bag can be attached to your walker or crutches to help you carry items.

Rearrange your cabinets and refrigerator, closets, etc., before admission to place frequently used items within easy reach.

 

Most patients are discharged home with physical therapy follow up. If you live alone, you may wish to stay with relatives or have them stay with you for the first four weeks after surgery. However, while in the hospital,  you will be closely monitored by the orthopaedic service and physical therapy and we may decide you would benefit from time in a rehabilitation facility.   Before your surgery, you should contact your insurance company for a list of approved rehabilitation facilities and take tours of a few facilities.  If you are recommended for rehabilitation you will already have an idea of were you want to go.  Our caseworkers will work closely with you to arrange for placement and transfer to the facility

You will be provided with prescriptions for pain medication and enteric coated aspirin after the surgery. Continue the aspirin for six weeks after the date of surgery to help prevent blood clots.

At home, keep your wound dry until after the staples are removed. This will usually be done in your surgeon's office 10 to 20 days after the surgery.

For transportation home you may ride in a car. If this is not possible, we will make other appropriate arrangements.

 

Patients commonly have questions about which activities are acceptable after TKR. It is safe and recommended that you walk as much as you can tolerate. In addition, you may engage in nonimpact activities, such as stationary bicycling, swimming, golf and bowling. However, impact activities, such as racquet sports, jogging and horseback riding are not advised because they may lead to excessive wear or loosening of the prosthetic components. You may kneel, but this may be uncomfortable because the incision is over the front of your knee. Don't be alarmed if you hear a "clunk" or clicking. It is common to hear these sounds as the metal and plastic parts move. Call the office, if these sounds are accompanied by pain.

Antibiotics

Before any dental, urological, gastrointestinal or surgical procedure you must notify your doctor that you have a joint replacement. You may need to take antibiotics to protect the joint replacement from infection. If you or your physician have any questions, you should contact your surgeon.

 Follow-up

 It will be necessary for you to return to your surgeon's office for regular evaluations. This is particularly important in the weeks and months immediately following your surgery. Generally, these office visits take place two weeks from the day of surgery, then at four weeks, three months, six months, one year and then, every other year. During these visits, several parameters will be assessed, including your incision, level of pain, range of motion, and x-rays. The surveys you completed before surgery will need to be filled-out at each postoperative visit.

This information should serve as a general guide for you in the care of your knee replacement. As this is general information, your own care after surgery may be modified by your surgeon based on the specific nature of your surgery and general condition. If your have any concerns or do not understand something, we hope you will call and ask questions.

 

Blood Donation Service (202) 444-5425

Joint Reconstruction Center (202) 444-5243

Georgetown Orthopaedic Case Management (202) 444-3750

Orthopaedic nurse practitioner (202) 444-7141

Pre-testing (202) 444-2746

Physical & Occupational Therapy (202) 444-3690

Sixth Floor Main Hospital (202) 444-2241

 

In case of emergency:

Orthopaedic resident on-call (202) 444-7243

Joint Reconstruction Center Department of Orthopaedics Georgetown University Medical Center Phone (202) 444-5243     Fax (202) 444-7804