TOTAL KNEE REPLACEMENT

There are many types of arthritis (rheumatoid, degenerative, post-traumatic, auto-immune induced, etc.). The most common form is osteoarthritis. It is also known as degenerative joint disease (DJD). While the exact cause is unknown, there are known to be several possible causes including: injury, age, congenital predisposition and obesity. It is characterized by the breakdown of the articular cartilage within the joint.

Articular cartilage is a firm rubbery protein material covering the end of a bone. It acts as a cushion or shock absorber between the bones. When articular cartilage breaks down, this cushion is lost, and the bones will grind together. This causes the development of symptoms such as pain, swelling, bone spur formation and decreased motion. Osteoarthritis commonly affects weight bearing joints such as the knee, but it may affect any joint.

Initially, arthritis of the knee is usually treated non-operatively. The treatment methods may involve weight loss, anti-inflammatory medications, physical therapy, injection of the joint with cortisone, injection of the joint with a type of synthetic joint fluid designed to lubricate the arthritic surfaces (Hyalgan), and arthroscopic debridement of the damaged tissue within the joint.

Eventually, a knee replacement may be indicated, after the other treatment methods have failed. Typically, the TKR is delayed as long as possible. This is primarily because the total knee replacements will eventually fail and the replacement may need to be replaced. Unfortunately, when this occurs, the quality of the result, and the amount of function in the reconstructed knee decreases. Currently, most total knee replacements have a life span of approximately 10 years. While the replacements typically work very well in a person who has a severely arthritic knee, the replacement is not like a normal knee joint. The types of activities that a person may do after surgery are limited. For example, jogging and skiing place too much stress on the total joint replacement and will increase the likelihood of failure of the joint, thereby requiring a revision (replacement of the TKR).

For a TKR, the preparations often start about a month before surgery. Most patients who have a total knee replacement will require blood transfusions after surgery. If the patient wishes to be transfused with his own blood, then the patient will often donate 1 unit of blood per week for the three weeks prior to surgery. During this time, the person is often doing physical therapy to get ready for the surgery. Usually, the patient is admitted the morning of surgery, taken to surgery where the knee replacement is performed, and then starts in physical therapy the morning after surgery. Most patients will stay in the hospital for approximately 5 days.

After surgery, you will go to the Recovery Room where you will be watched closely while you wake up from your anesthesia. Usually, you stay in the Recovery Room for about 1-2 hours before going to your room.

Your health care team will use different types of equipment and procedures to measure your progress and help you recover from your surgery.

• VITAL SIGNS & CIRCULATION: Your temperature, pulse, respiration and blood pressure will be checked along with the pulses on the top of your foot. You will be asked to wiggle your toes and foot frequently to help circulate your blood and use your leg muscles.

• TED HOSE: Specially-designed stockings may be used after your surgery to help increase the blood flow in your legs while you are in bed. These help prevent blood clots from forming in your legs. They should be taken off every 8 hours for about 1/2 hour and then put back on. You will want to wear these when you go home from the hospital also.

• FOOT PUMPS: For the first few days after surgery, special foot wraps will be used while you are in bed. These wraps attach to an air pump so that they inflate and deflate about every 5 minutes. These pumps increase the blood flow in your legs and help to prevent blood clots from forming.

• SURGICAL DRESSING: Your surgical site will be covered with a rather bulky dressing at first. Your nurse will look at your dressing periodically. Usually, this dressing is replaced by a lighter one several days after surgery.

• WOUND DRAINS: Sometimes a small tube is placed inside your incision during your surgery to collect any extra fluid or blood so it doesn't build up in your knee. The fluid drains into a container that the nurses will measure and empty periodically. Usually the drain is removed the second day after surgery.

• URINARY CATHETER: Sometimes, a small tube, or catheter, will be temporarily placed into your bladder during surgery to drain your urine into a collection bag. If you do not have a catheter, then you will use a bedpan or urinal to empty your bladder until you are able to get up to the bathroom. If you have difficulty urinating after surgery, then a catheter may be inserted after arrival to the floor.

• IV: Just before surgery, a needle will be placed in one of your veins, usually in your arm or hand. This needle, called an IV, will be used to give fluids and medicines during and after surgery. Once in place, it shouldn't be painful to you. Let your nurse know if you have any discomfort from the IV needle.

• INCENTIVE SPIROMETER: The Incentive Spirometer is a small device that helps you take deep breaths. This will help your lungs expand more fully helping to prevent pneumonia after surgery. Your nurse or Respiratory Therapist will teach you how to use this device. You may get a chance to see how to use this before surgery. It is very important to breathe into this device at least 10 times every hour while you are awake for the first few days after your surgery.

• OXVGEN: Sometimes, a little extra oxygen may be used after your surgery to help you breathe easier. Usually, if oxygen is used, it is only needed for the first day or so after surgery. The oxygen may be given through prongs placed close to your nose or through a mask over your mouth. A Respiratory Therapist will be working with you if you should need oxygen after your surgery.

• CONTINUOUS PASSIVE MOTION DEVICE (CPM): After surgery, it is advisable to begin moving the knee as soon as possible. This is done with a device known as a CPM unit which is applied to your leg after surgery. This device moves very slowly. By starting early motion, it is possible to shorten the rehabilitation time. Surprisingly, studies have shown that early motion allows for more rapid healing and lessens the pain after surgery. The CPM device should be used as often as possible.

  For more information on CPM machines:CPM - CONTINUOUS PASSIVE MOTION

• NAUSEA MEDICATIONS: Some people experience some nausea, or even vomiting, after surgery. Anesthesia causes nausea for some people, but this usually goes away during the first day. Your doctor will order medication to treat this, just in case it is a problem for you. Let your nurse know how you feel.

• PAIN MEDICATIONS: You will be able to discuss with your doctor or anesthesiologist the best way to control your pain after surgery. Several types of pain medications may be used. These include:
  • PCA pump: PCA stands for "Patient Controlled Analgesia". This is a machine that allows you to give your own pain medication within certain ranges set by your doctor. Don't worry, you can't give yourself too much medication, but because you know best when you need something for pain, you can control when your pain medication is given. The machine is connected to your IV and contains a vial filled with the type of pain medication your doctor has ordered for you. You will be given a control button to push when you need the machine to give your pain medicine. It is very important to give this medicine before your pain gets too bad, but it is also important that you, and not your family members, are the only one to operate your machine. Your nurse will give you more instructions on how to operate your PCA pump after your surgery.

  • Pain Shots and Pain Pills: Sometimes, pain shots or pain pills might work best to relieve your pain. Your doctor will determine which will work best for you. When using this type of medication, it works best if you take them before your pain is too severe, since they take at least 20-30 minutes to start working.

• BLOOD THINNERS: Many patients will need a "blood thinner" temporarily after surgery to help prevent blood clots. Some "blood thinners" can only by given by an injection, while others may be given in a pill form. Special blood tests will help your doctor give the exact amount of medicine that your body needs. Some people will need to take blood thinners for a while after surgery.

• ANTIBIOTICS: Antibiotics are special medicines which help treat or prevent infections. These will be given through your IV, usually for the first 48 hours after your surgery. Your doctor might decide to use them for longer depending on your needs.

• CONSTIPATION: After surgery, constipation is a problem for many people. Pain medications, decreased activity and changes in your diet all interfere with your normal bowel pattern. Stool softeners or laxatives can be given if you need them. Please don't be embarrassed to discuss this with your nurse.

• THERAPY: Therapy will begin the day of your surgery unless otherwise ordered by your doctor. Some pain should be expected when starting activities after surgery, but it is very important to begin as early as possible. Your doctor will prescribe medications to help minimize the pain you experience.

  The Physical Therapist will assist you in learning how to safely get in and out of bed and walk with your walker or crutches. The therapist will also assist you in regaining the strength in your leg. After surgery, you will be allowed to put as much weight as you can tolerate on your leg when walking.

  The Occupational Therapist will assist you in learning how to safely perform your daily activities like bathing, dressing, and getting in and out of the bath tub. The therapist will also assist you in increasing the strength in your arms.

At the time of discharge, patients are usually using crutches or a walker. The sutures or staples are usually removed at about 2 weeks after surgery. By 6 weeks, most patients are using a cane to walk. After being discharged from the hospital, most patients will be involved in a outpatient rehabilitation program several times a week. This is a physical therapy program that involves supervised PT visits as well as a program of home exercises that the patient must do. The purpose of these exercises is to regain motion of the knee joint, regain strength, and speed the recovery process. After recovery from the surgery, there may be activity limitations that a patient may have placed upon them. Your surgeon will usually go over these in detail. In addition, once a person has a total joint replacement, it is necessary to occasionally take antibiotics to prevent infection of the joint. Usually this is necessary for some dental procedures and some types of surgery. Your surgeon will also discuss this with you.

Finally, after discharge from the hospital, it will be necessary to have follow-up visits with your surgeon. However, if at any time during your care you have any questions, you should contact your surgeon. In addition, contact your surgeon if any of the following occur:

• Fever over 100 degrees
• Drainage from incision
• Redness around incision
• Chest pain
• Chest congestion
• Shortness of breath or difficulty breathing
• Calf pain or swelling in your legs
• Dizziness or confusion
• Any other questions or concerns that you may have

THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN FOR SPECIFIC TREATMENT RECOMMENDATIONS.

THE CENTER FOR ORTHOPAEDICS AND SPORTS MEDICINE
1211 JOHNSON FERRY RD.; MARIETTA, GA., 30068
770-565-0011
http://www.arthroscopy.com

Copyright (c)1999 by The Center for Orthopaedics & Sports Medicine - ALL RIGHTS RESERVED