Knee Replacement Surgery
The goal of knee replacement surgery is to relieve pain and to improve function and stability. Knee surgery is commonly performed for reasons such as osteoarthritis, rheumatoid arthritis, avascular necrosis, trauma or problems from birth.
Degeneration of the knee joint can affect people of all ages. In the young, it often begins due to trauma in an automobile/motorcycle accident, football injury, falling off a horse or bicycle, or medication which causes the bone to lose its blood supply (avascular necrosis). It can be caused by gradual eroding diseases such as rheumatoid arthritis or lupus. The most common cause is simply normal wear and tear of the cartilage over a lifetime of use, and it is called osteoarthritis. In order to be considered for a total knee replacement there will be three major reasons to have surgery. These are the severe pain you cannot stand it, inability to participate in activities you wish to do, and fear of falling.
Artificial knees last anywhere from one year to twenty years with an average life of 15 years. Since some bone is lost with each replacement, it is better to be in your 50’s or 60’s if possible before having your first knee replacement; however, we know that this is not always possible. To insure the longest life possible for your artificial joint, it is best to maintain a normal weight and avoid abusive activities, such as running for exercise.
A regular x-ray of your knee will give us a realistic picture of what has happened to your bone. The x-ray, the history you give, and a physical examination of your knee will help your surgeon diagnose your condition. Even with all the sophisticated diagnostic tools available today, an x-ray is all that is needed majority of the time.
In the early stages of knee disease (degenerative joint disease), a program of exercise, such as a recumbent bike, swimming, weight control, and non-steroidal anti-inflammatory drugs (NSAIDs), can help decrease the need for surgical treatment. For people under the age of 50, conservative treatment is important to try to delay the need for the knee replacement until they are older. When conservative measures are no longer helpful and one meets certain criteria including weight and strength capacity, a total knee replacement can be the answer.
When a knee replacement is decided upon, a combination of metal and plastic are implanted to create a new joint that will glide painlessly with a greater range of motion than one has had in years. Many different prostheses exist, and specific details about you dictate the type selected. The metals used are extremely strong metals designed specifically for use in orthopedic surgery. Polymethyl-methacrylate (PMMA, commonly called “bone cement”) may also be used to hold the tibial and femoral components in place. Dr. Bramlett generally does not use a tourniquet, if cement is not used.
For knee replacement surgery, an incision is made down the middle of the knee, four to eight inches long. The knee joint is exposed. The smallest amount of bone possible is removed and replaced with the metal and plastic components chosen for you. When the joint has been tested for maximum flexion and extension and your surgeon is satisfied with the stability of the knee, it is closed with a drain in place. A dressing is applied, and you are taken into the recovery room. The surgery itself takes approximately 30 minutes.
Complete recovery should be obtained within 3-6 months; yet, this is dependent on one’s health history. Most patients progressively return to their normal activities within 6 weeks, even though, healing will continue for weeks after that. Within a year you will forget you have an artificial knee. You may still have some stiffness with weather changes or increased activity, but your daily life will be much improved. Better quality of life is the main goal for this surgery. Eliminate pain and gain confidence in range of motion and function.
As with any type of surgical procedure, there are certain risks associated with knee surgery. These problems include infection, swelling, blood clots, nerve palsy, vascular injury, fractures, and pulmonary embolus. Rare complications do sometimes occur. Extensive measures are taken to prevent each of the above. You will be instructed in measures that will help to decrease the likelihood of problems and aid in a safe healing process. Your cooperation is vital in preventing many of the above complications.
Total knee replacements are excellent procedures when chosen and performed correctly on appropriate patients. Your surgeon can provide information regarding the specific procedure and implant selected for you.
We hope that you find this information helpful. If any of the material mentioned in this booklet is confusing or hard to understand, you may contact the office with any questions.
Thank you for taking the time to read this material. We understand that this manual contains a great deal of information. We also know that the best results come from the most informed patients and those motivated to see themselves in their best condition as quickly as possible.
Information needed BEFORE surgery:
- Total knee patients sometimes need to have a medical check-up before surgery with an internist or primary care physician. If you have any type of heart, kidney, or lung conditions, or you have had heart surgery, you will need to obtain a medical clearance letter from your physician. This is suggested in order to prevent any acute changes in your condition from occurring and will serve to insure a safer, less complicated hospital stay.
- If your medications change from the time of your office visit until your surgery, please notify the office. It is always wise to keep a complete list of your medications and allergies with you, especially when coming to the hospital. If you have not gone to Pre-Admission Testing (PAT) you will need to bring all medicine bottles to the hospital on the day of your surgery.
- If you are taking aspirin or an arthritis medication such as Naprosyn, Aleve, Advil, Ibuprofen Lodine, Voltaren, Feldene, Motrin, Relafen, or Daypro, you should stop taking it 5 days prior to your surgery date. You may continue Tylenol. If you are on Coumadin, Xarelto, Lovenox, Eliquis, Pletal, Pradaxa or any prescribed medication which thins your blood you should check with your primary care physician or cardiologist to see how soon you can get off your blood thinner before surgery.
- If you smoke/vape or use any type of nicotine product, we want you to stop at least two weeks before surgery. Smoking increases the risk of respiratory problems and other complications that impede the healing process. The cessation of smoking will enhance the overall improvement of your health and give your body the maximum opportunity to recover without complications.
- DO NOT EAT, DRINK, (NOT EVEN WATER OR ICE), SMOKE, CHEW GUM, OR EAT HARD CANDY after midnight the night before surgery. If you take any stomach, thyroid, or blood pressure medication in the mornings, you should take these with a sip of water the morning of your surgery. Pre-Admission Testing (PAT) will also go over which medications you should take the morning of your surgery.
- Work on the exercise program two times a day every day until surgery. Try to ride a recumbent-chair bicycle every other day for approximately 30 minutes. Arrange for family or friends to help you after being discharged from the hospital for the first week. A daily visitor or family member to assist with meals and a shower will make the transition easier. Please start preparing to return to a safe, familiar home environment. If you do not have any help, please let us know. Home Health Care or a rehab facility can be arranged at the hospital by a nurse case manager on the day of your surgery. Please check with your insurance to see if it covers these services.
- You will need to start showering with Hibiclens, Phisoderm, or Dial soap three days before your surgery. This will help guard against infection.
- Our office will call you 1-3 days before your surgery to discuss your arrival time for surgery. Please call us if you have not heard from us within 24 hours prior to your surgery. Surgery times cannot be determined sooner due to surgery schedule changes and emergencies. Please disregard any e-mail you receive stating a time to arrive at the hospital for your surgery.
- Each hospital day is carefully planned, yet changes are not always predictable. Please be patient if your surgery or discharge is delayed.
- You will prepare to come to the hospital the day of your surgery. Upon arrival at the hospital you will check in at the admitting desk in the main lobby of the hospital.
- The average hospital stay for knee surgery is 1 or 2 nights.
- As with all medical information in this manual, please be sure to consult your surgeon’s office if questions exist. All details are beneficial to the overall clinical outcome.
What you SHOULD bring to the hospital:
- If you have your own crutches or walker, please bring them, and be sure to put your name on them. The hospital therapists will make needed adjustments. Otherwise the hospital will provide you with a walker or crutches.
- Bring loose fitting clothes. Your leg will be swollen following surgery. The day after surgery you will start dressing in these clothes instead of a hospital gown. We suggest a loose pair of shorts, a very loose pair of slacks or jogging pants, shirts, and comfortable walking shoes.
- Insurance cards unless you provided the hospital with this information at Pre-Admission Testing.
- Medications you are currently taking. Please bring the bottles if you did not go to Pre-Admission Testing.
- Bring a copy of the results of tests such as EKGs, Echocardiograms, stress tests, and clearance letters from your internists and/or specialist. This is in case we don’t receive these in our office via fax.
- Personal items, such as deodorant/toothbrush/razor.
- Living Will, if you have one.
What you SHOULD NOT bring to the hospital:
- Unnecessary personal valuables
What you will need at home:
- Walker/crutches and a cane or staff
- A Game Ready ice machine. Dr. Bramlett highly recommends that you rent it for 2 weeks unless your budget doesn’t allow it. The cost is $100 a week. Insurance does not cover it. After 2 weeks a large zip lock bag for ice mixture or ice packs. You may make your own ice mixture by mixing 1 cup of rubbing alcohol and 3 cups of water into a zip lock bag and placing the bag in the freezer. It will be slushy and colder than a normal ice bag.
- Rubbing alcohol for cleaning the incision, along with tape and gauze pads for a dressing.
- Polysporin to apply to your incision IF you have staples. Do not use polysporin on Dermabond glue closures.
- Someone to assist you with a shower and meals for a week once you return home
- Tylenol for pain, headaches, or post-operative fever, which is a normal reaction of the body after surgery.
- A safe environment for walking, without loose rugs or cords, etc. Arrange your bedroom so
you can get in and out of bed easily.
A joint replacement reacts much like a heart valve replacement to bacteria circulation within the blood stream.
It is required that you have an antibiotic before you have any dental/oral procedures for life.
You cannot have any dental work until 3 months after your surgery.
We can call in a prescription or your dentist can do this for you. The antibiotic protocol for implant prophylaxis follows: Amoxicillin 2.0 grams, taken orally one hour before procedure.
For amoxicillin/penicillin-allergic patients:
- Clindamycin Adults, 600 mg given orally one hour before procedure
- Cephalexin or cefadroxil: Adults, 2.0 grams orally one hour before procedure
- Azithromycin or clarithromycin: Adults 500 mg orally one hour before procedure.
General Order of Events Following Surgery of the Knee:
Operative Day: After surgery you will have a drain, dressing, and a Game Ready ice machine on your knee. The ice machine helps with pain and swelling. Please let your nurse or physical therapist know if you need more ice. You may rest in bed, then stand at the bedside and/or sit in a chair. Once alert, you should begin doing your post-operative exercises by pumping your ankles. Point the toes of your surgical leg to your face, tighten your quads, and press your knee down. You can move any way that is comfortable for you. Early straightening and bending of your knee help you recover faster and decreases pain. Don’t forget you need to ask for help when getting out of bed. You will be given a spirometer to use after surgery to help you breathe deeply; use it hourly while awake. This will help to keep your lungs clear and prevent lung infections. You may start using a regular toilet the day of surgery.
Post-op Day 1: You need to eat all your meals sitting in a chair. Use the bed only for rest or sleep. The nursing staff and physical therapist will check to see if you are doing your exercises correctly. Initially, the physical therapist or nurse will help you get up and walk with you until you are independent. The nursing staff will also be assisting you in transfers from bed to chair if needed. These activities are important to your progress. Your drain will be removed and a smaller Mepilex or Silverlon dressing will be applied to your drain site. The Mepilex or Silverlon dressing on your knee is good for 7 days and will not need to be changed. You may go home after you finish afternoon physical therapy and are medically stable.
Post-op Day 2: You should be out of bed as much as possible if you went home post-op day 1. You should be getting up every hour during the day for 5-15 minutes. While sitting in your chair, alternate sitting with your legs on the floor with knees bent and sitting with your legs stretched out with heels on another chair. The goal is to have your leg straight and your knee flexed to 90 degrees. The sooner you bend your knee and straighten it, the less pain you should have.
If you are still in the hospital physical therapy will work with you again today. If you feel comfortable with all of the exercises and you are medically stable you may go home.
Post-op Day 3: Practice all the physical therapy exercises you received from the hospital and our office until you are comfortable performing them. Knee surgery patients who are planning to go to a rehab facility will be sent post-op day 3.
To insure your safe post-operative progression, your surgeon will ask you to return to the office 12-16 days after your surgery for x-rays and removal of staples, sutures, or tape from Dermabond glue. Your surgeon may ask to see you again at various intervals, for example, 6 weeks, 2 to 4 months, 6 months, and 1 year. For the long term, each patient is evaluated every two years with repeat x-rays and clinical exams.
Information needed AFTER surgery
- Keep the hospital’s Game Ready ice machine on your knee after surgery until you are discharged. Make sure to keep ice in the ice receptacle at all times. We highly recommend you rent a Game Ready by calling the representative for Game Ready, Kameron, at 205-269-0200. Patients usually rent these machines for 2 weeks for $100 a week and return them to our office’s front desk at your 1st post op visit. Instead of using ice from your freezer or bag of ice you can buy 14 8-oz bottles of water, freeze them, and use them instead. You will use 7 bottles in the machine at a time.
- Use your walker or crutches as instructed until you feel safe and confident enough to go to a cane, crutch, or staff. The cane or staff should be used on the opposite side of the operative knee.
- If there are no contraindications, take an 81mg aspirin daily for 30 days after finishing your Xarelto, Eliquis, Plavix, Coumadin, Aspirin 325mg, or Lovenox to decrease the risk of blood clots. If you are on Coumadin, please have your medical doctor do the blood test required to check the levels 2-4 days after being discharged from the hospital to regulate the dose. This is very important.
- Continue to wear your support stockings (anti-embolism hose) for 4 weeks after surgery. You should not sleep in them. You may request a second pair before you leave the hospital, or you may purchase regular support hose elsewhere. For best results, lie down with your legs up for 30 minutes then put your hose on with your legs still up.
- You may shower as soon as you go home. We are using a Mepilex or a Silverlon dressing which you will keep on for 7 days. On the 7th day, you will remove the dressing, shower, clean the incision with alcohol to dry the area thoroughly, and apply the Mepilex or Silverlon dressing provided by the hospital to keep incision clean. Keep this second dressing on for 7 days. If you use all the dressings that the hospital has given you gauze can be used with tape or an ace wrap.
- Surgical stainless-steel staples or Dermabond, a type of glue, are used to close the skin after surgery. The staples or Dermabond tape are removed in the office 12-16 days after surgery. The tape from the glue is a very thin mesh which you can barely see. DO NOT REMOVE THE MESH TAPE. To make the removal of staples easy, apply polysporin to the incision for the two days before the staple removal appointment. If you have Dermabond tape do not use polysporin. You may use Maderma cream, Aloe Vera creams, Vitamin E Cream, or skin lotion on the incision after it has healed completely (approximately 3 weeks). Steri-strips will be applied after removing the staples and left on for 5-10 days. Remember no tub baths until after steri-strips have been removed.
Reasons to Notify Us Immediately
- If you have a sudden increase in knee pain, which is not relieved by pain meds, icing or elevating.
- If you have sudden increase in swelling, which does not decrease overnight.
- If you have large amounts of drainage from surgery site.
- If you have increased pain, swelling, and redness in the calf or thigh, which doesn’t get better with pain medication. If this happens after hours or on the weekend, go to the ER. This might be a blood clot.
- If you experience chest pain, shortness of breath, and/or coughing up bloody sputum, you will need to go to the ER immediately. This is a symptom of a possible blood clot.
TOTAL KNEE EXERCISES
During your hospitalization, physical therapy is a vital part of your recovery. It helps you to regain your full potential. Once at home, continue to do the exercises your hospital therapy and booklet with each exercise four times a day. In addition to your exercises begin walking on flat surfaces after your first post-op visit. Start with a 1/4 mile and work toward 1-2 miles, three or four times a week. Start using your recumbent-chair bicycle 14-21 days after surgery if you are able to flex or bend your knee greater than 90 degrees. Remember when you start riding your recumbent bike to only ride it every other day. Outpatient physical therapy will be addressed at the time of your first post-operative office visit. If you are unable to do exercises on your own, you may call our office and schedule physical therapy. Please provide us with a phone and fax number of the facility you wish to go to.
Exercises Before and After Surgery
The following are some exercises you must do, particularly as you make preparations for your knee surgery. Work out 20-30 minutes, twice a day before surgery and three to four times a day after surgery. Remember to start out slowly and that with any new exercise program you will probably have increased muscle soreness and pain. Please do not stop, but continue and work through this phase.
After about 3 weeks you will find everything becoming easier. Each exercise protocol has been tested and developed during 20 years of successful implementation and follow up. They are designed to help you and will not impair or harm.
Exercises Before Surgery
- Quad Sets
Quad sets help you gain leg control after surgery and improve circulation. Lie on a bed or floor. Point the toes of your foot on your operative leg toward your face. Now tighten your thigh muscle and press the back of your knee down touching the bed. Hold for 10 counts and relax. You need to do this exercise 30 times, twice a day. You will also do this exercise immediately after surgery.
Swimming is also an excellent exercise. If possible, swim 20-30 minutes, at least three times a week. You may resume swimming 2-3 weeks after surgery.
- Knee Extensions
Knee extensions will assist you in moving from the bed to the chair and from the chair to a standing position. Lie on the bed or floor. Place a roll of towels (the size of a 3-liter coke bottle) under your knee. Push the back of your knee down on the roll and tightening your quadriceps muscle on the top of your leg. This will cause your lower leg to straighten and your heel to come off the bed. Hold for 5 counts and relax, allowing your heel to go back down to the bed. Rest for 5 seconds and repeat. You need to do this exercise 20 times, twice a day.
- Recumbent-Chair Bike
Before surgery, you should use a recumbent-chair bicycle to build up your endurance to ride it at least 30 minutes every other day. Normal to light resistance is all that is required. Begin riding the bicycle 2-3 weeks after surgery. Start with 5-10 minutes and work up to 30 minutes every other day. Icing your incision 10 minutes before and after each exercise for the first 2 weeks may make you more comfortable. If you do not have a recumbent bike, it is very likely that a relative, friend, church, or exercise club may have one that you can use. This is an exercise which should be done 3 times a week for the rest of your life. It is something that is safe and harmless.
Exercises After Surgery
- Ankle Pumps
Ankle pumps help to exercise your legs after surgery. While in the recovery room start these by flexing and extending your feet.
- Quad Sets
Point the toes of your operative leg toward your face. Now tighten your thigh muscles and press your knee down for 10 seconds. Do 10 times, four times a day.
- Chair to Chair Exercise
Sit in a chair and place the foot of your operative leg in another chair with your knee extended and straightened with nothing beneath your leg. Work on straightening your leg by pointing your toe to your face, tightening your quad, and pushing your knee down. If you have a Game Ready ice machine use it at this time to help with the pain during this exercise. After 2 weeks if you are unable to straighten your knee, you will place a 20 lb. bag of bird seed, etc. across the leg to help straighten your knee while doing the chair to chair exercise. Do this for 30 minutes, twice a day.
- Chair Flex Exercise
Stand in front of chair, stair, or stool and place the foot of your operative knee on the edge of the chair seat, stair, or stool. Lean forward bending your knee until it is uncomfortable. Hold for 2-5 minutes. Bend a little further holding for 2-5 minutes then relax. Repeat these 5 times, four times a day.
- Knee Flexion/Extension Exercises
Lean back in chair or lie down on bed. Raise operative leg up to your chest and grasp your thigh with both hands which are laced together. Slowly straighten your operative leg and hold for as long as you can. Pull your knee closer to your chest letting the knee bend by gravity. Do this slowly 3-4 times, four times a day
When you go home after being discharged get up and walk around every hour for 5-15 minutes during the day.
- Excessive Swelling Exercise
Elevate legs 60 degrees and pump your feet back and forth for 30 minutes. One of the easiest ways to do this is put your bottom where your pillow is and elevate both legs on your tall headboard. If you don’t have a tall headboard, put your feet up on the wall behind your bed.
Frequently Asked Questions
Your surgeon expects you to have a number of questions regarding your upcoming knee surgery. Please do not hesitate to request answers and clarification. The following are answers to some of the most common questions asked by orthopedic patients.
Should I expect swelling and bruising?
This is a very common occurrence following orthopedic surgery. Following a knee operation, muscle contractions in the legs are decreased because of low activity level. The veins become distended and the valves are no longer effective, thus, swelling occurs. Some people experience swelling while in the hospital, and others notice it after going home. Gravity takes the fluid and blood down the leg causing swelling from the knee to ankle. You will also notice bruising in the knee, calf, ankle, and foot area.
How much pain should I expect?
We have found that after the first 12-18 hours, the pain from the surgery decreases 40-60%. Those who work hard on their exercise program, quit smoking, and have not taken previous narcotics for pain relief at home, have less pain. It has been proven that pain decreases as you increase your post-operative activity and motion. A safe, adequate pain management program is planned and assessed daily in the hospital to allow for your comfort at home. The sooner you become mobile, the sooner the pain lessens. Don’t forget to ice after all exercises.
What should I watch for concerning blood clots?
The chances of a blood clot forming are low. If you experience the following symptoms please notify either your surgeon, primary care physician, or go to ER after hours.
- Leg swelling that does not change after sleeping and elevation
- Skin that is shiny and tight from swelling
- Severe pain and heat in the calf or groin.
- If the leg is swollen, shiny, the swelling does not go down any through the night, the swelling is accompanied by sudden pain in the calf or groin especially when doing the ankle pumps, please call your surgeon during the day or go to the ER after hours.
- Shortness of breath or pain in chest when breathing.
I’ve noticed some drainage from my incision. Is this normal?
Yes, it is not uncommon to see a clear yellow or blood-tinged drainage up to 2 weeks after surgery. Drainage does not always indicate an infection. Leave the incision open to air at home unless draining. Apply polysporin to your incision 2 days before your office visit for easier staple removal. DO NOT apply polysporin to your incision if the skin is closed with glue.
Is it common for my total knee to be warmer than my other knee?
Yes, you may notice a difference of temperature for 6-12 months after surgery.
What is a good policy regarding sitting or lying around?
Initially, it is best not to sit longer than 50 minutes at a time. You must get up, move, and walk around for 5-15 minutes during the day. This will help decrease the risk of blood clots and stiffness.
May I turn to my side or stomach while lying down?
Yes. You can on either side, but you should do so with a pillow between the knees to keep them apart for comfort.
What signs of infection would be of concern?
- A change in pain to a more constant, severe pain, whether standing, sitting, or lying down.
- Skin around incision is red, hard, and very painful. (warmth and mild to moderate redness are normal)
- A thick drainage of creamy yellow to green color.
- A temperature of over 101ºF for 36 hours and doesn’t respond to Tylenol. (A temp of 99º-101º off/on for 2-3 weeks is a normal response.)
Can I climb stairs following my surgery?
Yes, at first you will climb them basically the same way you did before surgery. Then, very soon you will climb them in a normal way. You will be instructed to safely do this before you discharge from the hospital. Start out by leading up the stairs with the non-surgical leg and when going down the stairs you lead with your operative leg.
When can I begin driving a car?
We routinely allow our patients to drive a car when they feel it’s safe. Do not drive until you have complete control of your leg and are no longer taking pain medication.
I can hear a pop sometimes when I take a step, is that normal?
Yes. After total knee surgery there will be fluid in the knee and the kneecap can be heard popping. As the swelling goes down, this will subside.
When do I stop taking my aspirin before surgery?
You may stop taking your aspirin 5 days before your surgery.
When can I stop wearing my support hose?
Normally you stop wearing the support hose one month after surgery. After 2 weeks you may stop wearing your support hose if your ankles don’t swell and you are up a lot during the day. Remember to remove your support hose at night.
We hope you have found this information helpful. We also trust you will know that if any of the material mentioned in this booklet is confusing or hard to understand, we will be glad to address your concerns. Surgery exists as a method of correcting a medical problem or improving a patient’s condition. Please be assured that your surgeon and the medical team are available to answer any questions or to review any material before and after surgery. The best results are obtained when people are confident about receiving the correct care and information to make a safe and speedy recovery.