Orthopaedic Nursing Division
Department of Nursing
The University of Iowa Hospitals and Clinics
Iowa City, Iowa 52242
Contents
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 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:
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:
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 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 often 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 to four units, which requires separate visits to the blood center. The first donation must be given at this hospital, but the blood bank personnel will make arrangements to have the rest drawn at a blood center nearer your home. Blood taken elsewhere is transported here automatically, so you will not need to get involved with this.
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 one week. 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.
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, as well as a chest x-ray. 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 or 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). You should wear
them on both legs to the hospital the morning of your surgery. 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 is
the preferred method of pain control for the first 2-3 days 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. Chest x-rays and an EKG are 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
Day of Surgery
You will be admitted to the hospital the day of your surgery. Report directly to the Orthopaedic Clinic, where a final assessment of vital signs and general health will be performed.
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 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:
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 1 week.
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 one to two days after surgery. You will work with physical therapy until you meet the following goals:
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.
The continuous passive motion machine may be ordered. The machine is used to maintain motion. However, this is not a substitute for your exercises. You may wear a knee immobilizer at night for comfort and to help keep your knee straight.
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.
What happens after I go home?
Medication
Activity
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 8:00 a.m. and 5:00 p.m., Monday through Friday, please phone the Orthopaedics Clinic 319/356-2377. After 5:00 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.
See related Patient Textbooks about Orthopaedic Surgery.
See related Patient Topics Bones, Joints and Muscles, Injuries and Wounds, Knee Injuries and Disorders, Orthopaedic Surgery, Procedures and Therapies, Rehabilitation or Surgeries.
See related Provider Textbooks about Orthopaedic Surgery.
See related Provider Topics Bones, Joints and Muscles, Injuries and Wounds, Knee Injuries and Disorders, Orthopaedic Surgery, Procedures and Therapies or Surgeries.
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