Please read this information early and often. It will answer many of your questions, help relieve some of your anxieties, and make your experience more predictable and understandable.
Prior to Surgery
Prior to surgery, I will make an assessment of your overall health. If you have significant medical problems, it may be necessary for you to be evaluated by a medical specialist or have additional tests, such as an EKG or treadmill test. Please be sure that I am aware of your significant medical problems. Please bring a list of your medication names and doses to your preoperative appointment. In addition, please bring a list of any drug allergies. Your blood tests and any other appropriate tests will be completed several days to a week before your surgery. You will be contacted by the Boulder Community Hospital preadmission nurse, who will review your health history and order appropriate preoperative lab work, EKG, and possibly a chest X-ray. If deemed necessary, she will make arrangements for you to see a cardiologist or other specialist to make sure it is safe to proceed with your surgery.
Boulder Community Hospital offers a joint class for all patients undergoing a total joint replacement. It provides you with a wealth of information on what to expect while hospitalized and after discharge. This class is offered multiple times per month. It is very informative and worthwhile. Patient feedback is very positive. I strongly encourage you and your spouse or significant other to attend. I believe you will find it worthwhile. Please be aware that the information given in the class is an overview of what all orthopedic surgeons at Boulder Community Hospital do. My written and verbal instructions may vary slightly based on my individual preferences.
Many patients are on some form of arthritis or anti-inflammatory medications, such as aspirin, ibuprofen, or prescription arthritis medication. These medications slightly thin your blood and may lead to excessive blood loss during and after surgery. I ask that you stop these medications 5 – 7 days before surgery. Tylenol does not thin your blood and may temporarily be substituted for pain relief.
I generally do not recommend predonation of blood for total knee replacement. The likelihood of needing a transfusion for a first-time knee replacement is very low—approximately 5 percent.
Blood clots (DVT, thromboembolic disease, pulmonary embolism) after surgery are known complications. These are potentially very dangerous complications. I make every effort to reduce your risk. Postoperatively, you will receive either oral blood thinning medication or mechanical leg pump devices. Please use these as directed, as they decrease your risk of blood clots. If you have a previous history of blood clots, please notify me, because additional precautions and treatment will be necessary.
Day of Surgery
You are asked to arrive at the hospital one and one half to two hours before your scheduled time of surgery. The preoperative nurses will prepare you for surgery by starting your IV and washing and shaving your knee. I will see you in the preoperative area before surgery to answer last-minute questions. The anesthesiologist will also see you in the preoperative area to review your medical condition and discuss the form of anesthesia to be used. I recommend a combination of spinal anesthesia and general anesthesia. The spinal anesthetic will give you good pain relief for 12 – 24 hours after surgery. Your general anesthetic will prevent you from being aware of the sounds and voices during surgery. You will not feel any pain during surgery. After discussion with the anesthesiologist, the final choice of anesthesia will be yours.
Once you are in the operating room and have been anesthetized, a catheter will be inserted into your bladder. This will be left in place overnight. By then, you should be mobile enough to use the bedside commode or bathroom. If you prefer not to have a bladder catheter, please mention it to me, Stacey, or the anesthesiologist. Intravenous antibiotics will be given prior to surgery to reduce the risk of infection and will be continued for 24 hours after surgery.
The surgery generally takes 2 hours. When you are taken to the recovery room, I will speak to your family in the surgical waiting room. If the surgery should take unusually long, I will send a message to the waiting room explaining the situation. In the recovery room, your condition will be closely monitored until you have recovered from your anesthetic. You will be placed in a constant passive motion machine (CPM), which will assist in moving your knee. The amount of motion will be increased daily. I do not use the CPM once you are discharged. It is more effective for you to actively move your knee. Your blood count will be checked on the first and second days after surgery to monitor your blood loss and assess any need for a transfusion. Your risk of blood transfusion is less than 5 percent.
On the first day after surgery, you will be assisted by a physical therapist to sit in a chair and take a few steps in your room. The therapist will instruct you in the use of crutches or a walker. You will work with the therapist one to two times per day. By the second or third postoperative day, the therapist will teach you to walk on stairs. Regaining your knee range of motion is very important to achieve a good result. In the early days, moving the knee is painful, but not harmful. The knee will be swollen and feel tight when you bend it. Even though painful, you will not break, tear, or in any other way damage the knee replacement when doing your therapy. When you are in bed, the constant passive motion machine will be used. Each day, the amount of flexion (bending of the knee) in the machine will be increased. You will have pain medication available (either pills or shots) to make you more comfortable so that you can participate in your therapy more effectively.
Most patients are quite comfortable during the first night after surgery. However, the block will wear off the next day. The second night will be more difficult than the first. Moving around on the first postoperative day also increases your pain.
Because of the anesthetic and pain medications, nausea and occasionally vomiting may occur in the first day or two following surgery. Each day will be less painful, allowing you to decrease your need for pain medication, thereby decreasing nausea and the associated sick feeling. Please be cautious with your diet in the first 48 hours after surgery. Constipation is common in the first week after surgery. Many patients will not have a bowel movement until the third or fourth postoperative day. You will be on a special bowel protocol to minimize constipation. If you have not had a bowel movement by the third day, you may request a suppository or enema. Other medical problems will also be monitored in the postoperative period. Patients with significant medical problems will also be followed by a hospitalist internal medical specialist while they are hospitalized. Most likely, this will not be your usual primary care doctor.
It is necessary to keep your surgical incision dry until the staples are removed 10 – 14 days after surgery. On the second postoperative day, your dressing will be changed and a waterproof dressing will be applied. You may shower over this waterproof dressing. You may continue this at home until the staples are removed. Following staple removal, you may shower or bathe normally. While hospitalized, the occupational therapist will assist you in performing other activities of daily living.
Most patients are hospitalized for two or three days at Boulder Community Hospital. If you progress fast enough, are strong enough, and have good home and family support, you may be able to go directly home. If this option is chosen, I will arrange home nursing care and home physical therapy. Even if you go to a rehabilitation facility, you will most likely have continued home physical therapy. Once discharged from inpatient care, I, my assistant Matt Schneider, or one of my partners will see you every day that you are in the hospital. Even when I am out of town, someone is available if you develop any problems. We will arrange your discharge and make arrangements for your home physical therapy. At the time of your preoperative visit, I will give you prescriptions for your home pain medication, nausea medication, and a prescription for outpatient physical therapy. Please fill your prescriptions before surgery so they are readily available when you arrive home.
Recovery at Home
Supervised physical therapy is usually continued 2 – 3 times per week for the first 6 – 8 weeks after surgery. In addition, you will be given instructions for exercises, which you will do on your own several times a day. If you have access to an exercise bicycle at home, it is a very effective way to exercise your leg and improve your knee range of motion. Swimming is permitted as soon as your surgical wound is healed and you are comfortable traveling to the pool. After surgery, you will be instructed in walking with either a walker or crutches (your choice). You may begin putting weight on the operated leg as tolerated. You will not damage the knee replacement by rapidly progressing to full weight bearing. Once you are comfortable and strong enough, you may switch to a cane. Your home physical therapist will assist you in your transition to full weight bearing.
By the time you leave the hospital, most of your knee wound bleeding should have stopped and you will be in a light dressing. The wound closure staples are usually removed 10 – 14 days after surgery. Please keep your incision and dressing dry until the staples are removed. If your dressing remains clean and dry, it is not necessary to routinely change it. Please report any wound healing problems or concerns to me or Stacey. Bruising or black and blue discoloration around the knee and lower leg are expected and should not be of concern.
Pain for 6 – 8 weeks after surgery is common, particularly when doing your exercises or when sleeping. Difficulty sleeping is a very common symptom or complaint for 6 – 8 weeks after surgery. Your knee discomfort may interfere with your sleep even after it is no longer painful during the day. If you would like sleeping medication, please ask, but I have found that it is not very effective. I will refill your pain medicine prescriptions as needed. Please call during normal working hours for renewals. Note that oxycodone, Percocet, Roxicet, Percodan, and OxyIR cannot be phoned to the pharmacy. For these medication refills, someone will need to pick up a new written prescription at my office. I will provide an application for a handicap parking permit at the time of your preoperative office visit. Most patients are able to drive again at approximately 2 – 3 weeks following surgery.
Most patients notice clicking and popping in their artificial knee joint. This is entirely normal and expected. The clicking and popping will tend to diminish with time but will always be present to some degree. For three or four months after surgery, also expect swelling and a warm feeling around the knee. You will see rapid improvement in your new knee during the first few weeks following surgery. It takes most patients about two months to begin to feel satisfied with their surgery. Maximum recovery usually takes 12 months, although some patients report further improvement in the second year. While most patients experience excellent pain relief, an occasional patient will experience mild to moderate persistent pain. I will make every effort to find the cause of the pain, but occasionally, it remains obscure or indeterminate.
Patients properly ask, “how long will my total joint replacement last?” The question is difficult to answer with precision because there are so many variables, and the materials and technology keep improving. In general, a knee replacement should last 15 – 20 years and many will last much longer. Your age, weight, and activity level are important factors. Knee replacements may fail by the prosthetic components loosening from the bone or from excessive wear of the polyethylene (plastic) component. It is a mechanical device, much like an automobile. Like a car, with good care, it should give you years of good service and mobility.
In my experience, about 75 percent of patients are very satisfied with their knee replacement. 20 percent are generally satisfied, although they may have some residual soreness, swelling, or stiffness. A small number of perhaps 2 – 5 percent are unhappy with their result, either due to pain, swelling, or failure to regain satisfactory range of motion. These are very difficult and frustrating situations because we frequently cannot determine why the result is not better. If I cannot determine what is wrong, I encourage you to obtain a second opinion to get other ideas.
Total knee replacements will tolerate mild to moderate impact activities. It is safe to walk, hike, swim, golf, bicycle, dance, and horseback ride. Tennis and skiing are discouraged, although some patients do go back to these activities. Higher impact activities, such as jogging, racquetball, soccer, and basketball, should be avoided. High-impact activities may shorten the life of a total knee replacement.
The importance of physical therapy in your recovery cannot be overemphasized. In order to obtain an optimum outcome, I wish to form a partnership with each patient. Fifty percent of the outcome will depend on a good surgical procedure performed by me, and fifty percent will depend on a strong rehabilitative effort by the patient. Together, an excellent outcome can be consistently expected.
I generally recommend that you avoid long car rides and air travel for the first 4 – 6 weeks following surgery. These activities increase your risk of blood clots. If it is necessary to travel by car, get out of the car every couple of hours and move around briefly. If you are flying, try to obtain an aisle seat so that you can get up and walk around frequently.
Hopefully, this information will be helpful in your understanding of total knee replacement and will enhance your recovery. If you have further questions, feel free to discuss them with Stacey or me.
This information is intended to describe the typical or average patient experience. There is considerable variation among patients, and all options and possibilities have not been described. It is also based on my experience and training and preferences. Other orthopedic surgeons may do things differently.
Dr. James Rector