Arthritis and Knee Replacement

The purpose of this content is to help you understand knee replacement surgery.  We will discuss:

• How arthritis affects the knee and causes pain and stiffness
• The steps of knee replacement surgery and the usual recovery process
• The typical results of the operation and possible complications which may occur

It is our hope and intention that this knowledge will assist you in making an informed decision concerning your own need for knee replacement surgery.

Orthopedic Evaluation
Your orthopaedic evaluation assesses the severity of your arthritis and leads to a treatment recommendation.

The evaluation begins with questions concerning the severity of your knee pain.  We attempt to discover how your knee pain and stiffness limits your usual daily activities such as walking, stair climbing and driving and riding in a car.  We also ask about previous treatments such as medications, cortisone shots and the use of a cane.

Examination of the knee includes assessment of knee range of motion (stiffness) and any knee deformity (bow-legged or knock-kneed).  In addition, ability to walk and the presence of a limp are noted.

X-rays are very useful in determining the severity of arthritis.  As arthritis and cartilage deterioration progresses, the "cartilage space" between the bones decreases in size and may disappear altogether ("bone rubbing on bone").   This cartilage deterioration may be confined to a limited area of the joint (one compartment) or involve the entire joint.

After completion of the orthopedic examination (symptoms, exam, x-rays) the various treatment options and specific recommendations can be discussed.

With mild arthritis, some moderation of activities and arthritis medications may be adequate.  The occasional use of a cane may be helpful and a cortisone injection into the affected joint may also be of benefit.

Moderate arthritis frequently responds to arthroscopic debridement and lavage - an operation where the joint is examined with a small scope, irrigated and degenerative meniscus tears and loose debris removed through small incisions.  The arthroscopy may or may not be combined with an "osteotomy" procedure, where the bow-legged or knock-kneed deformity is corrected.  The procedure is done in younger patients with arthritis and is analogous to "rotating the tires on a car", enabling the patient to enjoy more years with his or her own knee tissue before joint replacement is needed.

With more severe or constant pain and the inability to carry out daily activities, surgery with knee replacement may be the recommended treatment.

X-Rays of an An Arthritic Knee

Knee Prosthesis
Total knee replacement surgery requires replacement of the damaged joint surfaces with metal and plastic components (prosthesis).  Metal on plastic artificial joints have proven to be self-lubricating and show minimal wear despite years of use.

There are two types of knee replacements:  If the arthritic deterioration involves the entire joint, then a complete knee replacement is required.  This type of knee has three parts: femoral component (metal part which covers the thigh bone);  tibial component (plastic surface which covers the shin bone); and patellar component (plastic surface which covers the undersurface of the knee cap).  In some knees the arthritic damage is limited to just one area or compartment (usually the inner side).  In these knees, a uni-compartmental or partial knee replacement is carried out.  This type of knee has two parts --- a smaller metal femoral component and a plastic tibial component.  The appropriate type of knee replacement can be generally determined by reviewing x-rays.  The final decision is made at the time of surgery when the inside of the joint can be directly inspected.

The artificial knee components are held to the bone with a plastic cement.  In occasional cases, components which allow "bone growth" will be placed without cement.  A more recent trend in knee replacement involves implanting a noncemented "bone ingrowth" femoral component and cemented tibial and patellar components --- a "hybrid" total knee.  Recommendations regarding the use of cement versus bony ingrowth fixation will be made on an individual basis preoperatively based on your age, weight, activity level and bone density.

Results of Knee Replacements
After knee replacement you can expect nearly complete relief of pain.  While an artificial knee is not a normal knee, you can expect to resume most activities of daily living with comfort and ease.  Studies have confirmed that approximately 95% of all knee replacements can expect a very good result. Unlimited walking tolerance without pain is usually the case.  Recreational activities such as bicycling, swimming and golf are likely to be possible.  More strenuous sports such as jogging, tennis and skiing could damage the artificial knee and are not recommended.  There is a slight difference in the function of the complete and partial knee replacement.

People with a partial knee usually are able to bend their knee further and walk a bit easier.  People with a complete knee replacement typically are able to bend their knee just beyond a right angle, that is 90 to 115°.

Potential Risks of Knee Replacement
No surgery is without risk.  Understanding the risks of surgery is necessary in order to make an informed decision about your desire for surgery.

Anesthesia in surgery places increased stress on the body.  Serious complications such as heart attack, stroke or even death have been reported.  Fortunately, these occurrences are extremely rare.  A thorough medical evaluation prior to surgery minimizes these risks.

Infection is also a very serious complication of joint replacement.  Many precautions are taken to avoid infection and as a result, the risk of infection is very low (less than 0.5%).  Further surgery would be necessary if infection should occur.

Blood clots can occur after knee surgery but this occurrence has been minimized by the routine use of special "pump" stockings and either aspirin or blood thinners used after surgery.  Even rarer complications could include artery or nerve damage or fractures of the bones near the knee.

Most patients want to know how long they can expect their artificial knee to last. Over an extended period of time, the knee prosthesis may work loose from the bone.  This occurs when the bond between the bone and the plastic cement breaks down.  Even though this is the most common cause of artificial joint failure, it is quite unusual.  More than 90% of artificial knees continue to function well after 10 years.  If an artificial knee becomes loose and painful, it can usually be repaired with a second operation.  Only rarely does a knee prosthesis become loose prior to 10 years.

Preparations for Surgery
Once you have made a decision to proceed with knee replacement surgery, a number of arrangements will be made.  A date for surgery will be determined and scheduled at Meriter Hospital.  Many patients have similar arthritis in both knees and will require replacement surgery of each knee.  In this situation, we may recommend completing both surgeries during the same hospitalization 7 to 10 days apart, or rehabilitating the first knee and then proceeding to the second knee operation 3 to 6 months later.

A thorough pre-surgical medical evaluation will be arranged for you.  You will be seeing my physician assistant approximately 2 weeks preoperatively for a thorough history and physical.  During the evaluation, your surgical procedure and the pre and postoperative routine will be discussed.  Lab tests, chest x-ray and EKG will be ordered at that time and reviewed.  We will also arrange for you to be seen in the Physical Therapy Department prior to your hospitalization so that you can obtain either a walker or crutches and be instructed on the exercises that you will be doing in the hospital postoperatively. You should practice using the correct technique with the walker or crutches prior to being admitted to the hospital.  If your medical condition warrants, you will also be seen by either your family doctor, an internist or a cardiologist for further evaluation.  This further evaluation will be carried out if you have a very complex medical history or if some aspect of your medical condition warrants further investigation prior to surgical intervention.

You should not take aspirin, Ibuprofen or other non-steroidal anti-inflammatory medication during the two weeks prior to surgery. These medications thin your blood and increase your risk of bleeding complications.  You may take acetaminophen (Tylenol), propoxyphene (Darvon) or codeine for pain if needed.  Stopping smoking preoperatively helps decrease the chance of postoperative lung problems.

You will be admitted to the hospital the day prior to or the morning of surgery.  You will have further instructions on that day by the orthopedic nurses and will likely be seen by one of the orthopedic residents (M.D. taking further training in orthopedics) for your final exam.  We will review all of your laboratory tests the night prior to surgery and answer any further questions that you may have when you are admitted.

One of the anesthesiologists will see you and discuss the type of anesthesia that is recommended.  He or she can also answer your questions concerning anesthesia and the risks involved.  The nurses will orient you to the nursing unit and usual daily activities while you are hospitalized.  You may again be seen by one of the physical therapists who will review your knee exercises with you.

If for some reason the laboratory tests, chest x-ray or EKG have not been previously completed prior to your hospitalization, they will be done the night prior to surgery.

Blood transfusions may be necessary with knee surgery, particularly in the uncemented variety.  Many patients in this day and age are concerned about getting blood transfusions from unknown donors.  With the present screening techniques used by the blood bank, the risk of getting hepatitis, AIDS or other blood borne diseases is extremely low.  An alternative to getting bank blood is to donate your own blood preoperatively and have it stored in a liquid or frozen state until the time of your operation.  These donations have to be coordinated with the time of your surgery and we will discuss these options with you preoperatively.  My secretary will then arrange for your donation appointments if you decide on "auto-transfusion."

We routinely use a "cell saver" during the operative procedure to return irrigated blood into your system after it has been filtered.  We are also using a postoperative wound drainage auto transfusion device to try to diminish your need for transfusions.  If you have given your own blood preoperatively, you will likely receive this as a transfusion postoperatively.

Day Of Surgery
Your knee surgery will either be performed at 8:00 in the morning or 1:00 in the afternoon, depending on the availability of the operating room.  You will be informed of the expected time of surgery when you schedule it with my secretary.  You will not be allowed to eat or drink after midnight the evening before surgery.  You may wish a sleeping pill the night before surgery and this is fine.

On the morning of surgery, you will be taken to the operating room approximately 30 minutes before surgery.  Your family may accompany you and will be directed to the family waiting room near surgery.  The actual surgical procedure takes 1-1/2 to 2-1/2 hours.  You will then spend another 1 to 2 hours in the recovery room where you will be closely observed as you awaken from anesthesia.  When you are awake (but often very drowsy) and your vital signs are stable, you will be returned to your room.  Five to six hours may have elapsed since you first left your room.

 When you are back in your room, you will be aware of moderate pain in your knee.  This pain can be greatly relieved by the use of a "PCA pump" which allows you to administer your own pain relieving medication.  By simply pushing a button, a predetermined amount of pain medication is pumped into your IV line, which has been started in surgery.  This provides rapid relief of pain without the usual discomfort and delay of a "hypo."  In some circumstances, however, hypos are still used, particularly if the patient has a problem with nausea and vomiting.  Your IV line is usually left in place for at least 48 hours so that you can be given adequate fluids and also so that necessary antibiotics can be given.  Antibiotics help to prevent infection in your new knee. After surgery you will have an Ace wrap bandage on your leg from your toes to your groin.  You will also have 1 or 2 small drains coming out of the joint, which collect any blood within the joint or subcutaneous tissues.  These will generally be removed the morning of the second postoperative day.

After Surgery
Most patients will be allowed and encouraged to get out of bed the first day after surgery.  The increased activity in the upright position of sitting encourages the lungs to expand fully and helps eliminate any fever.  You will likely be given a "tri-flow" device to help expand your lungs every two hours during the day.

Several other important points about your hospital stay should be noted.  Following major lower extremity surgery, there is a risk of blood clots forming in the leg.  To minimize the risk of this occurrence, most patients are placed on one aspirin per day and also placed in special sequential compression stockings that continually assist in externally pumping the blood through the legs.  If you have had a previous history of blood clots or thrombophlebitis, a blood thinner called Coumadin may be used during your hospitalization.  A blood sample must be drawn every morning so that the proper dose of Coumadin can be determined; thus you should not be surprised if you need daily blood tests in the hospital.  The Coumadin is often continued for several weeks when you are discharged from the hospital.  You will need to have your blood tested on an outpatient basis and adjustments made in your Coumadin level.  Elastic stockings (TED hose) are also used to minimize risks of blood clots and control swelling in the lower leg and foot.  If possible, we like these stockings worn during the day but they may be removed at night for comfort.  Small metal staples are used to close your incision.  These will be removed approximately 7 to 10 days after surgery. This is relatively painless.

Going Home
Most patients are able to return home 7 to 10 days after surgery.  At this time we expect you to be able to walk independently with crutches (or walker), bend your knee to nearly 90° (right angle) and to lift your leg with the knee extended straight.  The following instructions are intended to make your return home as comfortable as possible.  Please read them carefully and ask either my physician assistant or myself if you have any further questions.

• Exercises
  We encourage you to be as active as possible.  You should not spend much time in bed other than at night to sleep.  You should walk several times daily.  These walks are by far the most important exercise you can do.  As your recovery progresses, you should be able to walk longer distances and with less fatigue.  Be careful not to push yourself too hard, too quickly.  Conversely, remember not to sit for extended periods of time, as this tends to retard the venous drainage from your leg.  It is better to get up and move around, walking every 30 to 45 minutes.  Exercise as noted previously.  Walking is the most important exercise.  You should also continue to work on bending the knee.  This can best be done by sitting in a chair and bending the knee as far as possible.  While sitting, you can also put your foot firmly on the floor and attempt to slide forward in the chair, causing the knee to bend even further.  You should also continue to do straight leg raises.  Try to lift your leg with the knee straight and hold it up for 10 seconds (do this 10 repetitions, 6 to 10 times a day).

• Bathing
  You may begin to shower as soon as you return home.  Bathing in a tub is alright too, but it is usually difficult for 1 to 2 months until your knee becomes more comfortable.  Neither a shower or a bath is harmful to your incision.

• Incision Care
  Usually the incision is well healed at the time of discharge and requires no special care at home.  If the incision becomes excessively swollen, red or begins to drain, you should call us.  It is not unusual for the knee to remain swollen and feel warm for several months after surgery.

• Elastic Stockings (TEDS)
  Please continue to wear the elastic stockings while you are awake for the first 2 to 3 weeks after discharge.

• Driving
  We do not recommend that you drive a car until after your first office appointment after surgery.
   
• Traveling
  It is reasonable to travel by car or plane soon after leaving the hospital.  When traveling long distances, you will be more comfortable if you stop and walk a little every hour.  Airport security metal detectors are generally not set off by these artificial joints.  We can, however, give you a letter stating that you have a joint replacement to keep with you just in case.
  

• Medications
  Most patients still require the use of pain medication for a period of time following discharge from the hospital.  We will provide a prescription for an appropriate medication.  In addition, you should resume any other medication you were taking prior to hospitalization unless otherwise instructed by a physician.

• Dental or Urologic Care
  If you require dental work (including regular cleaning) or any urologic evaluation after surgery, you should take a short course of antibiotics.  Many of the bacteria in the mouth are susceptible to Penicillin.  There may be a number that are resistant, so at the present time I am utilizing a combination of Pen VK 500 mg., 2 tablets orally 1 hour before and 6 hours after the procedure.  In addition, 1 prescibe Reflex 500 mg., 1 tablet 1 hour before and 6 hours after the procedure.  If the patient is allergic to Penicillin, Erythromycin 1 gm. orally 1 hour before and then 500 mg. 6 hours after the initial dose would be substituted.

• Return Appointment
  Your first return examination in our office will occur after about 4 weeks.  In most instances, you will be given an appointment card at the time of discharge.  If for some reason you did not receive an appointment card or if your appointment time is not convenient, please call our office at (608) 282-8370 during the normal office hours for an appointment time.

• Precautions
  It is extremely important after total joint replacement to be very careful regarding infections.  There have been reports of infections elsewhere in the body that have shed bacteria into the blood stream which then infected the joint replacement, even years after the initial procedure.  Therefore, it is imperative after a total joint replacement that infections are treated aggressively.  This includes pneumonias, bronchitis, urinary tract infection or external skin sores that may become infected.  The usual sore throat associated with some nasal drainage is frequently a viral infection and of no major concern.  However, if you develop marked sore throat or fever suggestive of a strep throat, you should see your family doctor immediately and be tested for strep throat and placed on antibiotics if your culture is positive.  In general, if you have questions as to whether or not you may have an infection that should be treated, please call my office so that myself or my physician assistant can discuss this with you.

Summary
Don't forget that you have a new knee but it is not a completely normal knee.  Your healing pattern will be somewhat cyclical.  It is common for you to feel very good for several days and then overdo it and then have the knee swell or stiffen up slightly.  This will again improve and go through a number of cycles until you are finally healed.  Don't look at your progress on a day by day basis, but more on a week to week basis.  Don't get too excited or depressed by the cyclical variations.

If you find when you go home that there is something new or different that you have a question about, please feel free to contact me. I am concerned about you as a person as well as a patient and would be happy to answer any questions that you may have.

Good luck with your new knee.
 

Back to Patient Education - Knee

Patient Education - Main Menu

3/1/2008

OUR SERVICES  |  PATIENT EDUCATION  |  ABOUT DR. ROGERSON
CLINIC INFORMATION  |  OUR TEAM  |  CURRICULUM VITAE