Download Colorado Joint Replacement

A Patient’s Guide to
KNEE
REPLACEMENT
Getting You Where You Want to Go
JOINT CARE CONNECTED
porterhospital.org/joint
Thank you
for choosing Porter Center
for Joint Replacement.
We want you to know what to expect every step
of the way during your joint replacement. We
hope this patient care book puts your mind at
ease, keeps you informed and gets you on the
road to recovery quickly.
At Porter Center for Joint Replacement, we
specialize in joints and you can rest easy knowing
that you have chosen some of the most highlytrained and specialized joint surgeons in the
region. Our surgeons and staff alike pride
themselves on providing you with the best care
available and will strive to make your experience
as pleasant as possible.
You will find comfort in the fact that:
• T
he Porter Center for Joint Replacement has
been recognized by national organizations
as a center of excellence for knee and hip
replacement.
These designations are awarded to those
centers that provide quality and cost efficient
care. Our center meets or exceeds nationally
recognized standards of care.
• O
ur joint replacement surgeons perform
more research than any other surgeons in
the region.
• O
ur operating rooms are specially designed
for joint replacement and our entire
operative team is specially trained in joint
replacement.
ur comfortable rooms located on the
• O
4th floor of Porter Hospital are specially
designed for and dedicated to joint
replacement patients. From gourmet
meals to family lounge areas, we will take
the extra care to be sure your stay and
recovery is as pleasant as possible.
• A
dedicated joint replacement therapy team
will work with you to get back to a pain free
life quickly.
The following are our nationally recognized
designations:
UnitedHealth Premium Knee and Hip Surgery
Specialty Center
Blue Distinction Centers for Knee and Hip
Replacement
U.S. News and World Report: High performing
center for orthopedics
Located nearby the Center for Joint
Replacement on the east wing of the 4th floor,
our own “Independence Square” is an area
that allows you to actively practice learned
skills with a Professional Physical Therapist in
an environment that replicates the activities of
daily living.
While recovering from surgery prior to
returning home, the patient and family
member are assisted in negotiating uneven
ground surfaces, climbing and descending
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stairs, being seated in an actual car, and
preparing meals in a fully equipped kitchen.
Other activities practiced include accessing
a grocery store, bus, post office and bank
environments - all accomplished under the
supervision of their therapist. Independence
Square provides a safe and secure environment
for the patient to learn to utilize assistive
devices such as walkers, crutches, reachers
and tools for dressing independently prior to
returning home.
Surgery Welcome Center
Your journey to good health will start with a
visit to our Surgery Welcome Center.
Location:
Surgery Welcome Center
2525 South Downing Street
Denver CO 80210
303-778-5678
You will check in at the front entrance of the
hospital and they will direct you to the Surgery
Welcome Center, located near the main entrance
on the 1st floor. Here you will undergo the
testing and teaching necessary to make your
experience on the day of surgery as calming
and efficient as possible. Depending on your
personal needs, expect to spend approximately
30 minutes to an hour with us in the Surgery
Welcome Center.
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• B
ring the following items with you:
medication list, allergy list, surgery
history and insurance card.
• P
re-operative blood tests and an EKG
will be performed in our office, unless
your primary care doctor has already
completed these.
• Y
our nurse will meet with you and
explain our pre-operative procedures
and answer all of your questions about
having surgery at Porter Hospital.
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TOTAL KNEE ARTHROPLASTY
(TOTAL KNEE REPLACEMENT)
Meet the Team
Nursing Staff
Pharmacist
Qualified nurses, including a Registered Nurse,
Nurse Manager, and Clinical Nurse Specialist,
will care for you throughout your hospital stay.
We encourage you to ask questions or express
any concerns to your nurse or doctor at any time.
A Pharmacist will follow you throughout your
hospital stay to monitor the medications you are
taking while in the hospital and to make sure
you know about any new medications that are
prescribed.
Physical Therapy
Case Manager
Your Physical Therapist will meet with you after
surgery to begin working on walking, general
mobility, strengthening exercises, and range of
motion. Your therapist will focus on making
sure you are up, moving, and getting stronger
each day.
The Nurse Case Manager coordinates the
services you receive during the course of your
hospitalization – from admission through
discharge. After your surgery, your case
manager will visit with you to help you plan and
coordinate your discharge needs. They will also
alert other resource departments – such as the
homecare coordinator – to arrange any services
you may need after you leave the hospital. The
case manager ensures that all health care team
members are working toward your goal of
wellness and independence.
Occupational Therapy
Your Occupational Therapist will focus on
promoting your overall independence in your
home. Your therapist will work with you on
your activities of daily living. In addition, your
therapist will assess your need for durable
medical equipment for your self-care at home.
They may issue special equipment to help you,
if needed.
Dietician
A Dietician will follow you throughout your
hospital stay to ensure that any special dietary
needs or requests are met.
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What is a Total Joint Replacement?
An arthritic or damaged joint is removed and
replaced or resurfaced with an artificial joint
called a prosthesis.
What is a joint?
The ends of two or more bones that are
connected by thick tissues form a joint. For
example, the lower leg bone (called the tibia
or shinbone), and your thigh bone (called the
femur), form your knee joint. Your hip is a ball
and socket joint, formed by the upper end of the
femur (the ball), and a part of the pelvis called
the acetabulum (the socket).
The bone ends of a joint are covered with a
smooth layer called cartilage. Normal cartilage
allows nearly frictionless and pain-free
movement. However, when the cartilage is
damaged or diseased by arthritis, joints become
stiff and painful. A fibrous tissue capsule
encloses every joint with a smooth tissue lining
called the synovium. The synovium produces
fluid that reduces friction and wear in a joint.
Why is total joint
replacement necessary?
to the cartilage. A physical examination, possibly
some laboratory tests and x-rays will show the
extent of damage to the joint. The pain may be
so severe, a person will avoid using the joint,
weakening the muscles around the joint and
making it even more difficult to move the joint.
Total joint replacement will be considered if
other treatment options do not relieve your pain
and disability.
How is a total joint replacement
surgery performed?
You will be given an anesthetic and the surgeon
will replace the damaged surfaces of the joint.
For example in an arthritic knee, the damaged
ends of the bones and cartilage are replaced
with metal and plastic surfaces that are shaped
to restore knee movement and function. In an
arthritic hip, the damaged ball (the upper end of
the femur) is replaced by a metal ball attached to
a metal stem fitted into the femur, and a metal
or plastic socket is implanted into the pelvis,
replacing the damaged socket.
The materials used in a total joint replacement
are designed to enable the joint to move just like
your normal joint. The prosthesis is generally
composed of two parts: a metal piece that fits
closely into a matching sturdy plastic piece.
Several metals are used, including stainless steel,
alloys of cobalt and chrome, and titanium. The
plastic material is durable and wear resistant
(polyethylene). Bone cement may be used
to anchor the prosthesis into the bone. Joint
replacements may also be implanted without
bone cement when the prosthesis and the bone
are designed to fit and lock together directly.
The goal of total joint replacement is to relieve
the pain in the joint caused by the damage done
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Is total joint replacement
permanent?
Most people can expect their total joint
replacement to last more than a decade. It
will give years of pain relief that would not
have been possible otherwise. Depending on
a person’s age, they may need revisions of
the implant components at some point in the
future. Materials and surgical techniques are
improving through the efforts of orthopedic
surgeons working closely with engineers and
other scientists. The future is bright for those who
choose to have a total joint replacement to achieve
an improved quality of life through greater
independence and a healthier level of activity.
What are the possible
complications/side effects of
surgery?
The complication rate following total knee
replacement is low. Serious complications,
such as a total joint infection, occur in less
than 2 percent of patients. Major medical
complications, such as heart attack or stroke
occur even less frequently. Chronic illnesses
may increase the potential for complications.
Although uncommon, when these
complications occur they can prolong or limit
your full recovery.
Blood clots in the leg veins are the most
common complication of knee replacement
surgery. Your orthopedic surgeon will outline
a prevention program, which may include
periodic elevation of your legs, lower leg
exercises to increase circulation, support
stockings, and medication to thin your blood.
It is important to adhere to your doctor’s
recommendations to prevent blood clots.
Tell your orthopedic surgeon about any medical
conditions that might affect the surgery. Joint
replacement surgery is successful in more
than 9 out of 10 people. When complications
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occur, most are treated successfully. Possible
complications include:
Infection — Infection may occur in the wound
or deep around the prosthesis. It may happen
while in the hospital or after you go home. It
may even occur years later. Minor infections
in the wound area are generally treated with
antibiotics. Major or deep infections may
require more surgery and removal of the
prosthesis. Any infection in your body can
spread to your joint replacement. For this reason
your surgeon may recommend a preventative
antibiotic schedule for certain surgical and
dental procedures following total joint surgery.
Blood Clots — Blood clots result from several
factors, including your decreased mobility
causing sluggish movement of the blood
through your leg veins. Blood clots may be
suspected if pain and swelling develop in your
calf or thigh. If this occurs, your orthopedic
surgeon may consider tests to evaluate the veins
of your leg. Several measures may be used to
reduce the possibility of blood clots, including:
• blood thinning medications
(anticoagulants)
• elastic stockings or TED hose
• exercises to increase blood flow in the
leg muscles
• early mobilization (avoiding periods
of prolonged sitting)
• foot wraps that inflate with air to
assist with circulation during your
hospital stay
Despite the use of these preventative measures,
blood clots may still occur. If you develop
swelling, redness or pain in your leg following
discharge from the hospital, you should contact
your orthopedic surgeon.
Loosening — Loosening of the prosthesis
within the bone may occur after a total joint
replacement. This may cause pain. If the
loosening is significant, a revision of the joint
replacement may be necessary. New methods of
fixing the prosthesis to bone should minimize
this problem.
Wear — Some wear can be found in all joint
replacements. Excessive wear may contribute to
loosening and may require revision surgery. It
is imperative that you adhere to the follow-up
schedule recommended by your surgeon so wear
of your implant can be monitored annually by
x-ray and examination.
the total joint replacement surgery, although this
type of injury is rare. This is more likely to occur
when the surgery involves correction of major
joint deformity or lengthening of a shortened
limb due to an arthritic deformity. Over time
these nerve injuries often improve and may
completely recover.
Any of these complications or side effects may occur
depending on the type of surgery you are going to
have. Discuss your risk for these complications/side
effects with your doctor.
Prosthetic Breakage — Breakage of the metal
or plastic joint replacement is very rare, but
may occur. A revision surgery is necessary if
this occurs.
Nerve Injury — Nerves in the vicinity of the
total joint replacement may be damaged during
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Total Knee Replacement: The Specifics
Total Knee Replacement
How the Knee Works
If your knee is severely damaged by arthritis
or injury, it may be hard for you to perform
simple activities such as walking or climbing
stairs. You may even begin to feel pain while
you’re sitting or lying down.
The knee is the largest joint in the body. Nearly
normal knee function is needed to perform
routine everyday activities. The knee is made
up of the lower end of the thigh bone (femur),
If medications, changing your activity level, and
using walking supports are no longer helpful,
you may consider total knee replacement
surgery. By resurfacing your knee’s damaged and
worn surfaces, total knee replacement surgery
can relieve your pain, correct your leg deformity,
and help you resume your normal activities.
which rotates on the upper end of the shinbone
(tibia), and the knee cap (patella), which slides in a
groove on the end of the femur. Large ligaments
attach to the femur and tibia to provide stability.
The long thigh muscles give the knee strength.
Total knee replacement was first performed in
1968. Improvements in surgical materials and
techniques since then have greatly increased
its effectiveness. About 676,000 total knee
replacements are performed each year in the
United States. Whether you have just begun
exploring treatment options or have already
decided with your orthopedic surgeon to have
total knee replacement surgery, this information
will help you understand more about this
valuable procedure.
The joint surfaces where these three bones touch
are covered with articular cartilage, a smooth
substance that cushions the bones and enables
them to move easily.
All remaining surfaces of the knee are covered
by a thin, smooth tissue liner called the synovial
membrane. This membrane releases a special
fluid that lubricates the knee, reducing friction to
nearly zero in a healthy knee.
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Normally, all of these components work in
harmony. But disease or injury can disrupt this
harmony, resulting in pain, muscle weakness,
and less function.
The most common cause of
chronic knee pain and disability
is arthritis.
Osteoarthritis usually occurs after the age of 50
and often in an individual with a family history
of arthritis. The cartilage that cushions the bones
of the knee softens and wears away. The bones
then rub against one another causing knee pain
and stiffness.
Indications That You May Benefit
From Total Knee Replacement
• S evere knee pain that limits your everyday
activities, including walking, going up
and down stairs, and getting in and out of
chairs. You may find it hard to walk more
than a few blocks without significant pain
and you may need to use a cane or walker.
• M
oderate or severe knee pain while resting,
either day or night.
• C
hronic knee inflammation and swelling
that doesn’t improve with rest or
medications.
• K
nee deformity – a bowing in or out of your
knee.
• K
nee stiffness – inability to fully bend and
straighten your knee.
• F
ailure to obtain pain relief from non-steroidal
anti-inflammatory drugs. These medications,
including aspirin and ibuprofen, often are
most effective in the early stages of arthritis.
Their effectiveness in controlling knee pain
varies greatly from person to person. These
drugs may become less effective for patients
with severe arthritis.
Rheumatoid Arthritis is a disease in which
the synovial membrane becomes thickened
and inflamed, producing too much synovial
fluid that over-fills the joint space. This chronic
inflammation can damage the cartilage and
eventually cause cartilage loss, pain and
stiffness.
Post Traumatic Arthritis can follow a serious knee
injury. A fracture or severe tears of the knee’s
ligaments may damage the articular cartilage
causing knee pain and limitations.
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• I nability to tolerate or complications from
pain medications.
• F
ailure to substantially improve with other
treatments such as cortisone injections,
physical therapy, or other surgeries.
Most patients who undergo total
knee replacement are age 60 to 80, but
orthopedic surgeons evaluate patients
individually. Recommendations for
surgery are based on a patient’s pain and
disability, not age. Patients as young as
age 16 and older than 90 have undergone
successful total knee replacement.
The Surgical Procedure
You will most likely be admitted to the
hospital on the day of your surgery. The
most common types of anesthesia are general
anesthesia, in which you are asleep throughout
the procedure, and spinal or epidural
anesthesia, in which you are awake but your
legs are anesthetized. The anesthesia team will
discuss the anesthesia options and determine
which type of anesthesia will be best for you.
Realistic Expectations About
Knee Replacement Surgery
An important factor in deciding whether to have
total knee replacement surgery is understanding
what the procedure can and cannot do.
After a reasonable recovery period, more than 90
percent of individuals who undergo total knee
replacement experience a dramatic reduction of
knee pain and a significant improvement in the
ability to perform common activities of daily
living. But total knee replacement won’t make
you a super-athlete or allow you to do more than
you could before you developed arthritis.
Following surgery, you will be advised to
avoid some types of activity for the rest of
your life, including running, jogging and
high impact sports.
The procedure itself takes about two hours.
Your orthopedic surgeon will remove the
damaged cartilage and bone and then position
the new metal and plastic joint surfaces to
restore the alignment and function of your knee.
Many different types of designs and materials
are currently used in total knee replacement
surgery. Nearly all of them consist of three
components: the femoral component (made
of a highly polished strong metal), the
tibial component (made of a durable plastic
often held in a metal tray), and the patellar
component (also plastic).
With normal use and activity, every knee
replacement develops some wear in its plastic
cushion. Excessive activity or weight may
accelerate this normal wear and cause the knee
replacement to loosen and become painful.
There are many activities that can be enjoyed for
years; those that do not create a large amount of
impact are recommended widely. It is generally
advised that high-impact activities be avoided,
such as jogging and running. Ask your surgeon
if there are any restrictions on your activity.
With appropriate activity modification, knee
replacements can last for many years.
After surgery, you will be moved to the recovery
room, where you will remain for one to two
hours while your recovery from anesthesia is
monitored. After you awaken, you will be taken
to your hospital room.
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Preparing for the Surgery
Checklist of things to do
before surgery:
• Visit to your Orthopedic Surgeon’s office:
— Scheduling of surgery date
— Schedule pre-admit testing date
— Schedule “Total Joint Pre-operative”
teaching class
— Sign consent form for surgery
— Pre-certification from insurance company
(if required)
•Medical Evaluation: If you decide to have
knee replacement surgery, you may be
asked to have a complete physical by your
primary care doctor or another Centura
medical doctor before your surgery. This
is needed to assess your health and find
conditions that could interfere with your
surgery or recovery.
•Pre-admission Testing: Several tests, such
as blood samples, a cardiogram (EKG), and
chest x-ray may be needed to help plan
your surgery.
•Total Joint Pre-operative Teaching Class:
This class will prepare you for what to
expect and how to participate in recovery
after surgery.
•Blood Donation (if needed): You may be
advised by your surgeon to donate your
own blood before surgery. It will be stored
in the event you need blood after surgery.
•Dental Evaluation: Although infections
after knee replacement are not common, an
infection can occur if bacteria enters your
bloodstream. Since bacteria can enter the
bloodstream during dental procedures,
treatment of significant dental diseases
(including tooth extractions and periodontal
work) should be considered before your
knee replacement surgery. Routine cleaning
of your teeth should be delayed for several
weeks after surgery.
•Medications: Tell your orthopedic surgeon
about the medications you are taking. Your
orthopedist or your primary care doctor will
advise you which medications you should
stop or can continue taking before surgery.
•Preparing Your Skin and Leg: Your knee
and leg should not have any skin infections
or irritation. Your lower leg should not
have any chronic swelling. Contact your
orthopedic surgeon prior to surgery if either
is present for a program to best prepare
your skin for surgery.
•Weight Loss: If you are overweight, your
doctor may ask you to lose some weight
before surgery to minimize the stress on
your new knee.
•Urinary Evaluation: Individuals with
a history of recent or frequent urinary
infections should consider a urological
evaluation before surgery. Older men with
prostate disease should consider a urologic
evaluation and treatment before having
knee replacement surgery.
•Social Planning: Although you will be able
to walk soon after surgery, you may need
some help for several weeks with such tasks
as cooking, bathing, grocery shopping and
laundry. If possible, enlist your friends and
family to have someone assist you at your
home if necessary.
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How long will you be
in the hospital?
Approximately 2 to 3 days will be spent in the
hospital. The day of admission is considered the
day of surgery. Post operative days are counted
as such: Day of surgery, the first day after your
surgery is Day One, the second day after your
surgery is Day 2 and so forth. Over ninetyfive percent of all total joint patients return to
their own home and do not require additional
inpatient services.
anti-inflammatory drugs. These
include Motrin, Advil, Feldene, Plavix,
Naprosyn, or other arthritis-type
medication, Alka-Seltzer, Bufferin,
Nuprin and many cold medicines.
— You may take Tylenol, Anacin-3, Tylenol
Cold Medicine, Sudafed, Actifed or
Vitamin C.
— If you have questions regarding a
medication, check with your doctor
or pharmacist first. Some surgeons
recommend discontinuing herbal
medicines, such as glucosamine and
ginseng etc. for 1 month prior to surgery.
• The night & day of your surgery
— The anesthesiologist will call you at
home the night before surgery.
— Do not eat anything for 8 hours
(nothing after midnight) before surgery.
— Do not drink alcohol or smoke.
Exercise
Before surgery – Maintain an exercise program.
Keep as active as you are able. It will speed your
recovery. Follow the pre-operative exercise guide
in this booklet.
What & when to eat/drink
• Before surgery
— Take your usual medications as directed
by your doctor with the exception of
aspirin and aspirin or ibuprofen type
products.
• One–two weeks before surgery
— Stop taking medication with aspirin
ingredients, ibuprofen or nonsteroidal
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— You may take prescribed medications
with a sip of water as directed by the
anesthesiologist. These would be blood
pressure medications, heart medications,
and anti-seizure medications that you
routinely take.
What to bring to the hospital
We want to make your hospital stay as
comfortable as possible. Please bring the
following items with you:
•Any paperwork from the doctor’s
office, including the Surgery Consent
Form.
•Your insurance cards and funds for the
co-pay.
•Robe and slippers/socks.
•Comfortable, loose-fitting clothes to
wear home.
•Bring a list of medications and
dosages you usually take.
•Cases or containers for eyeglasses,
hearing aids and dentures.
•Leave valuables and money at home
or with your family.
•Do not wear makeup or jewelry to
surgery.
home for 24-48 hours following your return
home.
• R
emember to adjust your work/social
schedule accordingly during your
anticipated recovery time.
• R
emove all throw rugs or other small
obstacles that may be in your path.
• I f you have pets, you may want to arrange
for someone to assist in caring for them for
a few days after your return home.
• Y
ou cannot drive while you are on
NARCOTICS.
• Y
ou are not allowed to take a bath or get
in a pool for four weeks following surgery
or until your incision is completely healed.
• Y
ou are not allowed to put creams,
lotions or an ointment on the incision
for one month or until the incision is
completely healed.
• Y
ou may get constipated following surgery.
MiraLax is shown to be very effective for
most patients. Start using it five days prior to
surgery and continue when you return home.
The hospital will provide you with a hospital gown,
towels and basic toiletries. If you have special items
you use for daily care, feel free to bring them with you.
WHAT YOU SHOULD KNOW:
• A
rrange for a family member or friend to
accompany you to the hospital the day of
your surgery.
• Y
ou will be discharged from the hospital as
discussed previously, so plan ahead to have
someone available for transportation home
the day of your discharge from the hospital.
• Arrange for someone to stay with you at
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The Day of Surgery
Arrival at the hospital –
The ‘Pre-operative Surgical
Preparation’ Area
Plan to arrive at the hospital 2 hours before your
surgery, or as directed by your surgeon.
Check in at the Registration Desk on the Ground
Floor inside the MAIN ENTRANCE OF THE
HOSPITAL. Following Admission procedures
you will be directed to the second floor “AM
Admissions” area.
We strongly encourage you to send any valuables
home with your family.
• A
n Intravenous catheter (IV) and/or
medications may be given to you at this
time if ordered by your doctor.
• Y
our family/loved ones may be with you
until you are taken to surgery.
You will meet with the anesthesiologist in the
Pre-Operative holding area. From this area you
will go directly to the Operating Room. Your
family will be directed to the Surgery Waiting
Room. Your family will be notified when the
surgery is complete and will be directed to
your room on the postoperative care unit.
Operating Room
You will be taken to the Surgical Preparation
Area where you can expect to:
• Complete admission forms.
• C
hange from your street clothing into a
patient gown. You will be given a patient
belongings bag to place your personal items
in. The bag will remain with you until you
are settled into your room after surgery.
• R
emove: 1) glasses/contacts 2) nail polish/makeup 3) braces/prosthesis 4) all jewelry
5) hairpins
6) hearing aids
7) dentures and removable dental work.
Once in the operating room, you will move to an
operating room bed. This bed works extremely
well during surgery but is not the most
comfortable piece of furniture you have been on!
Special care will be taken to respect your privacy
and make you comfortable with special padding.
You can expect:
• You will have monitors placed on you. • T
he nurses will be preparing the room for
surgery.
• Y
ou will notice the room will feel cool. Let
the nurses know if you are too chilly, and they
will make you as comfortable as possible.
• The surgery will take about 1-2 hours.
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Your family can wait in the Surgery Waiting
Room. After the surgery is complete, the doctor
will talk to your family and update them on how
the surgery went.
You can expect:
• C
ontinued monitoring of blood pressure,
pulse, respirations, and to be asked how
you are doing. You will be asked to rate
the level of your pain on a scale of 1 to 10,
1 being a very low level of pain and 10
being excruciating pain.
• C
ontinued monitoring of the condition of
your legs.
• C
ontinued administration of pain
medication as needed.
— There are many different pain medications
and several modes of administration. The
“orders” for your pain medication come
directly from your surgeon. Speak with
your doctor if you have concerns regarding
the method of pain control.
Recovery Room
When you wake up from surgery you will be in
the Recovery Room for 1-2 hours.
You can expect:
• A
nurse will check your blood pressure,
pulse, respiratory rate, and how you are
doing every 10-15 minutes.
• Y
ou will be asked questions relating to time
and place.
• Y
ou will be asked to cough, and deep
breathe.
• T
he condition of your legs and feet will be
checked. (The nurse will ask you if you can
feel sensation in various places, and to pull
your toes up and down).
The Postoperative Unit
Once you are fully awake you will be transferred
to a room on the Postoperative Unit. This will be
your room for the rest of your hospital stay.
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• C
ontinued requests to cough and deep
breathe. Use your Incentive Spirometer
(try to do this at least 10 times/hour).
• P
hysical Therapy and Occupational Therapy
treatment to begin.
Activity
You will be assisted at the bedside to sit up,
stand up and possibly even walk in the evening
following your surgery, depending on your
condition. Many doctors feel early mobilization
helps speed your recovery and prevents
complications.
The Recovery Period: Tubes and Equipment
During the surgery, many tubes are placed
and attached to you for the purpose of monitoring
how you are doing. Below are a few of the tubes
and names of the equipment you will have.
Learning about them will help you to understand
their purpose and know what to expect.
Intravenous catheter (IV):
An IV is a small, soft catheter inserted into a vein
in your arm. Fluids and medication are given to
you through the catheter.
What to expect:.
• Y
ou will feel a quick sting and pain when
the catheter is first inserted.
• O
nce inserted, you will not feel the fluids or
medication going through it.
Oxygen:
Oxygen will be given to you by facemask or
nasal cannula. The oxygen will be removed
once you are maintaining a satisfactory level of
oxygen in your system.
What to expect:.
• B
ecause of the flow of oxygen through your
nose, it may feel dry.
Urethral catheter (Foley):
The urethral catheter is a soft, rubber tube that
is inserted into the bladder. This tube will drain
urine from your bladder. This tube is held in
place by a small fluid-filled balloon inside the
bladder. This catheter is usually placed after you
are anesthetized in the operating room.
What to expect:.
• F
eeling or sensation of pressure in your
bladder or a need to urinate.
• Bladder spasm and/or rectal spasm.
Knee Dressing:
The knee that you had surgery on will be
wrapped in a dressing and an elastic bandage.
This dressing provides slight compression to the
surgical area to reduce swelling or bleeding.
What to expect:.
• Y
our knee will feel like it is swollen with
a tight bandage around it. Ask your
nurse to adjust the dressing if it becomes
uncomfortable.
Incision Drain
(e.g. Hemovac; Jackson-Pratt):
The incision drain is a small plastic tube that is
placed in the surgical incision and is connected
to a gentle suction device to collect drainage. It
will be removed before you are discharged from
the hospital.
What to expect:.
• T
here may be a tugging sensation where the
drainage tube enters the incision.
Continuous Passive
Motion machine (CPM):
The leg that you have had surgery on may be
placed in a CPM machine when your doctor orders
it. The CPM machine is designed to straighten and
bend your knee ‘passively’ while you are in bed.
The purpose of this machine is to move your knee
to ensure full range of motion as you recover.
What to expect:
• Y
ou may feel pain in your knee with
straightening and bending of your knee.
Tell your nurse if pain is present. The
23
machine may need to be repositioned or you
may need additional pain medication to keep
you comfortable.
Sequential Compression
Devices and Foot Wraps
Sequential Compression Devices help prevent
the formation of blood clots in your legs due to
immobility. These are worn only when in bed,
during your hospital stay.
What to expect:
• C
ompression leg wraps are plastic
“sleeves” that wrap around each leg and
gently massage by squeezing and releasing
the muscles in your legs. This helps pump
the blood back to the heart and helps
prevent blood clots from forming.
• F
oot pumps are like plastic socks that wrap
around each foot and gently pump the feet
to help pump blood back to the heart and
prevent blood clots from forming.
• E
lastic stockings (TED hose): You may
wear elastic stockings to help prevent the
formation of blood clots in your legs due to
immobility.
These stockings must be worn according to
your surgeon’s orders.
24
The Recovery Period:
What You Can Do To Help.
You have the right to help plan your care. The
healthcare team will work with you to help you
decide what treatment and recovery options are
best for you. You are encouraged to ask questions
about any of your concerns. You always have the
right to refuse treatment.
How to Control Pain
Nearly everyone experiences some pain after
surgery. Temporary swelling may take place
in your knee, and you will experience varying
degrees of discomfort in general. This is normal.
Not everyone has immediate relief of pain after
surgery. Our goal is to make you comfortable
enough to be able to participate in health recovery
activities like sitting, standing, and walking.
What to expect:
•Incision pain: Soreness with pulling felt
along the incision line.
• Knee pain.
What you can do:
•Request pain medication at the earliest
onset of pain and before activity.
•Tell the nurse how the pain medication is
working.
•Use proper body mechanics when moving
around.
If you have a femoral block for pain control:
A femoral block is a local anesthetic that is injected
around the femoral nerve during surgery. This
anesthetic provides pain control directly at the
surgical site, thus less systemic pain medication is
required. However, the sciatic nerve, that provides
sensation at the back of the knee, is not affected.
Therefore, the pain sensation at the knee is not
completely blocked and you can expect to experience
some pain in the knee.
The femoral block results in temporary loss of
quadriceps sensory and motor function. Therefore,
you will not be able to extend your lower leg or
bear weight while the block is in place. You can still
participate in physical/occupational therapies, but
you may only get up with assistance until the motor
and sensory function returns.
Diet Progression
• F
ood/fluids are important to maintain
strength and healing after surgery.
• L
ack of activity and taking pain medication
may cause constipation.
What to expect:
• You may feel sick to your stomach.
• Y
ou will have clear liquids for your first
meal after surgery.
• Y
ou will progress to more solid foods when
you are ready.
What you can do:
• T
ell the nurse when you feel sick to your
stomach. You may have medication for this.
To prevent constipation:
• Drink fluids.
• Increase your activity.
• I f needed, a stool softener or laxative may be
taken.
25
Activity
•Activity is important after surgery to
maintain muscle strength and flexibility;
to resume bowel function; to prevent the
complications of deep vein thrombosis
and pneumonia; and to keep a positive
mental outlook.
What you can expect:
• T
o be repositioned in bed at least every 2
hours.
• P
hysical and Occupational Therapy to begin
working with you the day of, or the day
after surgery.
What you can do:
• F
ollow your Physical Therapy &
Occupational Therapy plan while in the
hospital.
• D
o ankle pumps and change positions
frequently.
• U
se the incentive spirometer, cough, deep
breathe as directed.
• Do NOT put pillows under the knee!!
Remember: The health care team is here to
assist YOU, the patient, and your family. If you
have any questions about your care or how you
are progressing, please ask.
We are your partners in your path back to a
more satisfying and active lifestyle after your
surgery.
26
The Recovery Period:
Physical Therapy & Occupational Therapy
The Physical Therapist (PT)
& Occupational Therapist (OT)
Often referred to by their initials, the PT & OT
will play an integral role on your rehabilitation
team that will assist you after surgery. The PT
will help you to get up and moving and teach
you important information about your knee.
The PT assists with your recovery to ensure a
safe return home and to maximize your mobility
and range of motion.
will start out with the assistance of a walker,
particularly important to prevent falling. There
are some cases where the surgeon will restrict
weight through the leg. This will result in a partial
weight bearing for a short time, as ordered by
your doctor. You will receive specific instructions
by the therapist regarding any weight bearing
restrictions ordered by your surgeon.
The OT will play an important part in your
rehabilitation also. The OT helps you with
learning the skills necessary for completing
daily care like: bathing, brushing your teeth,
dressing and going to the bathroom, as well
as instructional training for use of adaptive
equipment.
The Initial PT & OT Session
Physical Therapy and Occupational Therapy will
begin the day of or the day after your surgery.
The PT & OT will come to your hospital room.
They will ask you questions about how you are
feeling and about your home situation. They will
tailor a therapy plan to fit your individual needs. They will begin to help you out of bed and start
activities so you can care for yourself again.
Your physical therapy and occupational therapy
team will see you twice a day during your
hospital stay.
Weight Bearing
Most often you will be able to put as much
weight through your leg as you can tolerate when
standing or walking after surgery. Everyone
27
The Recovery Period: Rehabilitation
Hospital Discharge Options
Depending on your medical progress, your
therapies, and your home situation, there are
several discharge options available to you:
• D
ischarge to your home, with or without
home health services
• D
ischarge to your home with outpatient
services
• Discharge to a skilled nursing facility
• D
ischarge to an acute inpatient
rehabilitation unit
All discharge options are based upon
medical necessity, physician orders, patient
choice, and insurance authorization. Your
Physician and your Case Manager will discuss
recommendations and available options with
you. Certain criteria must be met in order for
insurance to pay for rehabilitation services. If
you have any questions regarding the criteria,
please discuss with the case manager.
Home Health Services
Homebound patients may require home health
services. These services may include skilled
nursing services (such as wound care or
intravenous medication), physical therapy and
occupational therapy. Personal care (such as meal
preparation, bathing and household chores) is
not usually a covered insurance benefit.
services (for example, physical or occupational
therapy).
Skilled Nursing Facility
A skilled nursing facility (SNF) provides 24-hour
care to patients when they no longer require
an acute hospital stay but continue to require
skilled services of nurses and/or therapists in an
inpatient setting. “Skilled” services are defined
by guidelines developed by Medicare and other
organizations and typically include nursing
care, physical therapy, occupational therapy, and
speech therapy.
Acute Inpatient Rehabilitation
Acute inpatient rehabilitation (Rehab) provides
intensive inpatient services such as physical
therapy, occupational therapy, and speech or
cognitive therapy. This level of care most often
follows certain orthopedic surgeries (such
as joint replacement) that are complicated by
another chronic medical condition. Porter
Adventist Hospital has an acute rehab unit,
which may be a discharge option for you. A
basic criterion for admission to any acute rehab
facility is the ability to participate in 3 hours
of therapy daily. Patients who are unable to
participate at this level of intensity will be
referred for rehabilitation services in a skilled
nursing facility.
Outpatient Services
Outpatient services are received in a medical
office, physical therapy clinic, treatment facility,
or hospital outpatient department. You will
travel as needed to the designated provider of
29
Planning for Your Return Home
Here are some items and home modifications
that will make your return home easier
during your recovery.
•Safety bars or a secure handrail in
your shower or bath.
• Secure handrails along your stairways.
•A stable chair for your early recovery
with a firm seat cushion (height of
18-20 inches), a firm back, two arms,
and a footstool for intermittent leg
elevation.
•A stable shower bench or chair for
bathing.
• Removing all loose carpets and cords.
•Have small meals and snacks prepared
ahead of time.
•Let your family know that your hospital
stay will probably be 2-3 days so they
can be available for your ride home.
Your Recovery
Exercise is a critical component of home care,
particularly during the first few weeks after
surgery. You should be able to resume most
normal light activities of daily living within
three to six weeks following surgery. Some
discomfort with activity, and at night, is
common for several weeks.
Follow your instructions regarding pain
medication, apply ice packs over the knee to
reduce swelling and pain, pump your ankles
up and down and elevate your entire leg above
the level of your heart 3-4 times per day.
Activity
• C
ontinue your Physical Therapy Program.
Do your exercises as instructed at least 3
times per day. Change position frequently
as prolonged sitting or lying down could
produce stiffness. Your activity program
should include:
• A
graduated walking program to slowly
increase your mobility, initially in your
home and later outside.
• R
esuming other normal household
activities, such as sitting and standing and
walking up and down stairs.
• S
pecific exercises several times a day
to restore movement and strengthen
your knee. You probably will be able to
perform the exercises without help, but
you may have a physical therapist help
or may be in a therapy center the first
few weeks after surgery.
• A
fter your surgery, you may be permitted
to play golf, walk and dance and participate
in a large range of activities. You may be
discouraged from performing high impact
activities such as running, jumping, race
walking or playing basketball. Check with
your doctor if you have specific concerns
regarding activities.
• T
he motion of your joint will generally
improve after surgery. The extent of
improvement will depend on how stiff
your joint was before the surgery. Your
range of motion exercises (bending
and straightening of the knee) are very
important to the overall outcome of your
new knee joint.
31
Pain
• M
ost patients have some temporary
pain in the replaced joint because the
surrounding muscles are weak from
inactivity and the tissues are healing, but
it will decrease in a few weeks or months.
• T
ake your pain medication as prescribed
by your doctor.
Rest
• A
void fatigue. Take short rest periods
each day.
• I t is sometimes difficult to sleep through
the entire night. This is normal. You may
need a nap during the day.
Shower
• S
hower, if appropriate. Do not immerse
your incision in collected bodies of water
(bathtubs, pools, hot tubs) until the skin is
completely healed.
• U
se a shower chair or place a chair in the
shower to sit on.
Incision Care
• A
void soaking the wound in water until
the wound has thoroughly sealed and
dried.
• D
o not apply lotion, powder, oils, or
ointments to the incision.
• C
over with a clean, dry dressing after
showering to prevent irritation from
clothing or support stockings.
Food and Fluids
• You should eat a well balanced diet.
• F
oods high in iron will help improve your
blood counts (red meat, liver, spinach,
asparagus and broccoli, fortified cereals).
32
• F
oods high in calcium are recommended
(3-4 glasses of milk/day, cheese, rice,
yogurt).
• D
rink plenty of fluids to avoid
constipation.
• I f constipated, a stool softener or laxative
may be taken.
Driving
• Y
ou must be off narcotic pain medications
and feel that you have regained your
muscle strength and control.
Driving usually begins when your knee
bends sufficiently so you can enter and sit
comfortably in your car and when your
muscle control provides adequate reaction
time for braking and acceleration. Most
individuals resume driving about four to six
weeks after surgery. Check with your doctor.
Avoiding Problems After Surgery
Blood Clot Prevention:
Follow your orthopedic surgeon’s instructions
carefully to minimize the potential risk of blood
clots that can occur during the first several weeks
of your recovery.
Warning signs of possible blood clots include:
• P
ain in your calf and leg, unrelated to
your incision.
• Tenderness or redness of your calf.
• S
welling of your thigh, calf, ankle or foot
that does not recede with elevation.
Warning signs that a blood clot has traveled to
your lung include:
• Shortness of breath.
• Chest pain, particularly with breathing.
Notify your doctor immediately if you develop
any of these signs.
orally, OR AS DIRECTED BY YOUR
DOCTOR).
• Shaking chills.
• I ncreasing redness, tenderness, or swelling
of the knee wound.
• Drainage from the knee wound.
• I ncreasing knee pain with both activity
and rest.
Notify your doctor immediately if you develop
any of these signs.
Avoiding Falls:
A fall during the first few weeks after surgery
can damage your new knee and may result in a
need for further surgery. Stairs and curbs are a
particular hazard until your knee is strong and
mobile. You should use a cane, crutches, a walker,
handrails, or someone to help you until you have
improved your balance, flexibility, and strength.
Preventing Infection:
The most common causes of infection following
total knee replacement surgery are from bacteria
that enter the bloodstream during dental
procedures, urinary tract infections, or skin
infections. These bacteria can lodge in the bone
around your knee replacement and cause an
infection.
Following your surgery, you should take
antibiotics prior to dental work, including
dental cleanings, or any surgical procedure that
could allow bacteria to enter your bloodstream.
Warning signs of a possible knee
replacement infection are:
• Persistent fever (higher than 101 degrees
Your surgeon and physical therapist will help
you decide what assistive aides will be required
following surgery and when those aides can
safely be discontinued.
33
Your Postoperative Follow-up Visits
with Your Surgeon
You will be instructed on the follow-up schedule
by your surgeon before you leave the hospital.
After you get home from the hospital, call
the doctor’s office to schedule your follow-up
appointments:
At these appointments you can expect that the
doctor and his team will:
•Check your progress.
•Answer any questions.
•Remove the staples from your incision
(at 10-14 days).
•Incision check.
•Examination:
—A
ssessment of weight bearing
status;
— Assessment of your range of motion
and progress in your Physical
therapy program.
Further follow-up visits will then occur at
approximately 3 months, 6 months, 1 year, and
annually thereafter. The visits will include an
examination and x-ray of your new joint. Followup visits and x-rays are a vital part of your care
after surgery because they can sometimes show
a problem long before you feel that anything is
wrong. Schedule your return appointments even
though you are doing well and feeling fine.
Should you have a need for more frequent
followup, you may be asked to return at shorter
intervals.
Also, contact your primary care doctor when you
get home to see when they would like to arrange
a follow-up appointment. This visit will ensure
that you are as physically fit as possible and
allow you to maximize your recovery.
•X-rays at 4-6 weeks post operatively.
•You will be given further instructions
regarding use of the walker/crutches,
driving, physical therapy and
medications.
35
How Your New Knee is Different
You may feel some numbness in the skin
around your incision. You also may feel some
stiffness, particularly with excessive bending
activities. Improvement of knee motion is a goal
of total knee replacement. The motion of your
knee replacement after surgery is influenced
by the motion of your knee prior to surgery.
Most patients can expect to fully straighten the
replaced knee and to bend the knee sufficiently
to go up and down stairs and get in and out of
a car. Kneeling is usually uncomfortable, but it
is not harmful. Occasionally, you may feel some
soft clicking of the metal and plastic with knee
bending or walking. These differences often
diminish with time and most patients find these
are minor, compared to the pain and limited
function they experienced prior to surgery.
References:
Usher, Nancy (1993). Open Heart Surgery: Preoperative
Sensory Information. The University of Iowa Virtual Hospital.
Usher, Nancy (1993). Hardiness and patient participation in
health recovery activities. Master’s Thesis, University of Iowa.
American Academy of Orthopedic Surgeons. AAOS Research
Dept., arthroplasty and total joint replacement procedures 19901999; June 2001
The Joint Team. Porter Adventist Hospital. July 2004.
Your new knee may activate metal detectors
required for security in airports and some
buildings. Tell the security agent about your
knee replacement if the alarm is activated.
And remember, after surgery, make sure you
also do the following:
• P
articipate in regular light exercise
programs to maintain proper strength and
mobility of your new knee.
• T
ake special precautions to avoid falls and
injuries. Individuals who have undergone
total knee replacement surgery and suffer a
fracture may require more surgery.
• N
otify your dentist that you had a
knee replacement. You should be given
antibiotics before all dental surgery for the
rest of your life.
• S ee your orthopedic surgeon periodically
for a routine follow-up examination and
x-rays, usually once a year.
37
Total Knee Replacement Exercises
Patellar Mobilization
With leg relaxed, move
kneecap up and down and
side to side.
Quadriceps Set
Push knees down
into floor or table by
tightening thigh muscles.
Straight Leg Raise
Keeping leg straight,
tighten thigh muscles and
lift leg 8-10 inches from
surface, and then lower.
39
Sit to Stand
To strengthen the weaker leg,
slide heel toward chair. Push
up to a standing position.
Chair Push-up
To strengthen the arms, lean
forward and extend elbows.
Partial Squats
With feet shoulder width apart
and away from wall, slide
down wall 4-5 inches and then
return to starting position.
40
WHAT IS NORMAL AFTER
TOTAL JOINT REPLACEMENT
The following are a few of the most common
complaints by patients, and some things to try to
help alleviate your discomfort or fears.
SWELLING
Lie down flat (not in a recliner) and elevate your
operative leg with the foot higher than your knee,
and your knee higher than your heart, for at least
1 hour three times a day. Use ice for 20 minutes
on, 20 minutes off while elevating the leg. Wear
the TED hose until you finish your Coumadin.
Some swelling is expected for several months
after surgery.
TED HOSE
You must wear on both legs during the daytime
for 3-4 weeks from the date of surgery. Do not
wear them at night.
PAIN
Take your pain medications as directed.
Use ice: on 20 minutes, off 20 minutes.
Contact the Physician Assistant if your pain
medication is inadequate.
FATIGUE
Continue with a normal diet and drink lots of
fluids. Take non-prescription iron or a multivitamin with iron in it.
INSOMNIA
Try Tylenol PM with your pain medication. Don’t
nap during the day, and avoid caffeine. Get back
to your regular routine.
NAUSEA
Be sure to eat before taking medications. Eat light
foods, not heavy, greasy foods. You could be too
sensitive to your pain medication. The doctor’s office
may need to call in another kind for you to try.
CONSTIPATION
Increase your fluid (water) intake. Increase your
fiber (fruits, whole grain cereals). Take a stool
softener with a laxative such as Senokot or
Dulcolax, which are found over the counter at
your pharmacy.
LOSS OF APPETITE
Gently stretch. Apply warm compresses to your
thigh, but not on the incision.
Continue eating small healthy meals more
frequently. Drink lots of fluids. As pain allows,
switch to Extra Strength Tylenol as narcotics can
decrease your appetite.
WEAKNESS/STIFFNESS
WOUND DRAINAGE
Exercise. Do your physical therapy 3 times daily
on your own, keeping in mind your restrictions/
precautions and pace yourself. It is better to
exercise frequently each day for shorter periods of
time rather than extended periods less frequently.
Some drainage (bloody, clear, yellowish) and
bruising is not uncommon for the couple of
weeks after surgery, and will be evaluated at
your initial post-op visit(s). Excessive or persistent
drainage should be reported to the Physician
SPASMS/ACHING
41
Assistant.
INFORMATION TO REMEMBER
DURING THE POST-OPERATIVE
PERIOD
and motion, and do not have any weight
restrictions following surgery, you may begin
driving 3-4 weeks from surgery. Drive only short
distances, take it slow and use an automatic if
available.
PRESCRIPTIONS:
SHOWERING:
Call your pharmacy or the Physician Assistant
2 business days before you run out of your pain
medication for any refills. The pharmacist will
call us and your Doctor/PA will review the
request. Our office will call the pharmacist with
the decision. NO PRESCRIPTION REFILLS
AFTER HOURS OR ON THE WEEKENDS.
Do not wait until Friday afternoon to call your
pharmacy.
You may shower as usual after surgery. Do not
scrub the incision site, only let water run off
it. You do not need to cover the incision while
showering. Wait 24 hours after staples are
removed to shower again so that staple holes
have time to close.
COUMADIN:
You may take Coumadin for three weeks. You
need to have your PT/INR (a lab test for the
thinness of your blood) checked once a week.
A prescription or orders will be given to you or
your home care nurse for this lab test once you’re
discharged from the hospital.
**24 hours after your last Coumadin dose, begin
taking 1 aspirin per day for one month. You may
take 81 mg or 325 mg aspirin, they both work to
prevent clots.**
WALKER/CRUTCHES:
Unless told otherwise by your doctor or their
staff (not the physical therapist), you must use
two crutches or your walker for 6 weeks from
surgery. You will then go to 1 crutch or a cane
for another 3-4 weeks. This is not to protect the
joint directly, but to keep you from injuring
it by falling. If you trip or fall it could have
devastating consequences for your new joint.
DRIVING:
It is illegal to drive while taking narcotics. If you
are off narcotic painkillers, have good strength
42
CAUTIONS/
TUB BATHING/SWIMMING:
Bathing is usually okay 2-4 weeks after staples
have been removed. Make sure that all scabs are
gone and all holes are completely closed up.
STATIONARY BIKE:
Most knee patients will begin using a stationary
bike very early in physical therapy.
**We recommend that you do not go to the
dentist for a routine cleaning until 8 weeks
after your surgery, and you will need to premedicate prior to that visit.**
Dental Care
Dental Care for Joint Replacement Patients
All patients who have had a total joint
replacement must follow a strict regimen of
antibiotic therapy when they have dental
procedures performed. This protocol must be
followed for the rest of your life!
Patients not allergic to Penicillin,
Cephalexin, Cephradine or Amoxicillin:
Take 2 grams orally 1 hour prior to a
dental procedure.
Patients not allergic to Penicillin, but
unable to take oral medications:
1 gram of Cefazolin or 2 grams of
Ampicillin via IV or shot 1 hour prior to
a dental procedure.
Patients allergic to Penicillin:
Take 600 mg of Clindamycin 1 hour prior
to a dental procedure.
Patients allergic to Penicillin, but unable
to take oral medications:
Take 600 mg of Clindamycin via IV or
shot 1 hour prior to a dental procedure.
43
Follow-up Care
Follow-up care for your Joint Replacement
Long term followup of all total joint
replacements and partial joint replacements
likewise is critically important and the schedule
for this followup is as listed below:
You will typically have 2 or 3 followup
appointments early on after your surgery
within the first year of surgery to assess your
rehabilitation after your total joint replacement
surgery. These appointments are very important.
We need to see each and every joint replacement
patient at one year, two years and every two
years thereafter or biannually for clinical
assessment and for radiographic assessment
of the function of your joint replacement. The
purpose of this long term followup is to assess
for the potential development of problems
around your joint replacement which can be
silent yet destructive to either the prosthesis
or your bone. For instance, there is a process
called osteolysis, a silent and insidious bone
loss process around a prosthetic joint which
ultimately can lead to failure of the joint
replacement or fracture of the bone. Without
followup, the patient will be unaware that this
process is occurring. The only way to detect the
development of this problem is with standard
followup radiographs done at your annual or
biannual followup.
Write down your date of surgery here
_______________________ so that you can
maintain an appropriate long term follow-up
schedule for your total joint replacement. Should
you move out of state and are unable to follow up
in our office then you will need to follow up with
an orthopedic surgeon in your new location.
45
Leg Elevation
ELEVATION OF THE LEG
Swelling of the lower leg is a common after-effect
following total joint replacement. Please follow
this schedule to reduce swelling and improve
your lower leg circulation.
Recommended time schedule:
10:00 am, 2:00 pm, 6:00 pm
Lie flat on a bed or couch. You may use one
pillow beneath your head. Place 3 or 4 firm
pillows or folded blankets to create a height of
18 inches at the foot of the bed or couch. Place
your foot and ankle on top of the pillows. It is
important that the leg is straight and at least 18
inches above the level of your heart. Stay in this
position for one hour at least three times per day.
Moving your foot in a circular motion or the
ankle in a pumping action will also increase
circulation.
47