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A TOTAL KNEE REPLACEMENT MANUAL
FOR THE PATIENTS OF
JOHN R. MORELAND, M. D.
2001 SANTA MONICA BOULEVARD
SUITE 1280W
SANTA MONICA, CALIFORNIA
PHONE (310) 453-1911
FAX (310) 453-6902
This booklet is the original work of John R. Moreland, M.D.
Dr. Moreland requests that his material not be reproduced without
his written permission. Additional booklets can be obtained by
calling or writing his office.
July 2013
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WHAT IS THE KNEE? ................................................................................................... 5
WHAT MAKES A KNEE HURT? .................................................................................... 5
WHAT IS ARTHRITIS? ................................................................................................... 6
OSTEONECROSIS ......................................................................................................... 7
OSTEOPOROSIS ........................................................................................................... 8
WHERE WILL I FEEL KNEE PAIN? .............................................................................. 8
ACTIVITY AND KNEE ARTHRITIS ................................................................................ 9
MEDICATIONS FOR KNEE ARTHRITIS ..................................................................... 10
NARCOTICS FOR KNEE PAIN .................................................................................... 11
EXERCISE FOR PEOPLE WITH KNEE ARTHRITIS ................................................... 12
STEROID KNEE INJECTIONS ..................................................................................... 12
WHAT CAUSES MY LIMP? .......................................................................................... 13
WHEN SHOULD A CANE BE USED?.......................................................................... 13
SHOULD I LOSE WEIGHT? ......................................................................................... 13
OTHER TREATMENTS ................................................................................................ 14
WHEN SHOULD I HAVE MY KNEE REPLACED? ...................................................... 14
CAN I PUT OFF SURGERY? ....................................................................................... 15
OTHER SURGICAL TREATMENT ALTERNATIVES ................................................... 15
HISTORY OF KNEE REPLACEMENT SURGERY....................................................... 16
WHY IS IT CALLED A TOTAL KNEE REPLACEMENT? ............................................ 17
LOOSENING OF CEMENTED KNEE REPLACEMENTS ............................................ 17
SHOULD THE PATIENT DECIDE IMPLANT TYPE? ................................................... 18
OTHER NEW TECHNIQUES ........................................................................................ 18
INFECTION OF KNEE REPLACEMENTS .................................................................. 19
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WEAR ........................................................................................................................... 20
OTHER POSSIBLE COMPLICATIONS ........................................................................ 20
WRONG SIDE SURGERY ............................................................................................ 22
MINIMALLY INVASIVE KNEE REPLACEMENT .......................................................... 22
BILATERAL SIMULTANEOUS KNEE REPLACEMENT .............................................. 23
WILL DR. MORELAND DO THE SURGERY? ............................................................. 24
INITIAL CONSULTATION WITH DR. MORELAND ...................................................... 24
SURGICAL SCHEDULING ........................................................................................... 24
AUTOLOGOUS BLOOD DONATION ........................................................................... 25
OTHER PREOPERATIVE CONSIDERATIONS ........................................................... 25
THE PREOPERATIVE VISIT ........................................................................................ 26
WHAT DO I BRING TO THE HOSPITAL? ................................................................... 27
THE DAY OF SURGERY .............................................................................................. 27
NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES ........................................ 28
THE HOSPITAL STAY.................................................................................................. 29
DISCHARGE FROM THE HOSPITAL .......................................................................... 31
FOLLOW-UP APPOINTMENTS ................................................................................... 32
HOW CAN I PREPARE MY HOME? ............................................................................ 33
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WHAT IS THE KNEE?
The knee is the junction of the femur (thigh bone) and the tibia (shin bone). The patella
(kneecap) moves back and forth on the end of the femur as the knee bends and then
straightens out. In a healthy knee, the ends of the femur and the tibia and the under surface of
the patella are all covered with a layer of a smooth and slippery white substance about oneeighth of an inch thick called articular cartilage. When the knee moves, the cartilage-covered
femur moves back and forth on the cartilage-covered tibia. The cartilage-covered patella also
moves back and forth on the cartilage-covered femur.
Articular cartilage has no nerve endings to transmit pain signals to the brain and thus we are
not aware of movement between the two cartilage layers. Little friction is generated and no
discomfort is felt. Since cartilage does not stop x-rays and thus does not show up on film, an xray of the knee normally shows a space about one-quarter inch thick between the end of the
femur and the top of the tibia.
WHAT MAKES A KNEE HURT?
In most types of knee disease which can benefit from knee replacement, the articular cartilage
has deteriorated and is partially or completely absent. Without the articular cartilage layer, the
bone of the femur rubs on the bone of the tibia rather than being separated by this articular
cartilage. Radiographs will then show the femoral bone touching the tibial bone, since the
cartilage layers are absent. Bone, as opposed to cartilage, does have nerve endings and this
bone-on-bone contact usually causes pain.
Many people are surprised to hear that bones are alive and can hurt. Inside the calcium
crystalline structure of bone are nerve cells, which can transmit pain signals to the brain when
the bones touch. In addition, this bone-on-bone touching often causes wearing away of the
bone surface releasing bone and cartilage fragments into the joint cavity. These released
fragments irritate the lining of the joint (synovium) and cause a painful inflammation of the joint
lining (synovitis).
Early in the course of knee arthritis the knee cartilage space will only be narrowed and patients
usually have mild pain. As the knee deterioration progresses, the bones will gradually move
closer together on the x-ray as the cartilage layer thickness decreases. The cartilage-covered
knee surfaces can be compared to a man’s head covered with hair. During the process of
balding, the man first gets a thinned area of hair, and then the thin area gradually progresses to
a small bald spot. Later, the bald spot enlarges. Cartilage loss from the knee surfaces is
similar. As the bones touch over increasingly larger areas, the pain usually will gradually
worsen. At surgery the knee surfaces usually have large areas devoid of cartilage, but may still
have some areas of peripheral cartilage left even though the patient has severe symptoms. A
knee replacement is just a complicated replacement for the missing cartilage.
The bone surfaces become denser and highly polished from the repetitive rubbing. At times
patients can even hear a creaking noise (crepitation) coming from the knee caused by the
bone-on-bone contact. The body often attempts to heal the diseased joint by forming extra
bone at the joint edges. These extra bone formations are visible on the x-ray and are called
spurs, or better, osteophytes. As the cartilage wears out, normal knee flexibility is often
decreased by various mechanisms (pain, high friction, osteophytes, and muscle stiffness).
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Knee motion is reduced and the knee may not straighten all the way out and may not bend fully.
Poor knee flexion makes it more difficult to get out of a chair and climb stairs and ride a bicycle.
Patients often wonder why it is not possible to inject new cartilage into the knee. This will
probably not be practical in the foreseeable future because cartilage has an extremely complex
three-dimensional structure. No substitute for cartilage is likely ever to be placed through a
needle or even small incisions because the forces across the knee joint are very high (three
times body weight when walking). Only very strong metals and plastics have the potential to
stand up to such high forces.
The knee actually contains two types of cartilage. Articular cartilage is that which covers the
ends of the bone similar to tread on a tire. Meniscal cartilage is independent of the bone and
not attached to the femur, tibia, or patella. There are two c-shaped pieces of meniscal cartilage
in the knee, similar to incomplete washers, in the space between the femur and the tibia.
These meniscal cartilages are often injured during athletics. When torn, meniscal cartilage
often does not heal and pieces of it may become trapped in abnormal positions causing the
knee to give way. Patients can also experience knee fluid accumulation and pain with certain
twisting motions.
An arthroscope, an instrument the size of a large pencil, can be inserted into the knee
enabling the physician to see the contents of the knee. With delicate instruments placed within
the knee through small puncture wounds, the surgeon can often remove the torn bits of
meniscal cartilage and relieve the problems they cause. Many orthopaedic surgeons specialize
in knee arthroscopy, which can also be used to treat other problems. When articular cartilage
has worn out, arthroscopy is usually not helpful and knee replacement is often required. Dr.
Moreland limits his practice to the treatment of arthritic conditions of the knee and the hip and
does not do arthroscopy. His surgical expertise is in the area of hip and knee replacement. He
can assist in referring you to a specialist in arthroscopy if indicated by your condition.
.
WHAT IS ARTHRITIS?
Joint pain is called arthritis (arthr means joint and itis means inflammation). The word arthritis
simply means that a patient has at least one joint which is causing pain. There are many types
of arthritis. The most common type is called osteoarthritis. This is the result of wearing out of
the articular cartilage of the joint and can be caused by an old injury, by trauma, or by abnormal
development of the knee causing it to wear out sooner than normal.
Rheumatoid arthritis (RA) is another cause of knee deterioration. The inflammation of
rheumatoid arthritis is a generalized rather than a localized condition, usually affecting many
joints in the body as well as causing a general ill feeling. The severity of rheumatoid arthritis is
variable and most RA patients are under the regular care of a rheumatologist (an internal
medicine doctor specially trained in diseases which cause joint problems but who does not do
surgery). Rheumatologists and orthopedists often work together in the care of patients with RA.
Certain powerful drugs such as gold, methotrexate, penicillamine and prednisone have long
been used by rheumatologists to control the joint pain and swelling. Patients, who chronically
take the steroid drug, prednisone, need extra amounts of steroid during the surgical period,
because of adrenal suppression.
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Some newer and quite effective drugs to combat rheumatoid arthritis are now available. These
medicines are called disease-modifying antirheumatic drugs (DMARDs) and can slow or
sometimes prevent joint destruction. Starting treatment early with DMARDs can reduce the
severity of the disease. DMARDs are also called immunosuppressive drugs or slow-acting
antirheumatic drugs (SAARDs). Common ones are Humira, Enbrel, and Remicade. These
medicines work best when taken over a long period to help control the disease. These powerful
drugs have the potential for significant side effects and require regular follow-up with a
rheumatologist.
RA is probably an autoimmune disease (a disorder of the immune system in which the patient’s
tissues come under attack by the patient’s own immune system). Patients with RA sometimes
develop deterioration of the neck bones causing spinal instability and have an increased risk of
spinal cord damage during any general anesthesia. Neck stability x-rays before surgery and
special anesthesia techniques may be necessary. Patients with RA also sometimes have
arthritis of the jaw joint (temporomandibular joint) causing difficulty in opening the mouth wide
enough for the usual anesthesia techniques. Special anesthesia equipment and techniques
may be needed for such patients.
Children can get a variation of RA called juvenile rheumatoid arthritis (JRA). These children
suffer joint inflammation and resultant damage during childhood and may need joint
replacements even as a child but more commonly when they become adults.
Ankylosing spondylitis (AS) is another type of inflammatory arthritis that can damage joints.
Ankylosing spondylitis usually affects men. Patients suffer stiffening of the back and neck,
making it difficult sometimes to see straight ahead. The neck stiffness of AS can make the job
of the anesthesiologist difficult and special anesthetic techniques and instrumentation may be
necessary.
Other inflammatory conditions such as systemic lupus erythematosis (SLE or lupus), psoriatic
arthritis, and inflammatory bowel arthritis can also cause joint disease.
OSTEONECROSIS
Osteonecrosis is a condition in which parts of the bones die (osteo means bone and necrosis
means death). If extensive, the dead bone cannot stand up to the stress of walking and the
joint surfaces deform, resulting in pain. The most common causes of osteonecrosis (also called
aseptic necrosis and ischemic necrosis) are oral steroid intake (such as prednisone), excessive
alcohol intake and trauma. Other causes are hyperuricemia, systemic lupus erythematosis
(SLE), sickle cell syndrome, Gaucher’s disease, pancreatitis, pregnancy, liver disease, the
bends, caisson disease, polycythemia, diabetes, obesity, and hyperlipidemia. Sometimes, no
reason can be found for osteonecrosis (idiopathic osteonecrosis).
It is helpful to understand osteonecrosis by using the analogy of a building. Buildings are dead
but the people inside are alive and maintain the building. Window breakage is repaired and
roof leaks are fixed as these problems occur. Without such maintenance, buildings will decay
and eventually fall down. The calcium crystal structure of the bones is not alive but the tiny
bone cells in the bone are. These bone cells maintain the bones just as humans maintain
buildings. When a portion of a bone dies, what really happens is bone cell death. Without
bone maintenance the bone structure usually deteriorates in a year or two. Thus, there is
usually a delay between bone death and the onset of symptoms.
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Very early in the problem of osteonecrosis of the hip, a procedure called core decompression is
sometimes performed in which a hole is drilled up into the femoral head to decrease an
abnormally elevated pressure in the femoral head. This treatment may relieve pain as well as
allow blood supply to return to the femoral head. This coring procedure has also been rarely
applied to the knee. Core decompression is controversial and is not universally accepted by
orthopedic surgeons as a valid treatment.
If the area of osteonecrosis in the knee is small or does not involve damage to the bony support
to the articular cartilage, patients may have transient or no symptoms.
OSTEOPOROSIS
The terms osteoporosis (literally “porous bone”) and osteoarthritis are often confused.
Osteoarthritis, as explained above, is a problem with a joint. Osteoporosis is a condition of soft
bones. Osteoarthritis involves pain coming from the joints. Osteoporosis does not hurt unless
the softened bones fracture, as they frequently do, if the osteoporosis becomes severe.
Bone is not a solid structure, but instead has small holes in it similar to a sponge or bread. The
more holes there are and the larger the holes, the more osteoporotic the bone and the less
strong the bone.
Patients develop osteoporosis for various reasons. As we grow older, all of us have skeletons
which are becoming more porotic or osteoporotic. Patients with low activity levels do not
stimulate their skeleton to be strong and often develop osteoporosis. People with low calcium
and vitamin D intake and other metabolic deficiencies will develop osteoporosis. Lighter
skinned people have a greater tendency to develop osteoporosis than darker skinned people
do. Women as a group have a higher propensity to osteoporosis, which seems to accelerate
after menopause. Thus, lighter skinned women after menopause are at particular risk for
osteoporosis.
Osteoporosis can be treated in various ways but treatments are mainly directed against
minimizing further bone loss. All of us should have an adequate calcium intake in our diet and
if you do not, calcium supplements should be taken. In the past many women after menopause
took estrogen for a variety of reasons, one of which was to maintain bone strength. One can
detect osteoporosis by a variety of techniques but usually a reasonable assessment of the
quality of the bones can be made simply by a review of the hip x-rays. Dr. Moreland can tell
you whether you have significant osteoporosis and if so, further consultation and treatment for
this with the appropriate specialist can be arranged.
WHERE WILL I FEEL KNEE PAIN?
Pain coming directly from the knee is usually felt in the front of the knee, behind the knee, or on
the sides of the knee. Pain in the knee sometimes may not be coming from the knee joint itself.
Pain from the hip joint is usually felt in the groin (in the front of the body where the thigh joins
the torso). The pain often radiates down the front of the thigh to the knee and sometimes to the
mid-shin. Pain, which is perceived in areas of the body remote from the actual problem, is
termed referred pain. You may be aware that referred pain from the heart is usually felt in the
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left side of the neck and in the left arm, and referred pain from the diaphragm is felt in the
shoulder. The referred pain of the hip to the anterior thigh and knee occurs because the root
nerve supply to the hip and the anterior thigh and knee are the same. In some cases, the
referred pain to the knee area is so prominent that the patient, and sometimes even the
physician, thinks the knee itself is diseased, when really the hip is the problem. Pain from the
knee is usually felt in the knee itself and is rarely referred to other areas.
Back pain can also radiate to the knee. Lower back pain is often confused with hip disease.
Pain from the spine is usually felt across the low back, in the buttock, down the back of the
thigh, and often down to the foot. Pain radiating in these areas from the spine is called sciatica.
Sciatica is often accompanied by numbness and tingling, whereas hip pain is not. Most pain
felt in the back of the body in the buttock area is coming from the spine. Most pain felt in the
front of the body in the groin and in the front part of the thigh is coming from the hip. Patients
often expect the hip to cause pain in the buttock, but buttock pain is usually coming from the
low back or the sacroiliac joint. The buttock is not the anatomical hip, although the buttock is
usually referred to as the hip in everyday language. Patients with hip or knee problems also
often have lower back pain since the accompanying hip or knee stiffness puts extra stress on
the spine and since back pain, even without hip or knee arthritis, is very common.
This confusion of hip, back, and knee problems with problems often obscures and delays the
correct diagnosis. Sometimes back or knee operations are tragically done by mistake for
patients when the real problem is the hip.
Another disease entity often confused with hip arthritis is greater trochanteric bursitis. This is
an inflammation of the soft tissues just superficial to the greater trochanter (the bump of bone in
the area of your hip on which you lie when you are on your side). Patients notice pain (often
burning in character) and tenderness over the greater trochanter. Pain can radiate down the
outside of the thigh. Patients can develop a painful and sometimes audible snap or pop over
the greater trochanter with certain movements. Trochanteric bursitis is seen most frequently in
young adult women. Treatment is usually with NSAIDS, steroid injections and education.
Patients often see several physicians before this problem is correctly diagnosed.
It is, of course, possible to be bothered by back pain, knee arthritis pain, hip arthritis pain, and
trochanteric bursitis pain all at the same time, and deciding which is the main problem can be
difficult. Replacing an arthritic hip or knee often helps the commonly accompanying back pain.
Back surgery, on the other hand, will not help an arthritic hip or knee and, in fact, the failure rate
of back surgery (already higher than hip or knee surgery) is increased further for patients who
also have an arthritic hip or knee. Patients with an arthritic hip and a bad back are almost
always better off having the hip replaced before having back surgery. In many instances, the
best way to relieve back pain in a patient with hip arthritis is to replace the hip. This is not
common with knee arthritis since it usually does not affect the back as much as hip arthritis.
ACTIVITY AND KNEE ARTHRITIS
The knee is an important joint of the body for walking and thus, a person with knee pain has a
very serious disability. The more a patient with knee arthritis walks, the more the knee will
usually hurt. Often the first one or two steps after prolonged sitting or lying down may be
particularly painful. We call this start-up pain. Patients can minimize knee pain by simply
decreasing life’s activities: the elevator can be used rather than walking stairs, lifting can be
minimized, the patient can allow the car driver to let him or her out at the front of destinations
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and all long walks can be avoided. Running and playing vigorous sports such as tennis will
almost always significantly increase the discomfort.
All exercise involving an arthritic knee can increase knee inflammation and consequently,
aggravate the pain. Remember that exercise strengthens muscles but at the same time puts
increased stress on the joints. Many people assume incorrectly that the more exercise the
better. Exercise may help if you have significant muscle weakness, but the more exercise the
better is actually not good advice for an arthritic knee. Actually, rest is the most dramatic way of
decreasing arthritic knee pain, since rest will decrease the knee inflammation and thus give
pain relief. You may have noticed that if you are not active for a few days, the knee pain is a lot
less and if you become very active for a period of time, you may have pain at the end of the
vigorous activity or increased pain for the next few days. A sedentary life, however, can lead to
a decrease in muscle and bone strength as well as depress your morale, which sometimes
results in a significant loss of interest in life’s activities.
As you probably know, the State of California provides special handicapped parking for people
with difficulty walking. Ask our office personnel if you qualify and we will help you submit the
proper forms for this.
MEDICATIONS FOR KNEE ARTHRITIS
A large group of drugs called non-steroidal anti-inflammatory drugs (NSAIDS) can decrease the
inflammation that develops around an arthritic knee and lessen the pain. These drugs do not
slow the progression of knee arthritis (nothing really does). No particular one of these NSAIDS
has been proven to give better pain relief than the others, but individuals sometimes respond
better to a certain NSAID. Hence, your physician may try you on several of these NSAIDS in an
effort to find the one that suits you best. Periodically, new NSAIDS are introduced to the
market, often with a great fanfare of publicity. So far, none of these drugs have demonstrated
definite superiority. Some, such as Vioxx and Bextra, have been withdrawn from the market
when unforeseen serious side effects occurred with widespread use. It is probably better to
avoid new drugs until safety and effectiveness are well established.
The three most common NSAIDS are aspirin, ibuprofen (Advil, Nuprin, and Motrin) and
naproxen(Aleve). They all have the advantage of being inexpensive and available without
prescription (over-the-counter drugs). Aspirin and ibuprofen both require dosing every three or
four hours. Naproxen (Aleve) has the advantage of less frequent dosing (usually taken only
twice a day) and some studies have shown it to be safer for the heart than the other NSAIDS.
Dr. Moreland often recommends Aleve for patients with knee pain.
Most prescription NSAIDS have the advantage of once daily dosing but have the disadvantage
of increased cost and, of course, require a prescription. All of the NSAIDS commonly cause
stomach upset and have the potential for other side effects such as kidney, liver, heart, and
bone marrow damage. The best-tolerated form of aspirin is probably Ecotrin (a coated aspirin
tablet which protects the stomach by dissolving in the small intestine). All NSAIDS should be
taken with food. Cytotec, Zantac, Tagamet, Pepcid, Nexium, Prevacid and Prilosec are
sometimes given with NSAIDS to help the stomach tolerate the NSAIDS. These drugs
decrease the amount of acid produced by the stomach.
When used in large doses for long periods, NSAIDS require periodic blood tests to detect
possible side effects. If you take NSAIDS this way, your internist or family physician should
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monitor your NSAID intake with periodic blood tests. The side effects of NSAIDS are usually
reversible if the problem is detected and the medication stopped in time. Your internist or family
physician should always be notified if you are regularly taking moderate or large doses of
NSAIDS. NSAIDS can interact negatively with multiple other medications that you may also be
taking, so always first clear NSAIDS intake with your medical physician.
NSAIDS are not narcotics and are not habit forming, nor do patients develop a tolerance for
these drugs, which would make them less effective with time. Still, patients often report
decreased effectiveness of their NSAID with time. The reason for this is usually that the
disease process has progressed causing greater pain rather than that the patient has
developed drug tolerance.
Side effects of NSAIDS depend mostly on the daily dosage. Higher doses are more likely to be
effective but also are more likely to cause problems such as stomach upset and kidney
damage. Elderly patients are particularly susceptible to suffering complications from taking
NSAIDS.
For these reasons Dr. Moreland rarely recommends NSAIDS in the usual
prescription doses. He prefers low dose NSAIDS and usually recommends the over-thecounter doses of ibuprofen (Advil: up to six tablets per day) and naproxen (Aleve: up to two per
day) since these low doses are effective as well as safer and more economical.
Celebrex (celecoxib), Bextra (valdecoxib), and Vioxx (rifecoxib) are from a class of NSAIDS
called COX-2 inhibitors. These drugs were originally marketed as having fewer side effects than
regular NSAIDS, but claims were never made of better pain relief. Vioxx and Bextra have been
taken off the market because of associated heart problems. The FDA now has warned that all
NSAIDS can cause heart problems.
Those who cannot tolerate the other NSAIDS may be able to tolerate Celebrex, which remains
available. It is more expensive than older NSAIDS and may also cause heart problems. Unlike
the older NSAIDS, Celebrex does not cause increased bleeding and, thus, does not have to be
stopped during the surgical period. Celebrex seems to be particularly useful to relieve
immediate postoperative pain.
Acetaminophen (Tylenol) is not an NSAID. It is a pain reliever but not an anti-inflammatory. It
does not share with the NSAIDS their possible side effects. Pain can often be helped
significantly with acetaminophen and patients may usually safely take six pills a day. Large
doses of acetaminophen have been associated with liver toxicity, particularly in patients who
drink large amounts of alcohol. Acetaminophen can be used to supplement the pain relief of
the NSAIDS (acetaminophen and NSAIDS can be taken at the same time). A good over-thecounter regimen for arthritis pain is two Tylenol and one Aleve twice a day.
NARCOTICS FOR KNEE PAIN
Patients with sleep-disturbing knee pain can sometimes benefit from low doses of mild
narcotics such as Tylenol (acetaminophen) with codeine (Tylenol #3), Vicodin (hydrocodone
with acetaminophen), and Ultram (tramadol alone) or Ultracet (tramadol with Tylenol). These
drugs are habit forming, have the potential for physical and psychological dependence and, like
all narcotics, lose their effectiveness when used regularly. Thus, patients should carefully limit
their intake of such drugs to no more than one or two a day to maintain the effectiveness and to
decrease the risk of addiction. All narcotics tend to cause constipation and stool softeners can
help prevent this problem. Low dose narcotic use at night, when sleep is disturbed by knee
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pain, is relatively safe. Day use is less desirable, since mental alertness is decreased.
Operating machinery or driving a car under the influence of a narcotic should not be done.
The stronger narcotics such as Percodan (oxycodone with aspirin), Percocet (oxycodone with
acetaminophen), Percolone (oxycodone alone), Dilaudid (hydromorphone), Oxycontin (a long
acting and highly addictive preparation of oxycodone), and morphine are almost never indicated
for chronic knee pain because of their strong potential for addiction. All narcotics become
gradually less effective when taken for long periods and thus higher and higher doses will be
gradually required in order to continue to get pain relief. The patient then will develop another
problem: narcotic addiction. If the narcotics are stopped or decreased in addicted patients,
unpleasant withdrawal symptoms will develop. In most knee pain circumstances it is better to
have knee replacement, if indicated, rather than to become addicted to large doses of
narcotics. Dr. Moreland believes that some “Pain” physicians today seem too quick to give
patients high doses of powerful narcotics for arthritis pain and thus create unnecessary and
unpleasant addiction in their patients. The management of postoperative pain in heavily
addicted patients is complicated, since such patients will not get pain relief with ordinary
narcotic doses.
EXERCISE FOR PEOPLE WITH KNEE ARTHRITIS
Patients with knee disease, like everyone, need to exercise for general cardiovascular fitness.
Jogging and other exercises resulting in impact loading of the knee will probably cause an
increase in the knee pain and are usually best avoided. The best exercise to maintain
cardiovascular fitness for people with knee disease is swimming, since the buoyancy of the
water minimizes the stress on the knee. Bicycling (with road or stationary bikes) and the
elliptical machine are also better tolerated than running. Walking on the treadmill is
intermediate in stressing the knee and many people can tolerate this since there are usually
handrails, but again, the exercise bicycle will probably give more cardiovascular exercise with
less knee pain. After experimentation each patient usually becomes the best judge of what can
be done with an acceptable level of discomfort. Patients with significant knee arthritis should
avoid the leg press and knee extension machines.
Activity is unlikely to cause deterioration of the knee to a degree that the damage cannot be
fixed later by knee replacement, so remain as active as your knee allows. Think of activity as
irritating your knee, not as damaging your knee. Inactivity can damage the rest of your body
since activity is needed to maintain properly your muscles and bones, your cardiovascular
system and your mental health.
KNEE STEROID INJECTIONS
Direct injection of steroids (cortisone) into the knee, often in conjunction with a numbing drug
such as Novocain or xylocaine, is sometimes used to decrease knee inflammation and pain.
This is relatively simple to do. Sometimes patients get good relief for up to several months. At
times the steroid injection may provide no relief of the discomfort. Too many steroid knee
injections can accelerate knee arthritis. Usually injections are limited to two or three times per
year. There is a small risk of introducing infection.
Preparations of the chicken-derived hyaluronic acid (Synvisc, Hyalgan and others) or bacteria–
derived hyaluronic acid (Euflexxa) are sometimes injected into arthritic knees to relieve pain.
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Some patients report increased pain transiently and few seem significantly improved. Dr.
Moreland does not perform these injections, which are costly for patients and he does not
recommend this treatment for his patients.
WHAT CAUSES MY LIMP?
Most patients with significant knee disease have a limp. Since it usually hurts to spend time
weight bearing on the painful knee, the patient changes the gait to spend a shorter amount of
time bearing weight on the painful extremity. This is called an antalgic gait. It is common for the
patient to think that the reason for the limp is shortness of the extremity. Sometimes, the
extremity actually is short, but the limp is usually due to the pain. In fact, when patients limp
from a painful knee they are usually limping because it lessens the pain.
Sometimes with knee disease, leg shortening occurs from the bones getting closer together as
the cartilage wears out. This slight shortening is actually helpful for the patient, since it is easier
to walk with a painful knee if that extremity is a little shorter. One way of thinking about this is
to realize that the short leg is walking downhill all the time and the long leg is walking uphill.
The short leg, therefore, has to put out less effort. If the short leg is the painful leg, the patient
is better off leaving the painful leg short and not using a shoe lift. If the painful leg happens to
be the long leg, then shoe lifts can take some of the pressure off the painful extremity. Dr.
Moreland can advise you on the usage of lifts during your examination.
WHEN SHOULD A CANE BE USED?
When the symptoms worsen to a significant degree, a cane is usually very helpful to patients
with knee problems. The cane should usually be carried in the hand opposite the side that has
the knee disease. Special platform canes may be useful for people whose hand problems limit
their ability to push on a cane. Patients with rheumatoid arthritis often have this problem. The
Horton and Converse pharmacy on the first floor of our building has a wide selection of canes.
There are foldable canes that will fit in a large purse or a briefcase. The cane then can be
readily available if unexpected long distance walking is required. The cane should be the right
height (usually such that the elbow is bent about 20 degrees) and, thus, an adjustable cane is
convenient. We can help you adjust your cane length and instruct you in its use. Most patients
find the cane useful when going outdoors and for long walks (such as shopping malls, airports,
amusement parks and foreign travel). Since the cane gives tremendous mechanical advantage
when used in the opposite hand, just a little hand pressure will relieve a lot of knee pain and
control the limp.
SHOULD I LOSE WEIGHT?
Extra weight will aggravate knee pain. Weight loss will make you more comfortable, but is
unlikely to relieve the pain completely. Obesity also makes surgical treatment technically more
difficult for the surgeon and increases the risk of surgical complications for the patient. It is
more difficult with the extra weight for patients to walk on crutches during the healing period
and to move around in bed. This increased risk is rarely of a degree to make replacement not
possible. While weight loss is desirable, we rarely insist upon weight loss before surgery,
recognizing the well-known difficulty of weight loss, particularly when compounded by the
enforced sedentary lifestyle resulting from the knee pain.
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OTHER TREATMENTS
Massage, acupuncture, acupressure, ultrasound, diet, vitamins, minerals, magnets, Chinese
herbs, copper bracelets, hypnosis, TENS unit, special physical therapy techniques, water
therapy and many other treatment methods are occasionally used. At times some of these can
alleviate the pain but cannot correct the basic arthritic condition. Knee pain is often episodic. A
lot of activity will often cause a delayed increase in pain from the inflammation stirred up by the
activity. With rest, NSAIDS, and inactivity the pain may completely resolve for a while with or
without other treatment. This episodic nature of knee pain often confuses patients when they
try to evaluate the effectiveness of various activities and treatments.
Health food stores have marketed shark cartilage for arthritis. There are no scientific studies
supporting shark cartilage use for arthritis. Dr. Moreland has seen many patients who have
taken shark cartilage. Few have reported any benefit and Dr. Moreland does not recommend
shark cartilage.
By far the most popular health food store supplements for arthritis have been glucosamine and
chondroitin sulfate, which are usually taken together. Occasionally, patients have reported
some symptomatic relief but most patients report no effect. Definitely, we have not seen any
repair of arthritis damage or slowing of arthritis progression with use of these preparations and
there is no good scientific evidence of such benefits. Dr. Moreland does not recommend these
health food store supplements or any others. On the other hand, worrisome side effects have
not been reported with glucosamine and chondroitin sulfate.
WHEN SHOULD I HAVE MY KNEE REPLACED?
The decision to have a knee replacement is up to the patient. Knee replacement can
commonly be avoided as long as the patient is willing to put up with the pain and the disability.
In fact, most patients, if determined, can put up with one bad knee indefinitely, since the good
side can do most of the work. Patients with deterioration of both knees often are under more
pressure for surgery, since such patients literally do not have a good leg to stand on. Since
knee replacement surgery involves some risk, expense, several months of recovery and a
temporary increase in pain from the surgical procedure and may still not be a permanent
solution, surgery should not be undertaken unless the symptoms are significant and persistent.
If your knee disease is so bad that you cannot get around without a wheelchair or two crutches
or are even bedridden, then most orthopedists would urge knee replacement, assuming you are
physically fit enough to undertake the surgery. If you can walk without a cane or crutch for long
distances with minimal limp or pain and do not have any sleep disturbance, your symptoms are
probably not severe enough to proceed with replacement.
Most patients have their knee replaced when they experience significant and persistent pain,
need a cane at least part of the time, are having sleep disturbance, and are regularly taking
non-steroidal anti-inflammatory medications (NSAIDS), assuming such drugs can be tolerated.
If your knee is making life miserable, a replacement is usually a reasonable alternative to
putting up with the pain and disability. If the knee problem is only a minor and occasional
bother, non-operative treatments are probably more reasonable than surgery. The decision to
have surgery should be based on information acquired from the orthopedist, the family
physician, and possibly second opinions. The final decision is always the patient’s. Most
patients have knee replacement when the thought of having knee replacement surgery sounds
better than putting up with the pain and disability of the arthritic knee. We hope this knee
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booklet will give patients the information needed about knee replacement to make that decision.
There is almost never any urgency for replacement of the knee unless the pain is severe.
Patients who have only one painful and stiff knee can usually get by with a sedentary lifestyle
by avoiding airports, amusement parks, malls, and travel. The desire to have a more active
lifestyle can force surgery at an earlier stage. Many patients find that just at retirement age
when they finally have the time to travel and enjoy the world, an arthritic knee can make these
activities difficult, if not impossible. With a knee replacement the patient’s world can be
expanded and the retirement years can be more active.
Since introduced in the United States about 1970, knee replacement has gradually been
improved. In the early years there were problems with short term complications, long term
durability, and a long and uncomfortable recovery period. On all three issues there has been
tremendous progress. Today in the hands of an expert surgeon operating in a good hospital
with competent medical personnel, patients should expect extremely high short term success
rates as well as a shorter and more comfortable recovery period. Modern prostheses promise
durability that probably will exceed most patients’ life span. Durability has been so increased
that patients now are given less activity limitations than in the past. Knee replacement today is
truly a medical miracle.
CAN I PUT OFF SURGERY?
There are some advantages to putting off surgery. Progress in knee replacement surgery
continues. Thus, if you wait five to ten years, the technology available should be better than
what we have currently. If you wait, you will get older and thus need the replaced knee for a
shorter period of time. This is important since the major problem with knee replacements has
been durability, since loosening and wear occur occasionally. That said, the technology of knee
replacement today is so advanced that there is little reason to wait for further improvements.
Knee replacement is one of the best elective operations surgeons have to offer.
The disadvantages of waiting are the discomfort and disability, the possible loss of muscle and
bone strength from inactivity and the decreased mental and physical vigor from the diseaseenforced low activity lifestyle.
Do not worry that the knee deterioration will get so bad that it cannot be fixed or the chances of
surgical success will be less later. Such deterioration rarely occurs. Do not worry that you will
damage the other surrounding joints (such as your back, hips, or the other knee). While the
extra stress on these joints may irritate these areas, it is unlikely damage will occur. Also do
not worry you will get too old or too sick to have surgery later. It is very rare for a patient who
needs surgery to be too old or too sick to have it done. If you are too sick, usually you are so
inactive that surgery is not needed. The only valid reason to have knee replacement is a knee
that is giving you persistent and significant pain and disability resulting in a miserable lifestyle.
OTHER SURGICAL TREATMENT ALTERNATIVES
Knee disease can be treated by other methods besides knee replacement. One alternative is
knee fusion (arthodesis). This is a procedure in which the femoral bone is made to grow to the
tibial bone resulting in permanent and complete stiffness of the knee joint. This fusion
procedure is rarely performed today because most patients will not accept the complete knee
stiffness. Occasionally it is recommended for young people who would like to do vigorous
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labor. It is inconvenient to have a stiff knee when getting in and out of tight spaces, sitting in a
movie theater, airplane or bus, or driving a car since the knee cannot bend and fold up out of
the way. Tall people have more trouble with knee fusion since their leg is that much longer
when it is in a straight position. Although knee fusion is not a perfect solution, it is occasionally
performed when knee replacement is not a good alternative such as for patients with chronic
infections and those without adequate muscle to control a knee replacement.
Most patients who develop arthritis in the knees either become increasingly bow-legged (genu
varum) or knock-kneed (genu valgum). This deformity of the leg in turn aggravates arthritis in
the knee by off center loading of the knee. If the leg can be straightened out by a procedure
called osteotomy, then the knee will usually be improved. An osteotomy operation is a
procedure in which the leg is straightened by making cuts into the tibia or femur bone and then
allowing the leg to heal in its new and corrected position. Osteotomy of the knee is usually
reserved for younger patients and patients with milder degrees of osteoarthritis. As knee
replacement surgery results have gradually improved, osteotomy has been done less and less
frequently and is rarely performed today.
Often orthopedists will offer arthroscopy to patients with arthritis of the knee. Sometimes,
patients are improved, but many are not better and some are worsened. Generally the worse
your knee arthritis and deformity, the less likely arthroscopy will help.
HISTORY OF KNEE REPLACEMENT SURGERY
In 1962 Sir John Charnley, an English orthopaedist, put together the key ingredients of the
modern hip replacement. Hip replacement was received with such enthusiasm and success
that surgeons quickly began to work on knee replacement technology. Knee replacement
designs available in the early 1970's were decidedly inferior to the successful hip replacements
of that era. However, by the late 1970's much improved techniques and prostheses were
introduced. Today, knee replacement surgery is at least as successful as hip replacement
surgery and is actually done more frequently today than hip replacement.
The term "knee replacement" sounds more radical than knee replacement actually is. A more
intuitively appropriate name would be “knee resurfacing” since knee replacement simply
resurfaces the damaged bony surfaces that move against each other as the knee bends and
straightens out. The worn articular cartilage is replaced by a metal and plastic device
(prosthesis). The end of the femur (thigh bone) is resurfaced with a piece of metal, the top of
the tibia (shin bone) is resurfaced with a piece of plastic with metal backing and the back part of
the patella (kneecap) is resurfaced with a piece of plastic. These prostheses are fixed to the
bones by plastic cement called methylmethacrylate which is the same chemical compound as
Plexiglas and was first developed for human use by dentists. The cement acts as a grout
similar to the action of tile grout.
Cement comes as a powder and a liquid which are mixed together into a dough-like
consistency. This dough is pressed into the bone and the prosthesis is pressed into the dough.
The cement then hardens over 10 to 15 minutes to a stone-like configuration. After the knee
replacement is assembled, the metal covering the end of the femur rubs against the plastic
covering the top of the tibia and thus prevents bone from rubbing on bone, giving pain relief.
The plastic is ultra-high molecular weight polyethylene which has a low wear rate and has little
frictional resistance when moving against the highly polished metal femoral component.
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Total hip replacements were being done in the United States by 1969 and total knee
replacements followed shortly thereafter. These operations have become routine (over 700,000
knee replacements are done in the US. annually) and are considered successful 95% of the
time.
WHY IS IT CALLED A TOTAL KNEE REPLACEMENT?
A joint is an area of the body where two bones come together. Orthopedists refer to each bone
as being a separate side of the joint. Thus, the knee joint has the femoral side and the tibial
side. Surgery done on only one of the two bones, leaving the other bone unchanged, is called
a hemiarthroplasty. Hemi means half and arthroplasty means an operation to make a joint
better.
When hip replacements began and both bones were operated on, the term total hip
replacement was coined and came into common usage in the United States. When knee
replacements followed, they were given the “total” name also.
The term “total knee replacement” is actually not a good name for the procedure, since it
sounds more radical than the actual operation. A more intuitively appropriate term for the knee
replacement operation would be knee resurfacing.
LOOSENING WITH CEMENTED KNEE REPLACEMENTS
One possible long term problem with knee replacement is the development of loosening of the
bonding of the cement to the bone. The prosthesis then may move in a gradually increasing
degree with respect to the bone causing irritation to the bone and bone loss which results in
pain similar to arthritic pain. If the pain or bone loss from loosening is severe, a second surgery
may be necessary, usually referred to as revisional surgery.
The durability of the fixation of a cemented knee replacement is determined by three factors.
The skill of the surgeon is the first and most important factor. If the surgery is done well, it will
last much longer than if it is done poorly. The second factor is the stress the prosthesis will
have to withstand. This is dictated by the patient’s activity level. Vigorous activities such as
running and heavy lifting cause stress to be delivered to the prosthesis and can cause it to
become loose. Thus, patients with cemented knee replacements should avoid such very
stressful activities. Cemented knee replacement patients can participate in golf, swimming and
bicycle riding but should avoid other more stressful activities. The third factor affecting the rate
of loosening is the condition of the individual patient’s bones since some bones are formed in a
way that makes it difficult to get the replacement well fixed.
The precipitating reason to proceed with revisional surgery of a loose knee replacement is
almost always a degree of pain and disability sufficient that the patient and the surgeon think
that revisional surgery is indicated. Many patients have minor degrees of loosening determined
by various findings on their radiographs but have minimal symptomatology and therefore do not
need a revisional surgery. As the prosthesis loosens, there is commonly damage to the bones.
Some patients have x-ray changes of severe bone loss but few symptoms. Occasionally, we
advise revisional surgery for such situations, particularly in active patients with long life
expectancies.
Surgeons are continually trying to develop techniques which will not result in loosening, will be
more durable, and also give the same degree of pain relief. One alternative concept is to do
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the operation without cement using prostheses which have a rough (porous) surface into which
bone grows, permanently bonding the prosthesis to the bone. This is called a cementless total
knee replacement or a porous knee replacement and was introduced in 1982. Cementless hip
replacements have worked very well in the over thirty years they have been commonly used
and are now the standard in hip replacement surgery. Dr. Moreland always uses cementless hip
replacements.
Cementless knee replacements, on the other hand, have not demonstrated better durability
than cemented knee replacements and have more problems with pain and a higher reoperation
rate. Dr. Moreland, like most surgeons, stopped doing cementless knee replacements many
years ago and today always does cemented knee replacements. In fact, loosening of cemented
knee replacements in his hands is very uncommon.
SHOULD THE PATIENT DECIDE IMPLANT TYPE?
How well a patient does with a knee replacement depends upon a variety of factors. One factor
is prosthetic choice, but the choice of the surgeon and the hospital with its support personnel
and facilities are very important factors. In fact, the most important factor is how well the
surgery is technically done. The skill of the surgeon is overwhelmingly the most important
factor as to how well the patient does. While it is interesting and important to discuss types of
prostheses used and various surgical techniques, patients really should concentrate more on
making sure that they have selected a good surgeon and allow that surgeon to do the operation
in a way with which the surgeon is most confident and familiar. When arranging piano music
for a party, you would probably spend more time evaluating the pianist than selecting the piano.
A good pianist can get music from a bad piano and a poor pianist cannot get music from the
world’s best piano. Surgery is similar. There are many surgeons with excellent skills and
experience with knee replacement and Dr. Moreland would be happy to help you locate a good
surgeon in your area, if travel to our area is a problem or for any other reason.
OTHER NEW TECHNIQUES
Periodically, new implants and surgical techniques are introduced to the orthopedic and lay
community with great fanfare and claims of superiority to older techniques. In knee
replacement surgery we already have well-established techniques that quite consistently and
reliably give excellent pain relief and function. What has been lacking is an ability to give all
patients (especially the young, big and active patient) a knee replacement which will reliably last
the rest of the patient’s life. Thus, any new technique or implant can add to the state of the art
of hip replacement only by proving to be more durable. Durability can only be tested by human
implantation and long-term observation. Thus, all new techniques and implants do not
automatically represent improvements. The words “new and improved” go hand in hand in
most new product introductions such as cars, cell phones, computers, etc. and we almost treat
the words “new and improved” as synonyms. In knee replacement “new” and “improved” are
definitely not synonyms but instead “new” really equals unproved, or even harsher,
experimental. Remember we began knee replacement in the United States only in about 1970.
If a patient’s life expectancy is many decades, most types of knee replacement for that patient
should be considered experimental procedures for that patient, since virtually all knee
prostheses in common use today have usage history less than the life expectancy of such a
patient.
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The media, in an effort to increase viewership and thus revenue, often report various new
health developments in an exaggerated way and, thus, often falsely and cruelly raise the hopes
of patients. Some hospitals and some surgeons pay the media to report their supposed
dramatic advances in knee replacement surgery in a shameless attempt to attract more
patients. The media seems at times to try purposefully to disguise advertising copy as a
scientific report, making it difficult to differentiate reports of real scientific advances from simple
advertising. Many promising new techniques have with time proved to be big steps backward
and not steps forward.
Knee replacements using a robot and knee replacements with computer guided navigational
systems have received media attention. Neither the necessity nor practicality of these
experimental techniques has been proven and cannot be proven for many years despite the
glowingly positive media reports propagated by their enthusiasts.
Be wary of self-proclaimed “Institutes or Centers of Excellence in Knee Replacement” without
well-established community recognized expertise. There are, unfortunately, no requirements
for the use of the terms “institute” and “center”. Many institutes are truly substantial, but some
consist only of glossy brochures, an advertising agency, and a phone answering service
relaying referrals to physicians without particular extra expertise.
Knee replacement prostheses have been dramatically improved since introduced in the United
States in 1970. Prostheses available today have a dramatically lower potential for loosening
and wear than in the early days of knee replacement and have a probable durability exceeding
the life span of the average patient.
Interestingly, Dr. Moreland’s medical career almost exactly coincides with knee replacement in
the U.S., since he started medical school in 1968 and thus he has seen and participated in the
gradual improvement of total knee replacement surgery. The chances of short term
complications such as infection, patellar dislocation, nerve damage, and blood clots have been
dramatically decreased. Compared to 1973, when Dr. Moreland first became involved with
knee replacement as an orthopedic resident at UCLA, the average length of surgery and the
amount of blood loss are today much less. Knee replacement then took two to three hours and
often involved two or more units of blood loss (one unit is about one pint). Today Dr. Moreland
routinely does knee replacements in about 80 minutes and blood loss averages less than a unit.
INFECTION OF KNEE REPLACEMENTS
Knee replacement is very successful and complications are uncommon. There is easily a
greater than 95% chance that the replacement can be accomplished without serious
complications.
The most devastating complication is infection. The chances of an infection in a first time
operation are one out of several hundred. Infection can be introduced into the knee joint at the
time of surgery when the wound is open, since there are always bacteria in the air and on the
patient’s skin. Precautions are taken against this occurring by using special operating rooms
with extra clean air (laminar flow rooms) and by giving prophylactic antibiotics.
Infection also can be introduced into the knee by way of the bloodstream at any time after the
surgery. Although unlikely, infections in other parts of the body can spread to the knee
replacement. Dental work also can release bacteria into the bloodstream which then can travel
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to a knee replacement and cause an infection. Thus, patients with knee replacements may
need to take prophylactic antibiotics by mouth shortly before and after some dental work and
before other medical procedures which can cause bacteria in the bloodstream. Before any
medical or dental procedures, a patient with a knee replacement should always remind the
treating physician or dentist that the patient has a knee replacement. Responsibility for giving
prophylactic antibiotics is that of the physician or dentist performing the medical procedure.
Knee replacement patients should have any bacterial infections, other than those of the knee
replacement itself, treated promptly by their primary care physician. Viral infections, such as
colds, and fungal infections of the skin or nails are not a threat to a knee replacement.
WEAR
Wear of the ultra-high molecular weight polyethylene was considered for a long time a minimal
problem. During the 1970’s and 1980’s attention was focused on ways to improve fixation of the
implant. As fixation techniques improved and patients had higher activity levels, surgeons
found that the durability of the prosthetic fixation often exceeded the wear potential of the
polyethylene.
Wear is a problem from two standpoints. The metal parts of the knee replacement can wear all
the way through the plastic and the metal parts can touch and cause catastrophic problems.
This actually rarely occurs with today’s modern designs. There is also a potential problem from
bone loss which can occur from the wear particles themselves. The body’s tissues can react to
the tiny microscopic wear particles in a way that destroys bone. Most likely the body confuses
these tiny wear particles with bacteria and in an effort to clear these particles from the knee; the
body’s tissues reabsorb some of the bone. Patients will not necessarily have symptoms from
wear until very late in the wear process. Thus, patients should be followed by their orthopedist
with x-rays every two or three years to look for evidence of wear and possible bone destruction
from the wear particles. The plastic portion can usually be relatively easily changed without
disturbing the cemented surfaces of the implant. A reoperation for wear is usually a much
easier one than a reoperation for loosening.
Wear has been one of the most frequent causes of reoperation. Fortunately, significant
progress in wear reduction has been made. Several researchers working in different centers
have developed a new manufacturing process for the polyethylene which increases the crosslinking of the long chain polyethylene molecule and lowers the wear rate of the plastic. With the
current routine usage of modern polyethylene by Dr. Moreland wear has ceased to be a
problem in his patients.
Metal-on-metal and ceramic-on-ceramic hip replacements are being used but such articulations
are not available for knee replacements.
OTHER POSSIBLE COMPLICATIONS
Rarely, wound healing can be problem with knee replacement because the skin over the knee
sometimes does not heal and parts of the skin may die after surgery. Every precaution is made
to prevent this, as it can be a major complication since infection can be introduced if the skin is
not healed.
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Occasionally patients develop patellar (knee cap) instability, which causes clicking and prevents
normal movement. The chance of this occurring is much less than one percent and can be
corrected by a revisional procedure.
The surgical approach for a knee replacement cuts some of the small skin nerves over the front
of the knee and patients sometimes lose some of the sensation over the front of the knee. This
lack of sensation lessens usually with mature healing. Motor nerve damage occurs very rarely
with knee replacement. The motor nerve most commonly damaged is the one which brings the
foot up toward the face. Usually if this nerve is damaged, it will recover within several months.
Another remotely possible, but very serious complication, is injury to the major artery behind the
knee. It is very rarely injured (one out of thousands of operations) and can usually be repaired.
One of the more frequent medical complications in knee replacement surgery is blood clots
(deep venous thrombosis: DVT) which may develop in the legs following surgery. As long as
the blood clots do not move up to the heart, the only effect is swelling in the leg, usually with
calf or thigh pain. Occasionally, the blood clots may move up through the heart to the lungs
causing the patient to be short of breath and have chest pain (pulmonary emboli: P.E.). Almost
all patients are given Coumadin (warfarin) which thins (anticoagulates) the blood and helps
prevent clots after surgery. Very rarely death can occur from large clots moving to the heart
and lungs. Dr. Moreland, fortunately, has not had a patient die because of this problem. Other
measures such as compressive support hose (TEDS), bed exercises and early ambulation also
help to prevent blood clots.
A fat embolism is another potential complication of knee replacement. Fat exists in the cavity of
the bone where the instrumentation and some prostheses are placed. Apparently, if this fat is
pressurized, some of it can be driven into the veins which then can carry the fat back up to the
heart. Then the fat can be sent to the lungs and somehow, can also be sent to the brain. This
can cause the patient to have great difficulty breathing and develop neurological problems.
Evidence now suggests that evacuating the fat out of the femur before the prosthesis is placed
probably prevents this complication. Patients will usually recover from a fat embolism problem
if measures are taken to support the patient's breathing as the tissues are recovering from the
insult of the fat. None of Dr. Moreland's patients has ever had fat emboli syndrome with knee
replacement surgery.
Anesthetic complications can occur and, very rarely, death occurs. Your anesthesiologist will
see you before surgery and should explain the risk of anesthesia and your anesthetic choices.
There are two broad types of anesthesia which are used for knee replacement: general and
regional.
In general anesthesia you are completely asleep and so you are totally unaware during the
operation. In this technique an intravenous is first started in your arm. The anesthesiologist
next puts multiple monitoring devices on you (EKG, stethoscope, pulse oximeter, blood
pressure cuff), lets you breath pure oxygen for a few minutes, and then puts you to sleep by
injecting a sedative through your IV. Your next awareness is usually waking up in the recovery
room.
In the regional anesthetic, an IV is also started and the same monitoring devices are placed.
Then, while on the operating room table, the anesthesiologist injects medicine in your back next
to your spinal nerves. You will then gradually lose feeling from about your waist down. There
are two types of regional anesthetic: spinal and epidural (often given to women in labor). The
spinal can rarely cause postoperative headaches. You can be entirely awake with a regional
anesthetic, but the anesthesiologist usually sedates you with drugs given through your veins.
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The final anesthetic decision is the anesthesiologist's after consultation with the patient and the
surgeon. Dr. Moreland strongly prefers the spinal anesthetic, since it is associated with less
bleeding and a lower rate of blood clots, and patients seem to have less postoperative pain.
With all the new and advanced anesthetic monitoring techniques available, anesthesia is safer
today than ever before
Blood transfusions carry risk and most knee replacement patients receive no transfusions. We
use many measures to limit the usage of banked blood. With modern testing and screening of
donors, the blood supply today is safer than ever before.
Other complications can occur, but you should keep in mind that the chances of any significant
complication occurring is small. As with many things we do in life, major surgery cannot be
done without risk. We will do everything we can to minimize the risk you undertake. Keep in
mind that the worse your preoperative symptoms are, the more reasonable it is that you take
the risks inherent in having knee replacement.
WRONG SIDE SURGERY
Publicity about patients tragically having surgery on the wrong side of the body has made many
patients very anxious about this possibility.
Dr. Moreland has done over 6,500 hip
replacements and 3,500 knee replacements and has never operated on the wrong side. There
are many preventative mechanisms in place and you may get tired of being asked which side is
the correct one. during your preoperative visit in his office the day before surgery Dr. Moreland
will write his initials and the word “yes” on your knee. You can still shower but do not scrub the
writing off before surgery.
MINIMALLY INVASIVE KNEE REPLACEMENT
The term “minimally invasive surgery” in the last few years has acquired a special magic. The
term “laser surgery” has had a similar appeal to prospective surgical patients. The reason for
the excitement about this term “minimally invasive surgery” is that several surgical techniques
with this name have been developed which have revolutionized many operations. The interior
of various body cavities can now be easily viewed by a miniaturized camera attached to a small
tubular telescope (endoscope) with the image displayed on a monitor. Surgery can then be
performed using long thin surgical instruments inserted through small incisions, or through
natural body openings, with the instruments’ movements seen on the monitor. The resultant
smaller surgical insult to the surrounding tissues allows the patient to recover quicker and with
less pain in most situations.
In general surgery, laparoscopic cholecystectomy (removal of the gall bladder) has been a
dramatic advance using minimally invasive surgical techniques. Good examples in orthopedics
are arthroscopy of the knee, and later many other joints, which have allowed surgeons to see
the interior of joints better and to do surgeries through small incisions. There are many other
surgical examples. These procedures as a group have become known as minimally invasive
surgery and almost all involve the use of these small telescopes and cameras and very small
incisions. There is no wonder about the magic this term has today with patients, since these
revolutionary techniques have received appropriate and deserved wide publicity.
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Today, however, the term “minimally invasive surgery” is being applied somewhat
inappropriately to some total knee and hip replacement techniques, since the small telescopes
and cameras of the usual minimally invasive surgical techniques are not used in these knee
and hip techniques. In addition, minimally invasive surgical techniques typically involve
incisions less than one-half inch in length. Since all knee and hip replacements require the
insertion of prostheses of a significant size, the minimal incision length to allow the prosthesis
itself to go through the skin needs to be at least several inches and even this length requires
skin stretching, which can lead to delayed skin healing. Still, we should not quibble too much
with semantics and definitions, particularly if these “minimally invasive replacements” truly do
represent a significant advance over previously available techniques.
In fact, minimally invasive hip replacement techniques are now standard for almost all hip
replacement surgeons. Dr. Moreland has been routinely doing minimally invasive hip
replacement for many years. Surgeons perform minimally invasive hip replacement in many
different ways but the common surgical goal is to do minimal damage to the soft tissues so that
patients will have less postoperative pain and disability and quicker recovery.
Minimally invasive knee replacement, on the other hand, has not become standard. Knee
replacement techniques using very small incisions actually can cause more soft tissue damage
from the force needed to retract the tissues. Studies of very small incision knee replacements
have shown no quicker recovery and a higher complication rate. Dr. Moreland has decreased
the length of his knee incisions somewhat only consistent with minimizing soft tissue trauma
and surgical complications. If we use the term “minimally invasive surgery” loosely, what Dr.
Moreland does now could be considered minimally invasive.
Marketing for minimally invasive knee replacement emphasizes a quicker recovery as well as
shorter incision length. Recovery is hard to quantify and cannot be measured simply by the
length of the hospital stay. Certainly patients today recover much faster than 40 years ago but
whether one surgeon’s patients recover faster than another’s is difficult to document. Time of
discharge is heavily dependent on patient motivation, health, and home support systems. Most
patients in Dr. Moreland’s practice stay in the hospital for two or three nights and when home
need little nursing care but do need others to help with cooking, cleaning, and shopping.
BILATERAL SIMULTANEOUS KNEE REPLACEMENT
While it is possible to do replacement of both knees at the same surgical procedure, and some
surgeons regularly do this, Dr. Moreland prefers to do the knees one at a time. He believes that
the increased magnitude of the surgical insult in simultaneously doing both increases the rate of
serious complications, including death. This increased risk, however slight, seems not worth
taking.
However, many well-regarded and prestigious surgeons commonly perform
replacement of both knees simultaneously. Dr. Moreland's preference is to wait a minimum of
two months or, preferably, at least four to six months between knee replacements. This delay
allows full recovery from the first surgery and increases the safety of the second. Dr. Moreland
will do simultaneous knee replacements in selected, healthy patients who strongly prefer this
option and accept the increased risk.
.
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WILL DR. MORELAND DO THE SURGERY?
Some surgeons employ other surgeons to do parts of the knee replacement such as the
opening or closing of the wound and sometimes even the entire operation. Dr. Moreland
personally does all of the operation. He does the patient positioning for the surgery making
sure that the patient is properly placed and padded to prevent injury during the surgery. He
makes the incision and does all of the operation, including skin closure, as well as the
placement of the wound dressing. He also visits his hospitalized patients at least six and
sometimes seven days a week except when he is out of town. He also takes his own
emergency calls six, and sometimes seven, days a week when in town. Thus, if you have an
emergency after your surgery, you usually will have direct access to him instead of someone
not familiar with your situation. When he is not available, his calls are usually taken by Jack
Purdy M.D., an experienced, board certified orthopedic surgeon. Dr. Purdy has been assisting
Dr. Moreland at surgery since 1985 and they have done thousands of knee replacements
together. Dr. Purdy will often be familiar with your particular situation since he probably
assisted at your surgery. Dr. Moreland does not use surgeons in training, such as residents or
fellows, as surgical assistants nor do such physicians help with your postoperative care.
INITIAL CONSULTATION WITH DR. MORELAND
The initial office visit for patients who are considering knee replacement surgery involves a
discussion and examination with Dr. Moreland lasting thirty to forty-five minutes. Before your
visit you will be asked to fill out a questionnaire concerning the history of your knee problem.
An x-ray evaluation is always needed and if you have had previous films taken elsewhere, it is
useful to bring those films with you. We have an x-ray facility in our office and we can take
additional views as necessary. It would be helpful if you bring a list of medications that you take
with the dosages. We welcome spouses and other family members or important friends to
participate in the discussion of treatment. We routinely call and/or write your physicians telling
them of the situation and we will be happy to write anyone else that you wish to have a copy of
your consultation. We will send you a copy of your consultation also. Please feel free to ask as
many questions as you like. We believe strongly that an informed patient is a better patient
with a much higher chance of success with medical and surgical treatment.
If non-surgical treatment is chosen, you may be given prescriptions for arthritis medications,
walking aids or physical therapy, as well as advice about living with your hip arthritis.
SURGICAL SCHEDULING
If surgical treatment is elected, our office staff will normally arrange the surgery at Saint John’s
Health Center (1328 22nd Street in Santa Monica). Since this is major surgery, a medical
evaluation is usually indicated. Your internist or family practitioner will do this evaluation. If you
do not have such, we will assist you in making an appointment (seven to ten days before
surgery) to see a physician who can do a medical evaluation and preoperative laboratory work.
If you have a cardiologist or pulmonologist because of significant heart or lung problems, then
you should see that doctor also for a preoperative evaluation. If you are taking blood thinners
such as Coumadin, Plavix or Xarelto, these drugs will need to be stopped temporarily before
the surgery and this will need to be coordinated with your medical physicians.
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AUTOLOGOUS BLOOD DONATION
Autologous blood donation is a technique in which the patient donates blood which is then
stored and can be given back later to the patient. Autologous blood donation was very popular
for knee replacement patients before effective screening programs for the AIDS virus and
hepatitis C were developed. Experts now recommend against autologous blood storage for
knee replacement patients because analysis has shown that today the risks of an autologous
blood program itself outweigh the benefits.
All units of blood, including autologous units, have the risk of being given to the wrong patient
despite precautionary systems to prevent this tragedy and have a remote risk of bacterial
contamination. All units of blood are stored for some period of time before transfusion and the
blood deteriorates while in the refrigerator and then creates negative reactions in the recipient.
The usual blood loss for a first time uncomplicated knee replacement is less than a unit and
almost all patients can tolerate the usual blood loss of a knee replacement without a
transfusion.
Patients may also have friends and relatives donate blood. Compatible units can be specifically
reserved for the patient. This type of donation is called directed donor blood donation. Blood
banking experts do not believe directed donor blood is safer than bank blood, since directed
donor blood involves some potential for coercion in collection, however minimal. The blood
bank offers directed donor blood as a service to patients, since many patients are more
comfortable getting blood from friends and relatives. It usually takes 48 hours or longer to
process directed donor blood. Thus, trying to arrange directed donor blood postoperatively is
usually impractical. The blood bank will not first test the directed donor for compatibility with the
patient, so there is no assurance that you will be compatible with all your directed donors.
It is rare to need blood transfusion for the usual patient having first time knee replacement.
Patients with preoperative anemia are the most likely patients to need a transfusion. Most
patients can get by without any blood transfusion. Dr. Moreland estimates that for the usual
uncomplicated knee replacement in a patient without preoperative anemia the risk of needing a
bank unit is less than five percent.
OTHER PREOPERATIVE CONSIDERATIONS
you are currently taking any nonsteroidal anti-inflammatory medications (NSAIDS), you should
stop taking these three days prior to surgery; since all NSAIDS except Celebrex can cause
increased bleeding during surgery (NSAIDS inhibit platelet function). Aspirin (an NSAID)
particularly can cause bleeding, and if you are taking aspirin, or aspirin containing drugs such
as Percodan, Ecotrin, Excedrin or Anacin, you should stop taking these at least seven days
prior to surgery. For pain before surgery you may take Tylenol, Tylenol with codeine, Tramadol,
Percocet, Vicodin and other drugs not containing aspirin or any other NSAIDS. The COX-2
inhibitor, Celebrex, can be continued right up until surgery, since it does not affect bleeding.
Smoking increases operative risk, and should be stopped or hopefully at least decreased in the
period before surgery. Smoking also increases the chance that the new hip replacement will
not get fixed to the bones. Patients should not smoke for at least two months. Smoking is
strongly associated with slow healing. All hospitals are now non-smoking facilities. Obesity also
increases operative risk and weight loss before surgery, if indicated, is desirable but not
essential.
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To reduce the risk of postoperative wound infection dermatological experts recommend:
1. Avoiding washing your skin with sponges or loofah as these may harbor staph bacteria.
2. Avoiding hot tubs one week before and three weeks after surgery as these may harbor
pseudomonas bacteria.
3. Applying prescription mupirocin skin ointment twice daily inside each nostril for three days
before surgery and one week after surgery.
4. Showering with Hibiclens wash (as a soap) applied to chest, back and thighs once daily for
three days before surgery
To improve wound healing and to minimize risk of a raised or spread scar dermatological
experts also recommend:
1. Enhancing collagen formation by taking zinc gluconate 50 mg once daily for 2 weeks before
surgery and taking vitamin C 500 mg twice daily for two weeks before and after surgery.
2. Avoiding scratching the wound area.
3. Applying BioCorneum topical suspension to the scar. You may start this three weeks after
surgery. Rub onto scar twice daily for three months. This is available on Amazon.
4. Avoiding sun exposure on the scar (the sun's rays can darken the healing tissues). Zinc
based sunscreens provide good protection. Vanicream SPF 50-60 OR Elta MD sport are good
choices.
THE PREOPERATIVE VISIT
We will usually ask you to come back for a final preoperative visit the day before surgery to
check that surgical arrangements are complete. At that time we will give you final instructions
and we will again discuss the surgical arrangements and the potential complications and risks.
Sometimes, a preoperative visit to the hospital is also made that same day, and your blood is
drawn again for usage by the blood bank and for a final blood count. Of course, your questions
will also be answered.
Patients are not admitted to the hospital until the morning of surgery. This practice of
admission the day of surgery, rather than the day before surgery, began in about 1986 when
most insurance companies began insisting that patients not be admitted the day before surgery
because of the expense of that extra day. This procedure has now become standard across
the country. If your surgery is the first one of the day, check-in time at the hospital is 5:00 a.m.
If your surgery is later, you will check in at a later appropriate time.
In the Santa Monica area there are many hotels which are conveniently located near Saint
John’s. The Gateway Hotel (a Best Western Hotel) offers discounted prices for patients who
are entering Saint John’s. It is located at the corner of 20th Street and Santa Monica Boulevard
and can be reached by calling (310)829-9100. Loews Santa Monica Beach Hotel at (310)4586700, Shutters on the Beach at (310)458-0030, and the Fairmont Miramar Hotel at (310)5767777 are all located close to the beach in Santa Monica and many rooms have views of the
ocean.
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WHAT DO I BRING TO THE HOSPITAL?
In general, the items you bring to the hospital should be limited. You should not wear valuable
jewelry or bring expensive music devices, computers, or cell phones. A small amount of cash
(less than ten dollars) may be useful. It is helpful to bring a telephone calling card or to know
your numerical code for long distance calling if you are planning any calls from the hospital.
Orthopedic patients now fortunately are usually hospitalized on the Orthopedic Unit in the new
St. John’s North Pavilion. All of the rooms there are private without additional charge and have
42 inch plasma televisions and other modern amenities.
Personal hygiene items, such as cosmetics, lip balm, toothbrush and toothpaste, should be
brought with you to the hospital. You may bring an electric shaver. Hair washing is difficult at
the hospital, as you will not be ready to shower; however, a beautician can assist you with this.
You may bring clothing to wear instead of a hospital gown. The day of surgery you will have to
be in a hospital gown; however, the next day you may wear your own pajamas, nightgown or
loose fitting, comfortable clothing. Some patients are sensitive to the detergent the hospital
uses to clean bed linens and gowns. Wearing your own nightgowns, pajamas or T-shirt will
protect your skin and help prevent skin problems. You may bring underwear and something to
cover yourself while walking in the hallways. Bathrobes and gowns should not be so long as to
make walking difficult or dangerous. You will need comfortable and safe shoes such as tennis
shoes or sturdy slippers.
THE DAY OF SURGERY
The night or morning before surgery, you should take a shower or bath. This will decrease the
bacterial population on your skin and decrease the chance of infection. The night before
surgery, you should not have anything to eat or to drink after midnight. Food in the stomach
can cause anesthetic complications. Sometimes the primary care physician or the
anesthesiologist or Dr. Moreland will tell you to take all or some of your usual morning
medications with a small sip of water the morning of surgery. Patients who usually take blood
pressure medications in the morning should almost always take these the morning of surgery
with a small sip of water.
On arrival at Saint John’s Hospital the day of surgery, you should report to the preoperative
suite on the second floor. During your preoperative visit to Dr. Moreland’s office, directions and
maps to the preoperative suite will be given to you. There is a visitors’ waiting area for surgery
patients on the second floor directly adjacent to the PACU (recovery room) and your family and
friends can remain there while you are in surgery. The volunteer at the desk in the surgery
waiting area should be told that your family is there so that Dr. Moreland can update them after
surgery.
The anesthesiologist will usually call you the night before surgery to discuss the anesthesia.
The anesthesiologist will also to see you in the preoperative suite before you go to the
operating room.
You will ultimately be taken to the operating room suite where you sometimes see Dr. Moreland
before you are sedated, and the surgery will commence after you are given your anesthetic. A
catheter is placed in your bladder after you are given your anesthetic. First time, uncomplicated
knee replacements usually take one to one and a half hours of actual operating time (not
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including preparation). You are usually in the operating room itself for two to three hours.
Revisional surgeries can take anywhere from one to three hours of operating room time or,
rarely, even more in particularly difficult situations.
Friends and relatives should wait in the surgical waiting area at Saint John’s (second floor).
Patients are usually in the PACU (recovery room) from one to two hours. Patients usually
cannot be visited in the recovery room but can be visited in the patient’s room after leaving the
recovery room. Joint replacement patients are usually hospitalized on the Orthopedic Unit on
the third floor of St. John’s North Pavilion. Patients do not go routinely to the ICU (intensive
care unit).
NEW POSTOPERATIVE PAIN RELIEVING TECHNIQUES
Over the last decade there has been dramatic progress in preventing and treating postoperative
pain. These revolutionary postoperative pain control techniques were introduced about the
same time as minimally invasive hip replacement and many authorities believe the current more
rapid and less painful recovery period after hip replacement is related more to these pain
control techniques than to the minimally invasive hip replacement surgery itself.
In the past postoperative pain was simply treated with narcotics until the patient was more
comfortable. There were many problems with this approach. Patients need widely varying
amounts of narcotics for pain control. Since too large a dose of narcotics can cause the patient
to stop breathing and even die, physicians must first use lower doses for safety and then
increase doses, if initial doses are not sufficient. Patents thus can be in a lot of pain before an
adequate dose of narcotics is determined.
Narcotics are not really that good at controlling pain. Some authorities say narcotics do not
make pain go away but that they make the patient not care about the pain. Narcotics have a lot
of side effects. Narcotics sedate patients and decrease their mental alertness. Elderly patients
particularly can become confused. Some patients can hallucinate. The respiratory depression
can cause other problems such as pneumonia. Narcotics depress the smooth muscles of the
gastrointestinal tract and cause nausea, vomiting and constipation.
Patients sometimes put off needed knee surgery from fear and dread of postoperative pain. A
new approach was greatly needed.
It has now recognized that if a patient feels a lot of pain, the brain gets sensitized to pain such
that the patient will feel later pain more intensely. It is important than this extra pain sensitivity
not be allowed to develop.
Today we prevent postoperative pain by treating pain even before it occurs and use several
types of medications for pain. Narcotics are still used but in smaller doses. The morning of
surgery you will be given the NSAID, Celebrex (if not allergic). Celebrex is great for
postoperative pain and will be given both before and after surgery. You will also be given a
dose of the pain medications Tramadol and acetaminophen (Tylenol). We also will give you a
dose of Oxycontin which is long acting, well tolerated, and effective preparation of the narcotic,
oxycodone.
A spinal anesthetic is strongly recommended rather than a general anesthetic. With a general
anesthetic your brain still knows that you are having an operation and your brain is being
sensitized to postoperative pain. With a spinal the brain receives no pain impulses from the
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operative site and is not being sensitized to postoperative pain. Patients are sedated and are
completely unaware during the operation. Spinal anesthetics also have the advantage of less
bleeding and fewer postoperative problems with blood clots.
A small dose of narcotic is injected with the local anesthetic of the spinal anesthetic. This can
give pain relief for 12 hours or more. Your gastrointestinal tract does not see this narcotic dose
and GI side effects are minimized.
At the end of the operation before wound closure the wound is injected with a long acting local
anesthetic similar to the Novocain used by the dentist. The pain relieving effects of this may
last 12 hours or more.
Postoperatively you will usually receive more Celebrex for two days and oral doses of the long
acting narcotic Oxycontin every 12 hours for two days. It has been found that patients do better
with oral narcotics than those given by IV or by injection.
THE HOSPITAL STAY
After surgery most patients today experience little or no pain, particularly right after the surgery
when so many things have been given already for pain. Break through pain is pain not
controlled by the medicines given without a request from the patient. If you are having break
through pain, call your nurse and additional pain medication will be given to you.
Almost all patients develop postoperative constipation due to the narcotics and need to take a
mild laxative, typically a rectal suppository, on the second day after surgery. Prolonged urinary
catheter use can cause urinary infections, which rarely can spread to the knee replacement.
Thus, we usually remove urinary catheters two days after surgery. All patients are given
intravenous antibiotics to prevent knee infection just before the operation and then usually only
two doses after surgery.
A suction drain is usually placed in the wound to remove any blood which collects after surgery
in the wound. Dr. Moreland usually removes these suction drains the morning after surgery.
Your blood count will be monitored at least daily for two days. We normally do not give iron
supplementation in the hospital due to the stomach upset it can cause. Transfusions of all
types of blood are always minimized to avoid the risks of disease transmission and transfusion
reactions.
The day of surgery you will be placed in the CPM (continuous passive motion) machine. The
machine will slowly and gently bend your leg. The nurses and physical therapists will
demonstrate to you how to adjust the machine, turn it off or on and how to adjust it. The CPM
should be used most of the time while you are in the hospital. Most patients do not have any
need to use the CPM at home as they are able to actively bend their knee. The flexion (amount
of knee bend) is gradually increased over the duration of the hospital stay and patients normally
have 90 degrees of bend prior to leaving the hospital.
The physical therapists at the hospital will begin working with you on the day following surgery.
Exercises to strengthen the muscles around the knee and encourage active knee bending and
straightening will be taught to you. The therapist will get you up out of bed on the morning after
surgery. Most patients require pain medication prior to the physical therapy sessions.
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Knee replacement is uncomfortable initially and it would be nice if we could avoid exercises until
the pain in the knee goes away. However, if we did this, the knee would become stiff and after
the scar heals around the knee, the knee would not bend. Thus, exercise is important even
though the knee is still in the process of healing and it is uncomfortable. After the initial surgical
dressing is changed, the therapist may offer to put an ice bag on your knee following therapy
and many people find this is helpful to them.
To prevent blood clots, patients are given Coumadin (warfarin) which is a blood thinner
(anticoagulant). The level of blood thinning must be monitored on a daily basis requiring your
blood to be drawn each morning. Dr. Moreland will order a dose of Coumadin each evening
depending on how thin your blood was that morning. It is important that your blood not be too
thin since this can cause bleeding. TED stockings, which also help prevent blood clots, will be
applied to both legs after the surgical dressing is changed. After discharge most patients are
instructed to take one aspirin a day (if able to tolerate) to prevent blood clots and the Coumadin
is stopped. Patients with a history of blood clots may need Coumadin for longer after surgery.
Most patients stay in bed until the morning after surgery at which time the physical therapist will
get you up and help you walk. In addition to walking, there are some gentle exercises which
the therapist will teach you to prevent blood clots from forming in your legs. Most patients, by
the second day after surgery, no longer have an IV, are eating normally, are not taking
antibiotics, need only pain pills for pain relief, have no monitoring devices or any tubes, and are
feeling quite well.
Initially you will either need two crutches or a walker to help walk. The therapist will help you
decide which is best for you, and the social worker will help you obtain them. There are no
postoperative restrictions on weight bearing other than pain. Exercise before surgery to
increase the strength of your triceps muscles will make postoperative crutch or walker use
easier. Crutches are more convenient in tight areas and for climbing stairs, but do require more
strength and balance than a walker. A walker is easier to learn to use, requires less strength
and balance and is generally used by the older patients. Some patients like to have both types
of devices available for differing situations.
Each day you will progress with the physical therapist. They can teach you to use either the
crutches or the walker initially. If you need to learn to walk up or down stairs, the therapist will
assist you with this. Most patients find that it is helpful for them to take pain pills prior to the
physical therapy sessions and the therapists and the nurses will help you to coordinate this.
We have noticed that some of our patients report feelings of depression postoperatively. These
feelings are usually transient, lasting a day or so. We theorize that the excitement of surgery is
over, but the patient realizes that the recovery is not complete and gets depressed. Soon,
however, the plan for going home progresses and the depressed feeling is relieved. So, if you
experience these feelings, do not worry since they will probably be transient and other patients
have had similar experiences.
Some patients develop a low-grade fever in the first few days after surgery. The temperature is
usually up in the evening and down in the morning. The patient will sometimes have fever up to
101 degrees for the first few days. This is a normal reaction to the surgery and does not mean
infection. As the fever goes up, the patient may feel a chill and as it goes down, the patient
may have a sweat. Some wounds occasionally drain a light yellow fluid for several days after
surgery. This does not mean infection and usually resolves in a few days.
30
The discharge planner and the physical therapist will talk to you about supplies you will need
when you go home. Patients usually get a bedside commode which sits up higher than a
normal toilet seat. It is easier to get up from a raised toilet seat during the postoperative period.
By the time of discharge (usually after two or three nights after surgery) most patients can
without assistance get in and out of bed, go to the bathroom, and take short walks comfortably.
Older patients and some patients with other musculoskeletal problems may take longer to reach
these recovery milestones. It is best to be able to go to a home after discharge in which there
are other people around for portions of the day to assist you with shopping, meal preparation,
etc. Constant nursing care is rarely needed. Once home, most patients stay there for one or
two weeks while strength is returning. By two to three weeks after surgery most patients are
feeling well and begin to go out to eat and shop. Some also return to work at that time if they
have a sedentary occupation which will allow walking aids. You can start using a cane held in
the opposite side from the new knee when you feel comfortable. There certainly is no reason to
rush to using a cane.
Patients often wonder about the need for a hospital type bed for home use. Features such as
adjustable height, adjustable head and a trapeze can be useful but are rarely essential. It is
very unusual for an insurance policy to cover the cost of such a bed for a patient with a recent
knee replacement. Dr. Moreland’s ordering the bed for a patient does not mean that it will be
covered by insurance policies. The insurance companies are very restrictive about paying for
equipment which they determine is not required for the patient’s care. Patients can still rent a
bed, if needed or desired, and assume the financial obligation personally.
If you do not have a satisfactory home situation and you need extended care facilities, such can
be arranged with the discharge planner at the hospital in consultation with your family. Our
office has a list of local extended care facilities and you may visit them or speak with them.
Many patients are apprehensive about the drive home. Virtually all patients can go home via
private car, assuming usual car size and configuration. Occasionally, patients go home via
ambulance in situations where the patient cannot easily negotiate serious obstacles such as
long, high, or narrow stairs. The physical therapist can help with planning and practicing
maneuvers for the trip home.
DISCHARGE FROM THE HOSPITAL
On the second postoperative day your original surgical dressing will be removed and a special
usually watertight dressing will be placed. Until two weeks after surgery, it is best to keep the
wound dry. If a good seal with the occlusive dressing is maintained you may shower at home
but still try to keep the wound dry. Alternatively you can just do a sponge bath. After two weeks
you can remove the plastic dressing and the tapes and shower normally. Do not immerse the
wound in bath water or a spa or a swimming pool until at least two and one half weeks after
surgery and only then if the wound is well healed. We recommend avoiding a bath tub for
several weeks after surgery, because of the difficulty of climbing in and out of the tub and the
awkward position that one commonly assumes when taking a bath in a small tub. It is usually
safer to shower rather than trying to get in and out of tubs.
After the hospital discharge, any wound drainage should be reported to Dr. Moreland’s office.
The wound should gradually become more comfortable. If you notice increased swelling,
warmth, and redness over the knee wound, our office should be notified and in most instances,
31
you will need to come in and let us examine the wound. If you begin to run a significant fever
(greater than 100 degrees), we also need to know about this. In general, your knee should be
gradually getting better but if you think you are getting worse, please give us a call.
Most patients who have a knee replacement need further coaching and instruction from the
physical therapist at home. A home physical therapist will be arranged through a home health
agency in your area and will normally visit you within 48 hours of discharge from the hospital
and two to three times a week as needed to assist you with obtaining the necessary range of
motion and gait. It is very important that knee replacement patients continue to actively
exercise at home both with the physical therapist and on their own. It can be very helpful to the
patient if the family members learn the exercises so that they can provide coaching and
encouragement to the patient in addition to the home physical therapist. It is very important the
exercises be done vigorously in the first few weeks after surgery so that flexibility can be
maximized.
Frequently, patients develop swelling of the foot and ankle after surgery. If this occurs, you
should elevate your foot and be sure to wear the white compressive stockings (TED hose) that
you received in the hospital. Severe swelling can be due to inflammation or clots in the veins
(DVT) and Dr. Moreland’s office should be notified if this occurs, especially if considerable
swelling is associated with pain in the calf or thigh. There is a simple non-painful, non-invasive
test (Doppler) to detect blood clots (DVT). If a DVT is found, the patient is usually readmitted to
the hospital for a few days of treatment with heparin (another blood thinner), followed by a few
months of Coumadin as an outpatient.
It is best to avoid driving until four weeks after surgery, particularly if the right knee has been
replaced, since most driving is with the right foot. The main issue is whether the patient can
control the car rather than injuring the new knee replacement. Some patients, however, may
need to do so sooner and this can be discussed with Dr. Moreland. It is good to continue to
wear the special white stockings for about four weeks after surgery. If, however, you are not
having any swelling and you find these stockings uncomfortable, they can be discontinued
before this.
FOLLOW-UP APPOINTMENTS
The first office visit after discharge is usually at nine days after surgery to remove the staples.
The next visits are at three weeks, six months, and two years after surgery and then every three
years. Regular visits to have an x-ray and to have your knee examined are essential for
monitoring the result of the surgery and giving you periodic advice for the care of your knee
replacement.
The longevity of your cemented knee replacement can be increased by avoiding stressful
activities such as all types of impact sports including: running, jogging, tennis, snow and water
skiing, racquet ball, badminton, football, and baseball. Heavy lifting, weight lifting, jumping from
a height, falls, and some exercise machines for the legs are dangerous for you. It is important
that you not become overweight, since excess weight increases the stress on the knee
replacement and can cause loosening.
Another concern about your knee replacement is the possibility of infection occurring around
the replacement. If you develop an infection elsewhere in your body, it can travel via the
bloodstream to the replacement. Infections likely to do this are urinary tract infections, as well
as skin and toenail infections. If you develop any of these, you should consult your family
32
physician or internist and be treated promptly. Dental work can push bacteria into the
bloodstream and can cause very rarely an infection in your joint replacement. Your dentist may
recommend that you take antibiotics with your dental work. You should always notify any
treating physician that you have a joint replacement since other medical procedures, tests, and
surgeries can involve infection risks to the replacement. The physician or the dentist doing the
procedure should give the appropriate antibiotic coverage for the procedure. Since there really
is no proof as to what the best antibiotic to give is and exactly how it should be given, Dr.
Moreland is satisfied with whatever antibiotic treatment your physician or dentist wants to give
you. It is more convenient and appropriate for that physician or dentist to prescribe the
antibiotics, than for Dr. Moreland since he doesn’t know exactly what procedure you are having.
Patients with a knee replacement often trigger the airport metal detection devices. We can give
you a card attesting to the presence of your knee replacement. Unfortunately our card has no
official status.
Finally, it is important to see us at least every two or three years for an x-ray and examination,
so that we can advise you as to how your joint replacement is doing and recommend possible
activities. This serial x-ray record of your knee replacement often is helpful in the evaluation of
any possible future problems. Wear of the polyethylene plastic in your knee replacement can
be a problem, and the patient does not always feel symptoms from the wear until the damage is
extensive. The best way to look for wear is to take a radiograph every two or three years.
HOW CAN I PREPARE MY HOME?
Most patients need to make a few modifications to their home environment prior to undergoing
joint replacement surgery. Planning your postoperative needs will help you to more easily
adapt to the transition from hospital environment to home. The hospital has an advantage over
home in that it is a smaller room with all the necessities delivered right to you and a nurse to
assist you with such needs as eating and toileting.
Prior to discharge, most patients are able to independently get out of bed safely and walk a
functional distance. You do not need to purchase a walker or crutches prior to admission to the
hospital as these will be supplied to you there. If you have already obtained a walker or
crutches, you should bring these with you to the hospital so that the physiotherapist can adjust
them to your size and check them for safety. Borrowing another person’s used equipment is an
acceptable way to reduce costs as long as the equipment is in good shape and adaptable to
your size.
If you live alone at home or if you think you will need additional help, there are nursing agencies
that can provide people to take care of such necessities as changing and washing the bed
linens, shopping, and meal preparation. They can also assist you with watering plants and the
maintenance of pets. Our office can supply you with names of agencies and phone numbers to
call and make arrangements to meet the people prior to your surgery. Most insurance
companies, including Medicare, do not cover the cost of homemaker/chore persons. The fees,
however, are usually reasonable and professional home help can allow you to enjoy the
comforts of your own home rather than having the inconveniences of an institution.
If your bedroom is located upstairs or is too far away for you to get to the bathroom or kitchen
conveniently, you may want to set up another room in your house as your temporary bedroom.
Most patients do not need a hospital bed. If you have concerns about your sleeping
arrangements, you can contact our office to discuss the situation.
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You will need a comfortable chair with arms at home. Look around your house for a chair with
arms and a firm seat which is not too low. The arms will allow you to get in and out of the chair
more easily. You may want to consider such items as baskets that you can attach to walkers to
carry things, or attachments you can place on crutches to allow for movement while carrying
something to drink. Remember that your hands will be used for the walker or crutches so, in
order to carry an item with you from one room to another, you must be able to put it in
something. Pockets, preferably large ones, are a very convenient way to carry things which
won’t spill. Some patients like to utilize small backpacks or fanny packs.
We are pleased to be able to present this manual to you and we hope it helps you in
understanding your condition and the possible treatments which are available. Please feel free
to ask additional questions. We look forward to taking good care of you!
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