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Lahey Clinic Department of Orthopaedic Surgery A Patient’s Guide to Department of Orthopaedic Surgery 41 Mall Road • Burlington, Massachusetts 01805 (781) 744-8650 See The Department of Orthopaedic Surgery at www.lahey.org KNEE REPLACEMENT A Patient’s Guide to Knee Replacement Dear Knee Replacement Patient, We hope this Patient Guide to Knee Replacement provides valuable information as you prepare for your knee replacement operation. More information about the Lahey Clinic Department of Orthopaedic Surgery is available at www.lahey.org/OrthopaedicSurgery. Enjoy your new knee! Lahey Clinic Knee Replacement Surgeons (Left to right) Brian J. Jolley, M.D., Stephen E. Lemos, M.D., Richard Iorio, M.D., John F. Tilzey, M.D., William L. Healy, M.D., Richard M. Wilk, M.D., Michael S. Thompson, M.D., Lawrence M. Specht, M.D., Mark J. Lemos, M.D., Bernard A. Pfeifer, M.D. If you have any questions or concerns about your knee replacement operation, please call your Orthopaedic surgeon at Lahey Clinic, (781) 744-8650. A Patient’s Guide to Knee Replacement • Stay active and bear weight on your reconstructed knee. • Airline travel within the first 2 months after knee replacement operation increases the risk of developing a blood clot. Please discuss this with your surgeon. Walking is an essential part of physical therapy. You should take daily walks, lengthening your walking distances as your strength improves. FOR THE REST OF YOUR LIFE Your knee replacement should provide mobility, stability, and pain free function for many years. You can participate in many activities with your “new knee”. However, you should protect your knee replacement from excess stress which can lead to premature failure of the artificial joint. Avoid weight gain which will increase stress on your new knee. High impact loading activities such as jumping, running, jogging, and heavy weight lifting should be avoided. Sports, such as basketball, racquetball, squash, volleyball, and tennis, increase the risk of implant loosening and implant wear. You may choose to participate in these sports, but you must accept the associated risk. Low-impact loading activities such as walking, boating, cycling, swimming, bowling, and golf are excellent activities for recreation and exercise after knee replacement. CONTENTS Choosing Knee Replacement ..............................................2 What is a Knee Replacement? ............................................3 Types of Knee Replacements ..............................................4 Innovation, Technology, and Information ..........................5 Getting Ready for Surgery ..................................................6 Scheduling Your Operation ................................................6 Informed Consent ..............................................................7 Academic Medical Center ..................................................7 Physical Examination/Tests ................................................7 Blood Management ............................................................8 Case Manager......................................................................9 Anesthesia ..........................................................................9 Personal Preparations For Surgery ......................................9 Physical Therapy ..............................................................12 Final Pre-operative Visit ....................................................14 Day Before Surgery ..........................................................15 Operation and Hospital Stay ............................................16 After Surgery: Day by Day ................................................17 Leaving the Hospital ........................................................23 To Rehabilitation Facility ..............................23 To Home ......................................................23 Important Information As You Leave Lahey Clinic ..........24 Follow-up Visits ............................................24 Knee Range of Motion ..................................24 Wound Care ..................................................24 Toileting ........................................................25 Bathing..........................................................25 Dressing ........................................................25 Compressive Stockings ..................................25 Driving ..........................................................26 Sexual Relations ............................................26 Dental Work..................................................26 Infections ......................................................26 Guidelines After Knee Replacement ..................................27 For the First Two Months ..............................27 For the Rest of Your Life................................28 CHOOSING KNEE REPLACEMENT Knee replacement is an elective surgical procedure. This operation is one of several non-surgical and surgical options which are available for treatment of your arthritic knee. It is important for you to be familiar with all possible treatments for your knee. Non-operative treatment options for an arthritic knee include: anti-inflammatory medicine, pain medication, physical therapy, weight loss, walking aids such as a cane or crutches, nutritional supplements, injections, and restricting your activities. Many patients with arthritic knees try non-surgical treatment before choosing surgical treatment. Surgical treatments for an arthritic knee include: arthroscopy, osteotomy, fusion, partial knee replacement, and total knee replacement. Each operation has specific indications, and all surgical treatments are not appropriate for all patients. Generally, knee replacement is very successful. Knee pain is relieved, deformity is corrected, and function improves. It is not clear how long a knee replacement will last. The long-term success rate will vary, depending on your age, your weight, and your activity. “Plan on ten to fifteen years and hope for twenty”. If a knee replacement becomes loose or wears out, generally it can be fixed with a revision knee replacement operation. 2 Knee replacement is major surgery. When choosing to have a knee replacement, it is important to be aware of potential risks and complications such as: problems from anesthesia, bleeding, damage to nerves or blood vessels, instability, dislocation, fracture, ligament injury, blood clot, infection, and very rarely, death. GUIDELINES AFTER KNEE REPLACEMENT For your safety, and to ensure a successful outcome following your knee replacement operation, you should adhere to the following guidelines. FOR THE FIRST TWO MONTHS • Push to gain maximum range of motion during the first four weeks following surgery. Knee motion is critical to the success of this operation. • During the day time get up every half-hour or so and take a brief walk. Prolonged sitting may allow muscles around your knee to get stiff. • Avoid slippery surfaces which may allow your leg to give way. • When sleeping, do not place a pillow under your knee. This will prevent you from gaining full extension (straightening) of your knee. Try to sleep on your back with a towel roll under your ankle. • When your surgeon prescribes strengthening exercises, work hard to make your hip and knee muscles strong. 27 %SJWJOH 8)"5*4",/&&3&1-"$&.&/5 :PVTIPVMEOPUESJWFVOUJMZPVDBOTBGFMZDPOUSPMZPVSWFIJDMF ɨ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mDJBM LOFF "DDPSEJOH UP SFDPNNFOEBUJPOT GSPN ɨF "NFSJDBO "DBEFNZ PG 0SUIPQBFEJD 4VSHFPOT BOE ɨF "NFSJDBO %FOUBM "TTPDJBUJPOXFSFDPNNFOEUIBUZPVUBLFBOBOUJCJPUJDCPUI CFGPSF BOE BGUFS BOZ EFOUBM XPSL JODMVEJOH TJNQMF UFFUI DMFBOJOHGPSUIFmSTU UXPZFBSTBGUFSLOFFSFQMBDFNFOUɨF QSFGFSSFEBOUJCJPUJDJT"NPYJDJMMJOPSJGZPVBSFBMMFSHJDUPUIBU ESVH$MJOEBNZDJO&JUIFSXFPSZPVSEFOUJTUDBOQSPWJEFZPV XJUIBQSFTDSJQUJPOGPSUIJTNFEJDBUJPO *OGFDUJPOT 3BSFMZ JOGFDUJPOT GSPN PUIFS TJUFT PG UIF CPEZ DBO USBWFM UISPVHIUIFCMPPEBOETFUUMFJOBOBSUJmDJBMLOFF"OZUJNFZPV TVTQFDUZPVNBZIBWFBOJOGFDUJPOPGBOZLJOEPGZPVSTLJO ZPVSUISPBUZPVSVSJOFZPVSUFFUIFUDTFFZPVSQSJNBSZDBSF EPDUPSTPPOFSSBUIFSUIBOMBUFS-FUZPVSEPDUPSLOPXUIBUZPV IBWF BO BSUJmDJBM LOFF )F PS TIF XJMM EFDJEF XIFUIFS JU JT BQQSPQSJBUFUPCFHJOUSFBUJOHUIFJOGFDUJPOXJUIBOUJCJPUJDT 26 GFNVS QBUFMMB JNQMBOU QBUFMMB GFNPSBM JNQMBOU UJCJBM JNQMBOU UJCJB /PSNBM,OFF "SUISJUJD,OFF ,OFF3FQMBDFNFOU ,OFF SFQMBDFNFOU TVSHFSZ SFTVSGBDFT BO BSUISJUJD LOFF KPJOUXJUIUISFFJNQMBOUT BNFUBMGFNPSBMJNQMBOUmYFEUP UIFFOEPGUIFGFNVSBNFUBMBOEQMBTUJDPSBMMQMBTUJDUJCJBM JNQMBOU mYFE UP UIF UPQ PG UIF UJCJB BOE B QMBTUJD QBUFMMB JNQMBOUmYFEUPUIFQBUFMMB,OFFSFQMBDFNFOUTVSHFSZBMTP SFDPOTUSVDUT PS CBMBODFT TPGU UJTTVF TUSVDUVSFT TVDI BT MJHBNFOUT BOE UFOEPOT ,OFF SFQMBDFNFOU SFMJFWFT QBJO SFTUPSFT NPUJPO DPSSFDUT EFGPSNJUZ BOE JNQSPWFT GVODUJPOGPSQBUJFOUTXJUIBSUISJUJDLOFFT 3 TYPES OF KNEE REPLACEMENTS Toileting Total Knee Arthroplasty (TKA) Most home toilet seats are low. A commode or raised toilet seat will be helpful. Toilet grab bars may also be helpful. Total Knee Arthroplasty or Total Knee Replacement is the operation described in this booklet. TKA can be a fixed bearing knee replacement or a mobile bearing knee replacement. The goal of TKA is to relieve pain and improve function. TKA is the most common type of knee replacement. Unicompartmental Knee Replacement (UKA) Unicompartmental Knee Arthroplasty or Unicompartmental Knee Replacement resurfaces part of the knee joint. This operation may also be called a partial knee replacement. Either the medial (inside) or the lateral (outside) tibiofemoral joint is resurfaced. This operation is less common than total knee replacement. Minimally Invasive Knee Replacement (Minimal Incision/Less Invasive) A Minimally Invasive Knee Replacement operation (TKA or UKA) is performed through a small incision with less tissue dissection. Some patients are not candidates for minimally invasive knee replacement. Revision Total Knee Arthroplasty Revision total knee arthroplasty is an operation which revises or fixes a knee replacement which has developed a problem such as loosening of fixation, wear of bearing surfaces, fracture, or instability. Bilateral Total Knee Arthroplasty Some patients with two equally symptomatic arthritic knees may be candidates for Bilateral TKA on the same day. 4 Bathing While your skin staples or sutures are in your knee incision, please use sponge baths for personal hygiene. Please do not get your knee replacement wound wet. You may shower or bathe after your skin staples or sutures are removed. Bathing is best done in the shower – getting in and out of a tub can be difficult and dangerous when recovering from knee surgery. Grab bars in the shower/tub area may be helpful. A longhandled sponge, can be helpful for bathing your lower body. Some patients find a tub seat in the shower to be helpful. Be cautious when walking on slippery bathroom floors. Dressing Some patients will need assistive devices in order to dress independently. A stocking aid may enable you to put on your socks without bending over too far. A long-handled shoehorn will assist you in putting on your shoes. Long-handled reachers may assist you in putting on and pulling up your pants. You will be evaluated during your hospital stay for your particular needs at home. Compressive Stockings The white TED stockings should be worn on both legs when you are up during the day. They help control swelling in your legs (especially in your operated leg). At night, you can remove them and launder them, if necessary. Usually, you will be asked to wear these stockings for four to six weeks after surgery. 25 IMPORTANT INFORMATION AS YOU LEAVE LAHEY CLINIC INNOVATION, TECHNOLOGY, AND INFORMATION Follow-Up Visits Total knee arthroplasty uses anatomically designed implants made of high grade biomaterials to resurface arthritic knee joints. As new materials, designs, and techniques are developed to improve knee replacement, Lahey knee surgeons evaluate new technology for possible use with Lahey patients. Lahey Clinic orthopaedic surgeons use the best techniques and best implants available to provide predictably successful knee replacement operations. Two Weeks: Usually, your surgeon or his assistant will see you in the outpatient clinic to remove skin staples or sutures two weeks after surgery. If you go to a rehabilitation hospital, they may remove your staples or sutures. Four to Six Weeks: Usually, you will see your surgeon four to six weeks following surgery for a clinical and radiographic examination. Knee Range of Motion It is your responsibility to achieve a full, functional range of motion from 120˚ flexion (bend) to 0˚ extension (straight). Your surgeon, your therapist, CPM machines, and your family will help, but ultimately, each knee replacement patient must achieve knee motion by him/herself. Please do not put pillows under your knee in slight flexion to be comfortable. This will slow your therapy. When resting put your knee in a maximum flexion or maximum extension position. Wound Care 24 Keep your incision dry while staples are in. You should keep a dressing on your wound if there is drainage. If the wound is clean and dry, you can leave it open to air. Look at your wound each day. If you notice signs of possible infection such as: increasing redness, increasing warmth, or new drainage that looks like pus, call your surgeon immediately. If your doctor or nurse want to give you an antibiotic for your knee, please ask him/her to call your surgeon first. Innovations that may be appropriate for some patients include: • modular knee replacement • all polyethylene tibial implant • mobile bearing knee replacement • bilateral knee replacement • minimally invasive knee replacement • computer assisted surgical navigation Information on total knee arthroplasty is available from many sources including the internet and direct-toconsumer marketing programs. Some of this information is accurate and useful. Some of this information is not accurate. Information on clinical services, educational programs, and orthopaedic research in the Lahey Clinic Department of Orthopaedic Surgery is available at www. lahey.org/OrthopaedicSurgery. The Lahey Clinic hospital is a “high reliability organization” committed to patient safety and prudent use of new “cutting edge” technology in caring for our patients. All Lahey Clinic hospital rooms are private rooms equipped with flat screen personal computers which provide knee replacement patients with access to television, radio, games, music, email, and the internet. 5 GETTING READY FOR SURGERY LEAVING THE HOSPITAL Once you have decided to have your knee replaced, there is much to do to prepare for your operation. Lahey Clinic provides a team approach to your care. You will have a chance to meet members of the team before surgery. They will answer your questions and make arrangements to insure that your surgery, hospital stay, and post-operative recovery will go as smoothly as possible. To a Rehabilitation Facility SCHEDULING YOUR OPERATION Surgical scheduling is a complex process. Your operation requires you, your surgeon, an anesthesiologist, surgical assistants, nurses, an operating room, surgical instruments, knee implants, and many pieces of equipment to be in the same place at the same time. You will work with a surgical scheduler to select an acceptable date for your knee replacement operation. Please be as flexible as possible in working with your surgical scheduler. INFORMED CONSENT If you choose to go to a rehabilitation facility, and if your health plan approves this choice, you will be discharged on the second or third day after surgery. Your case manager will assist you and your family with discharge plans. You will bring a Lahey Clinic Knee Replacement Post Acute Care Plan with you to the rehabilitation facility. Follow-up with your surgeon will also be arranged. To Home If you are medically stable, independent with walker/crutches/ cane, and knowledgeable in knee replacement precautions, and if you have help available at home, you may choose to be discharged to home. Your case manager will assist you and your family with discharge plans. Physical Therapy at a therapists office or at home will be arranged. You will take pain medication and blood thinners at home. Usually, you will resume your routine medications at home – review these medications with your primary care physician. You will be asked to sign an informed consent document which gives Lahey Clinic and the Lahey Clinic professional staff permission to give you a knee replacement operation. This booklet will teach you about knee replacement so you will be a well informed patient. You will also be asked to give Lahey Clinic permission to collect information about your knee replacement in the Lahey Clinic total joint database. 6 23 Postoperative Day #4 ACADEMIC MEDICAL CENTER - Your knee range of motion will be measured and charted. Lahey Clinic is an academic medical center. Lahey Clinic doctors teach residents, students and post graduate fellows how to be doctors and surgeons. Boston University orthopaedic surgery residents train at Lahey Clinic. You will meet the students, residents and fellows as members of the orthopaedic team. Orthopaedic residents and fellows will participate in your operation to help your surgeon and learn about knee replacement. Students and visiting doctors may observe your operation. Your orthopaedic surgeon will do your knee replacement operation. - Continue all motion and strengthening exercises PHYSICAL EXAMINATION/TESTS - Practice independent transfers. Generally, a physical examination by an internal medicine doctor is recommended to ensure that you are healthy enough to undergo major surgery. If you are new to Lahey Clinic, or if you have a primary care physician outside Lahey, please bring a letter from your doctor to your pre-operative visit which describes your past medical history and your current medical condition. Consultation with other medical specialists may also be necessary. Several diagnostic tests, including chest x-ray, EKG, and blood and urine tests may be scheduled. You need to bring a list of all your current medications, including prescription drugs, over the counter medicines, vitamins, herbs, and nutritional supplements when you come for your preoperative visit. An up-to-date medical history which includes current and past health problems, allergies, hospitalizations, and surgeries will be recorded. If you have dental problems, please inform us and seek appropriate care well before your surgery date. Dental infection can lead to knee infection. • The dressing on your wound will be changed. If your wound is dry, it may not be necessary to cover it. • The CPM machine will be advanced to gain motion. • Physical therapy continues: - Practice independent ambulation with crutches/walker. - Practice stair climbing. - Review knee safety precautions. Lahey Clinic Physical Therapy Department ROM DATA GRAPH Degrees 120 110 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 Post-operative Day 22 flexion (bending) extension (straighten leg) 6 7 8 9 10 11 12 13 14 your own motion! ChartChart your own motion! 7 BLOOD MANAGEMENT Most patients who have one knee replacement will not require blood transfusion. A tourniquet is placed on your thigh to prevent blood loss during the operation. However, you will lose blood into your knee and leg after the operation when the tourniquet is removed. Some patients will require a blood transfusion after knee replacement. Factors associated with a need to transfuse blood include; a low hemoglobin or hematocrit (“low blood count”) before operation, cardiac conditions, medical disease, extensive knee reconstruction, unexpected post-operative blood loss, and bilateral knee replacements on the same day. In some cases, your surgeon may ask you to donate your own blood for possible transfusion – autologous transfusion. This blood is refrigerated and stored until the time of your operation. If transfusion is necessary, you will be transfused with your own blood. In some cases, on the day of your surgery, your anesthesiologist may draw off some of your blood before the operation in order to give it back to you after surgery – hemodilution. In some cases it may be necessary for you to be transfused with Blood Bank blood. Postoperative Day #3 • The dressing on your wound will be changed. • The CPM machine will be advanced to gain knee motion. • If you have been unable to have a bowel movement (pain medicine commonly causes constipation) and you are uncomfortable, please tell your nurse. • Physical therapy continues: - Continue exercises. - Your knee range of motion will be measured and charted. - You should become independent with transfers. You will require less assistance for transferring in and out of bed. - If it is possible, you will practice ambulating with crutches instead of a walker. Your goal should be to walk independently with a walker, crutches, or cane as soon as possible. • If you will be discharged to a post-acute care facility, you will probably be transferred by ambulance today. You will bring a Lahey Clinic Knee Replacement Post-Acute Care Plan with you to the rehabilitation facility. 8 • If you will be discharged to home, the Occupational Therapist will assist you with the performance of everyday activities such as bathing and dressing. They will show you techniques to assist with these activities at home. 21 Postoperative Day #2 • The dressing on your wound will be changed. • A blood test will be drawn to measure the effectiveness of the blood thinner (Coumadin). This blood test will be drawn intermittently as long as you take Coumadin. • If you are constipated, you may request medications, a suppository, or an enema. • The CPM machine will be advanced to gain knee motion. • Physical therapy continues: - Continue exercises from post-operative day 1. - Your exercises will be advanced by the physical therapist. These exercises will focus on maximizing range of motion of your knee – flexion (bending) and extension (straightening). - Your knee range of motion will be measured and charted. - Muscle strengthening exercises will begin. - Practice transfers. You should be getting into a chair at least two times a day with assistance from the physical therapy or nursing staff. - You will begin walking with a walker or crutches. 20 • The case manager, in discussions with you, your family, your physicians, your therapists, and your healthcare insurance company will finalize discharge planning. Transfer to a rehabilitation hospital will occur on postoperative day three. Discharge to home will be on postoperative day four or five. CASE MANAGER Before your operation, you will be contacted by a Lahey Clinic Case Manager who will help you plan your discharge from the hospital to a rehabilitation facility or to home. Advance planning helps alleviate concerns you and your family may have about what will happen after you leave the hospital. Your health insurance company will have input concerning where you may go after hospital discharge. Speak to your health insurance representative about your options. ANESTHESIA Most patients will meet their anesthesiologist on the day of surgery. He or she will review your medical records and answer questions you may have about anesthesia. If you have a preference for a type of anesthesia, please tell your anesthesiologist. We encourage you to follow your anesthesiologist’s recommendations. If you have a specific condition which requires a pre-operative consultation with an anesthesiologist, please let us know. PERSONAL PREPARATIONS FOR SURGERY Prepare Yourself: • Stop smoking. This will help your breathing, improve wound healing, and reduce postoperative complications. (At least cut back). • Eat well-balanced meals. This is not the time for serious weight loss. • Start taking an over-the-counter iron supplement one month prior to surgery (FeSO4 325 mg three times per day). 9 • Get plenty of rest. • Cut back or eliminate alcohol. • Exercise to improve and maintain muscle tone and joint motion. • Develop a positive attitude for knee replacement. Prepare Your Home: • If possible, arrange a one floor living area with kitchen/bed/bathroom to minimize stairs. • Rearrange furniture to enlarge walking paths for crutches or a walker. • Remove scatter rugs. • Make sure all doorknobs are clear and accessible. • Install night lights. • Obtain an apron with pockets or a backpack. Your hands will be using crutches. • Stock freezer and pantry. • Obtain a cordless phone. • Non-skid mats for shower/tub. • Grab bars in the shower/tub, near toilet. • Tub seat. • Raised toilet seat or commode. • Long handle sponge. • Stocking aid. • Long handle shoe horn. • Long handle reacher. Prepare For Hospital Discharge: • Discuss hospital and discharge plans with relatives and friends. • Evaluate the options of home discharge or rehabilitation facility discharge. • Review insurance coverage as it pertains to discharge. 10 - You will begin the exercises which you learned before your operation (Page 12). 1. Ankle pumps 2. Quadriceps sets/knee straightening 3. Gluteal sets 4. Lower leg lifts/short arc quadriceps sets 5. Straight leg raise 6. Heel slides - The therapists will measure the range of motion of your knee. They will note your progress on a wall chart (use the chart on page 22). During the first two weeks after your operation, your most important job is to achieve functional range of motion. Your goal is to maximize flexion (bending) to 120˚ and extension (straightening) to 0˚. - The therapists and the nurses will help you out of bed and into a chair. Hopefully, you can do this two or three times on postoperative day one. During transfers (getting in and out of your bed or chair) you can generally put as much weight on your operated leg as you wish. Weight bearing may be restricted for some patients. • Safety precautions for patients with knee replacements will be discussed. • A case manager will visit with you and your family. Planning for your discharge from the hospital now begins in earnest. 19 • You will receive an antibiotic to prevent infection. • You will receive a blood thinner medication to prevent blood clots. • When you are ready, and when your room is ready, you will be transferred from the recovery room to your hospital room. Family members and friends may visit you in your hospital room. Prepare A Hospital Bag: • Personal care items. • Loose, comfortable clothing. • Shorts, sweatpants, t-shirts. • Low-heeled supportive shoes or sneakers with non-skid soles. • “Walkman” type tape/CD/MP3 player if you like music. • Cash for newspaper, snacks, etc. • Credit card for TV/telephone/internet access. • Some patients will spend their first night in the hospital in the recovery room. Postoperative Day #1 • Use your incentive spirometer to expand your lungs. • Several blood tests will be drawn to monitor your recovery. • Your diet will begin with clear liquids. It will be advanced when it is safe to do so. • A bowel regimen including stool softeners will be instituted to prevent constipation. • If you have a bladder catheter, it will probably be removed. • The CPM machine will be advanced to gain motion. • Physical therapy begins: 18 - The physical therapy exercises and the CPM will help the knee to bend. When you are not bending the knee in the CPM or with therapy, it is very important to keep the leg straight. Do not put pillows or blankets under your knee. It is best to put a rolled up towel or pillow under your foot and ankle, to help straighten out your knee. 11 PHYSICAL THERAPY AFTER SURGERY: DAY BY DAY Successful knee replacement requires careful, compulsive rehabilitation. Physical therapy is essential to the success of knee replacement. This schedule presents a sequence of events that usually follow knee replacement operations at Lahey Clinic. Physical therapy will begin the day after your operation. The therapist will teach you to get in and out of bed, get in and out of a chair, walk using a walker or crutches, and climb stairs. You will be taught exercises to mobilize and stretch your knee. After your operation, the therapist will work with you for a brief period each day, and you will do your exercises on your own several times a day. You must know how to do these exercises on your own. • When your knee replacement operation is finished, you will be taken to the recovery room. You will be drowsy, and you may not recall much about the operation or recovery room experience. Your family will be able to see you briefly in the recovery room. We recommend that you practice the following exercises before your surgery. You will perform similar exercises after surgery. Perform each exercise 10-15 times. Ankle Pumps: Move your foot up and down slowly feeling a gentle stretch in the calf muscle. This can be performed lying down in bed or sitting in a chair. After operation, this exercise will help prevent a blood clot. Quadriceps Sets/Knee Straightening: With your leg out straight, tighten your thigh muscle and push the back of your knee down into the bed. Hold for 510 seconds. Relax. After operation, this exercise will help gain knee extension. 12 Gluteal Sets: Squeeze your buttocks muscles together and hold for 5-10 seconds. Relax. This exercise can also be done sitting in a chair. Day of Surgery • When you arrive in the recovery room, you will have an intravenous line for fluid replacement. Support stockings or elastic bandages will be on your legs to prevent blood clots. • To control pain after surgery, you will be given medication through an intravenous line or by injection. The next day you will be given pills for pain. • After surgery, some patients will have their operated leg placed in a continuous passive motion (CPM) machine. This machine will flex (bend) and extend (straighten) your knee while you are in bed. • The nurses will give you an incentive spirometer. You will take long, deep breaths with this machine to fully expand your lungs. It is important that you do this at least 10 times every hour, when you are awake. • You may discover that when you were anesthetized, a catheter was passed into your bladder to monitor your urine output. This will be removed on the first day after your surgery. 17 OPERATION AND HOSPITAL STAY Please arrive on time on the day of your operation. You will be admitted to the hospital, and you will dress in hospital clothes. A name band will be placed on your wrist. All jewelry must be removed. Your family will take your personal items. You will see your surgeon and his/her assistants prior to your operation. Your surgeon will mark your surgical site with a marker. Your nurse will record your temperature, blood pressure, pulse rate and respiratory rate. You will be asked to empty your bladder. An intravenous line will be started. Extra blood may be drawn for testing or blood management. Lower Leg Lifts/Short Arc Quadriceps Sets: Place a rolled up towel (approximately 8 inches in diameter) under your knee. Straighten out your knee by lifting up your lower leg and foot. Hold for 3-5 seconds. Slowly lower down placing heel on bed. Straight Leg Raise: Lie on your back. Bend your good leg. Keep your opposite leg straight. Lift your straight leg up 8 inches, slowly lower your leg. Heel Slides: Lie on your back. Slide your heel towards your buttocks (as far as you can go). Slowly straighten your leg. When the operating room is ready, and the operating team is assembled, you will be escorted into the operating room on a stretcher. In the operating room, you will be transferred onto the operating table, where anesthesia will be induced. At this point, your knee replacement operation is ready to begin. Family members who wish to wait at Lahey during your surgery may do so in the Family Waiting Room. Your surgeon will speak with them after your surgery. Otherwise, your surgeon will call a family member or friend after surgery. 16 13 FINAL PRE-OPERATIVE VISIT: DAY BEFORE SURGERY You will have a pre-operative visit with a physician assistant or nurse practitioner who will perform a history and physical, check your tests, review your consultations, and answer questions. You will be asked to sign an Informed Consent document regarding your operation. On the day before your knee replacement, you can eat or drink anything you wish up until midnight. After midnight you must not eat or drink anything unless directed otherwise by your doctor. You will be asked to take one anticoagulation pill (Coumadin) on the night before your surgery. You may have small quantities of water up until two hours prior to your scheduled time of arrival to the hospital. A week before surgery please stop taking all anti-inflammatory drugs. If you are uncertain if your arthritis pain medication is an antiinflammatory drug, please ask your doctor. It is possible to take acetaminophen or Tylenol for pain up until the night before surgery. On the day before surgery, you will be called and told what time to report to Lahey Clinic for your operation. Please leave all jewelry and valuables at home. Your family and friends can bring personal items to you after your operation. Please stop taking fish oil, vitamin E, or ginkgo two weeks before surgery as these supplements can affect bleeding. If you take an immune system modifying drug such as Methotrexate, Enbrel, Remicaide, or Humira, please discuss this with your medical doctor and your surgeon. You will need to discontinue this drug in the peri-operative period. If you take anticoagulation medicine please ask your surgeon if and when to discontinue this drug before your knee replacement. If you get a cold, or the flu in the week or two before your surgery, please notify your surgeon. 14 15 FINAL PRE-OPERATIVE VISIT: DAY BEFORE SURGERY You will have a pre-operative visit with a physician assistant or nurse practitioner who will perform a history and physical, check your tests, review your consultations, and answer questions. You will be asked to sign an Informed Consent document regarding your operation. On the day before your knee replacement, you can eat or drink anything you wish up until midnight. After midnight you must not eat or drink anything unless directed otherwise by your doctor. You will be asked to take one anticoagulation pill (Coumadin) on the night before your surgery. You may have small quantities of water up until two hours prior to your scheduled time of arrival to the hospital. A week before surgery please stop taking all anti-inflammatory drugs. If you are uncertain if your arthritis pain medication is an antiinflammatory drug, please ask your doctor. It is possible to take acetaminophen or Tylenol for pain up until the night before surgery. On the day before surgery, you will be called and told what time to report to Lahey Clinic for your operation. Please leave all jewelry and valuables at home. Your family and friends can bring personal items to you after your operation. Please stop taking fish oil, vitamin E, or ginkgo two weeks before surgery as these supplements can affect bleeding. If you take an immune system modifying drug such as Methotrexate, Enbrel, Remicaide, or Humira, please discuss this with your medical doctor and your surgeon. You will need to discontinue this drug in the peri-operative period. If you take anticoagulation medicine please ask your surgeon if and when to discontinue this drug before your knee replacement. If you get a cold, or the flu in the week or two before your surgery, please notify your surgeon. 14 15 OPERATION AND HOSPITAL STAY Please arrive on time on the day of your operation. You will be admitted to the hospital, and you will dress in hospital clothes. A name band will be placed on your wrist. All jewelry must be removed. Your family will take your personal items. You will see your surgeon and his/her assistants prior to your operation. Your surgeon will mark your surgical site with a marker. Your nurse will record your temperature, blood pressure, pulse rate and respiratory rate. You will be asked to empty your bladder. An intravenous line will be started. Extra blood may be drawn for testing or blood management. Lower Leg Lifts/Short Arc Quadriceps Sets: Place a rolled up towel (approximately 8 inches in diameter) under your knee. Straighten out your knee by lifting up your lower leg and foot. Hold for 3-5 seconds. Slowly lower down placing heel on bed. Straight Leg Raise: Lie on your back. Bend your good leg. Keep your opposite leg straight. Lift your straight leg up 8 inches, slowly lower your leg. Heel Slides: Lie on your back. Slide your heel towards your buttocks (as far as you can go). Slowly straighten your leg. When the operating room is ready, and the operating team is assembled, you will be escorted into the operating room on a stretcher. In the operating room, you will be transferred onto the operating table, where anesthesia will be induced. At this point, your knee replacement operation is ready to begin. Family members who wish to wait at Lahey during your surgery may do so in the Family Waiting Room. Your surgeon will speak with them after your surgery. Otherwise, your surgeon will call a family member or friend after surgery. 16 13 PHYSICAL THERAPY AFTER SURGERY: DAY BY DAY Successful knee replacement requires careful, compulsive rehabilitation. Physical therapy is essential to the success of knee replacement. This schedule presents a sequence of events that usually follow knee replacement operations at Lahey Clinic. Physical therapy will begin the day after your operation. The therapist will teach you to get in and out of bed, get in and out of a chair, walk using a walker or crutches, and climb stairs. You will be taught exercises to mobilize and stretch your knee. After your operation, the therapist will work with you for a brief period each day, and you will do your exercises on your own several times a day. You must know how to do these exercises on your own. • When your knee replacement operation is finished, you will be taken to the recovery room. You will be drowsy, and you may not recall much about the operation or recovery room experience. Your family will be able to see you briefly in the recovery room. We recommend that you practice the following exercises before your surgery. You will perform similar exercises after surgery. Perform each exercise 10-15 times. Ankle Pumps: Move your foot up and down slowly feeling a gentle stretch in the calf muscle. This can be performed lying down in bed or sitting in a chair. After operation, this exercise will help prevent a blood clot. Quadriceps Sets/Knee Straightening: With your leg out straight, tighten your thigh muscle and push the back of your knee down into the bed. Hold for 510 seconds. Relax. After operation, this exercise will help gain knee extension. 12 Gluteal Sets: Squeeze your buttocks muscles together and hold for 5-10 seconds. Relax. This exercise can also be done sitting in a chair. Day of Surgery • When you arrive in the recovery room, you will have an intravenous line for fluid replacement. Support stockings or elastic bandages will be on your legs to prevent blood clots. • To control pain after surgery, you will be given medication through an intravenous line or by injection. The next day you will be given pills for pain. • After surgery, some patients will have their operated leg placed in a continuous passive motion (CPM) machine. This machine will flex (bend) and extend (straighten) your knee while you are in bed. • The nurses will give you an incentive spirometer. You will take long, deep breaths with this machine to fully expand your lungs. It is important that you do this at least 10 times every hour, when you are awake. • You may discover that when you were anesthetized, a catheter was passed into your bladder to monitor your urine output. This will be removed on the first day after your surgery. 17 • You will receive an antibiotic to prevent infection. • You will receive a blood thinner medication to prevent blood clots. • When you are ready, and when your room is ready, you will be transferred from the recovery room to your hospital room. Family members and friends may visit you in your hospital room. Prepare A Hospital Bag: • Personal care items. • Loose, comfortable clothing. • Shorts, sweatpants, t-shirts. • Low-heeled supportive shoes or sneakers with non-skid soles. • “Walkman” type tape/CD/MP3 player if you like music. • Cash for newspaper, snacks, etc. • Credit card for TV/telephone/internet access. • Some patients will spend their first night in the hospital in the recovery room. Postoperative Day #1 • Use your incentive spirometer to expand your lungs. • Several blood tests will be drawn to monitor your recovery. • Your diet will begin with clear liquids. It will be advanced when it is safe to do so. • A bowel regimen including stool softeners will be instituted to prevent constipation. • If you have a bladder catheter, it will probably be removed. • The CPM machine will be advanced to gain motion. • Physical therapy begins: 18 - The physical therapy exercises and the CPM will help the knee to bend. When you are not bending the knee in the CPM or with therapy, it is very important to keep the leg straight. Do not put pillows or blankets under your knee. It is best to put a rolled up towel or pillow under your foot and ankle, to help straighten out your knee. 11 • Get plenty of rest. • Cut back or eliminate alcohol. • Exercise to improve and maintain muscle tone and joint motion. • Develop a positive attitude for knee replacement. Prepare Your Home: • If possible, arrange a one floor living area with kitchen/bed/bathroom to minimize stairs. • Rearrange furniture to enlarge walking paths for crutches or a walker. • Remove scatter rugs. • Make sure all doorknobs are clear and accessible. • Install night lights. • Obtain an apron with pockets or a backpack. Your hands will be using crutches. • Stock freezer and pantry. • Obtain a cordless phone. • Non-skid mats for shower/tub. • Grab bars in the shower/tub, near toilet. • Tub seat. • Raised toilet seat or commode. • Long handle sponge. • Stocking aid. • Long handle shoe horn. • Long handle reacher. Prepare For Hospital Discharge: • Discuss hospital and discharge plans with relatives and friends. • Evaluate the options of home discharge or rehabilitation facility discharge. • Review insurance coverage as it pertains to discharge. 10 - You will begin the exercises which you learned before your operation (Page 12). 1. Ankle pumps 2. Quadriceps sets/knee straightening 3. Gluteal sets 4. Lower leg lifts/short arc quadriceps sets 5. Straight leg raise 6. Heel slides - The therapists will measure the range of motion of your knee. They will note your progress on a wall chart (use the chart on page 22). During the first two weeks after your operation, your most important job is to achieve functional range of motion. Your goal is to maximize flexion (bending) to 120˚ and extension (straightening) to 0˚. - The therapists and the nurses will help you out of bed and into a chair. Hopefully, you can do this two or three times on postoperative day one. During transfers (getting in and out of your bed or chair) you can generally put as much weight on your operated leg as you wish. Weight bearing may be restricted for some patients. • Safety precautions for patients with knee replacements will be discussed. • A case manager will visit with you and your family. Planning for your discharge from the hospital now begins in earnest. 19 Postoperative Day #2 • The dressing on your wound will be changed. • A blood test will be drawn to measure the effectiveness of the blood thinner (Coumadin). This blood test will be drawn intermittently as long as you take Coumadin. • If you are constipated, you may request medications, a suppository, or an enema. • The CPM machine will be advanced to gain knee motion. • Physical therapy continues: - Continue exercises from post-operative day 1. - Your exercises will be advanced by the physical therapist. These exercises will focus on maximizing range of motion of your knee – flexion (bending) and extension (straightening). - Your knee range of motion will be measured and charted. - Muscle strengthening exercises will begin. - Practice transfers. You should be getting into a chair at least two times a day with assistance from the physical therapy or nursing staff. - You will begin walking with a walker or crutches. 20 • The case manager, in discussions with you, your family, your physicians, your therapists, and your healthcare insurance company will finalize discharge planning. Transfer to a rehabilitation hospital will occur on postoperative day three. Discharge to home will be on postoperative day four or five. CASE MANAGER Before your operation, you will be contacted by a Lahey Clinic Case Manager who will help you plan your discharge from the hospital to a rehabilitation facility or to home. Advance planning helps alleviate concerns you and your family may have about what will happen after you leave the hospital. Your health insurance company will have input concerning where you may go after hospital discharge. Speak to your health insurance representative about your options. ANESTHESIA Most patients will meet their anesthesiologist on the day of surgery. He or she will review your medical records and answer questions you may have about anesthesia. If you have a preference for a type of anesthesia, please tell your anesthesiologist. We encourage you to follow your anesthesiologist’s recommendations. If you have a specific condition which requires a pre-operative consultation with an anesthesiologist, please let us know. PERSONAL PREPARATIONS FOR SURGERY Prepare Yourself: • Stop smoking. This will help your breathing, improve wound healing, and reduce postoperative complications. (At least cut back). • Eat well-balanced meals. This is not the time for serious weight loss. • Start taking an over-the-counter iron supplement one month prior to surgery (FeSO4 325 mg three times per day). 9 BLOOD MANAGEMENT Most patients who have one knee replacement will not require blood transfusion. A tourniquet is placed on your thigh to prevent blood loss during the operation. However, you will lose blood into your knee and leg after the operation when the tourniquet is removed. Some patients will require a blood transfusion after knee replacement. Factors associated with a need to transfuse blood include; a low hemoglobin or hematocrit (“low blood count”) before operation, cardiac conditions, medical disease, extensive knee reconstruction, unexpected post-operative blood loss, and bilateral knee replacements on the same day. In some cases, your surgeon may ask you to donate your own blood for possible transfusion – autologous transfusion. This blood is refrigerated and stored until the time of your operation. If transfusion is necessary, you will be transfused with your own blood. In some cases, on the day of your surgery, your anesthesiologist may draw off some of your blood before the operation in order to give it back to you after surgery – hemodilution. In some cases it may be necessary for you to be transfused with Blood Bank blood. Postoperative Day #3 • The dressing on your wound will be changed. • The CPM machine will be advanced to gain knee motion. • If you have been unable to have a bowel movement (pain medicine commonly causes constipation) and you are uncomfortable, please tell your nurse. • Physical therapy continues: - Continue exercises. - Your knee range of motion will be measured and charted. - You should become independent with transfers. You will require less assistance for transferring in and out of bed. - If it is possible, you will practice ambulating with crutches instead of a walker. Your goal should be to walk independently with a walker, crutches, or cane as soon as possible. • If you will be discharged to a post-acute care facility, you will probably be transferred by ambulance today. You will bring a Lahey Clinic Knee Replacement Post-Acute Care Plan with you to the rehabilitation facility. 8 • If you will be discharged to home, the Occupational Therapist will assist you with the performance of everyday activities such as bathing and dressing. They will show you techniques to assist with these activities at home. 21 Postoperative Day #4 ACADEMIC MEDICAL CENTER - Your knee range of motion will be measured and charted. Lahey Clinic is an academic medical center. Lahey Clinic doctors teach residents, students and post graduate fellows how to be doctors and surgeons. Boston University orthopaedic surgery residents train at Lahey Clinic. You will meet the students, residents and fellows as members of the orthopaedic team. Orthopaedic residents and fellows will participate in your operation to help your surgeon and learn about knee replacement. Students and visiting doctors may observe your operation. Your orthopaedic surgeon will do your knee replacement operation. - Continue all motion and strengthening exercises PHYSICAL EXAMINATION/TESTS - Practice independent transfers. Generally, a physical examination by an internal medicine doctor is recommended to ensure that you are healthy enough to undergo major surgery. If you are new to Lahey Clinic, or if you have a primary care physician outside Lahey, please bring a letter from your doctor to your pre-operative visit which describes your past medical history and your current medical condition. Consultation with other medical specialists may also be necessary. Several diagnostic tests, including chest x-ray, EKG, and blood and urine tests may be scheduled. You need to bring a list of all your current medications, including prescription drugs, over the counter medicines, vitamins, herbs, and nutritional supplements when you come for your preoperative visit. An up-to-date medical history which includes current and past health problems, allergies, hospitalizations, and surgeries will be recorded. If you have dental problems, please inform us and seek appropriate care well before your surgery date. Dental infection can lead to knee infection. • The dressing on your wound will be changed. If your wound is dry, it may not be necessary to cover it. • The CPM machine will be advanced to gain motion. • Physical therapy continues: - Practice independent ambulation with crutches/walker. - Practice stair climbing. - Review knee safety precautions. Lahey Clinic Physical Therapy Department ROM DATA GRAPH Degrees 120 110 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 Post-operative Day 22 flexion (bending) extension (straighten leg) 6 7 8 9 10 11 12 13 14 your own motion! ChartChart your own motion! 7 GETTING READY FOR SURGERY LEAVING THE HOSPITAL Once you have decided to have your knee replaced, there is much to do to prepare for your operation. Lahey Clinic provides a team approach to your care. You will have a chance to meet members of the team before surgery. They will answer your questions and make arrangements to insure that your surgery, hospital stay, and post-operative recovery will go as smoothly as possible. To a Rehabilitation Facility SCHEDULING YOUR OPERATION Surgical scheduling is a complex process. Your operation requires you, your surgeon, an anesthesiologist, surgical assistants, nurses, an operating room, surgical instruments, knee implants, and many pieces of equipment to be in the same place at the same time. You will work with a surgical scheduler to select an acceptable date for your knee replacement operation. Please be as flexible as possible in working with your surgical scheduler. INFORMED CONSENT If you choose to go to a rehabilitation facility, and if your health plan approves this choice, you will be discharged on the second or third day after surgery. Your case manager will assist you and your family with discharge plans. You will bring a Lahey Clinic Knee Replacement Post Acute Care Plan with you to the rehabilitation facility. Follow-up with your surgeon will also be arranged. To Home If you are medically stable, independent with walker/crutches/ cane, and knowledgeable in knee replacement precautions, and if you have help available at home, you may choose to be discharged to home. Your case manager will assist you and your family with discharge plans. Physical Therapy at a therapists office or at home will be arranged. You will take pain medication and blood thinners at home. Usually, you will resume your routine medications at home – review these medications with your primary care physician. You will be asked to sign an informed consent document which gives Lahey Clinic and the Lahey Clinic professional staff permission to give you a knee replacement operation. This booklet will teach you about knee replacement so you will be a well informed patient. You will also be asked to give Lahey Clinic permission to collect information about your knee replacement in the Lahey Clinic total joint database. 6 23 IMPORTANT INFORMATION AS YOU LEAVE LAHEY CLINIC INNOVATION, TECHNOLOGY, AND INFORMATION Follow-Up Visits Total knee arthroplasty uses anatomically designed implants made of high grade biomaterials to resurface arthritic knee joints. As new materials, designs, and techniques are developed to improve knee replacement, Lahey knee surgeons evaluate new technology for possible use with Lahey patients. Lahey Clinic orthopaedic surgeons use the best techniques and best implants available to provide predictably successful knee replacement operations. Two Weeks: Usually, your surgeon or his assistant will see you in the outpatient clinic to remove skin staples or sutures two weeks after surgery. If you go to a rehabilitation hospital, they may remove your staples or sutures. Four to Six Weeks: Usually, you will see your surgeon four to six weeks following surgery for a clinical and radiographic examination. Knee Range of Motion It is your responsibility to achieve a full, functional range of motion from 120˚ flexion (bend) to 0˚ extension (straight). Your surgeon, your therapist, CPM machines, and your family will help, but ultimately, each knee replacement patient must achieve knee motion by him/herself. Please do not put pillows under your knee in slight flexion to be comfortable. This will slow your therapy. When resting put your knee in a maximum flexion or maximum extension position. Wound Care 24 Keep your incision dry while staples are in. You should keep a dressing on your wound if there is drainage. If the wound is clean and dry, you can leave it open to air. Look at your wound each day. If you notice signs of possible infection such as: increasing redness, increasing warmth, or new drainage that looks like pus, call your surgeon immediately. If your doctor or nurse want to give you an antibiotic for your knee, please ask him/her to call your surgeon first. Innovations that may be appropriate for some patients include: • modular knee replacement • all polyethylene tibial implant • mobile bearing knee replacement • bilateral knee replacement • minimally invasive knee replacement • computer assisted surgical navigation Information on total knee arthroplasty is available from many sources including the internet and direct-toconsumer marketing programs. Some of this information is accurate and useful. Some of this information is not accurate. Information on clinical services, educational programs, and orthopaedic research in the Lahey Clinic Department of Orthopaedic Surgery is available at www. lahey.org/OrthopaedicSurgery. The Lahey Clinic hospital is a “high reliability organization” committed to patient safety and prudent use of new “cutting edge” technology in caring for our patients. All Lahey Clinic hospital rooms are private rooms equipped with flat screen personal computers which provide knee replacement patients with access to television, radio, games, music, email, and the internet. 5 TYPES OF KNEE REPLACEMENTS Toileting Total Knee Arthroplasty (TKA) Most home toilet seats are low. A commode or raised toilet seat will be helpful. Toilet grab bars may also be helpful. Total Knee Arthroplasty or Total Knee Replacement is the operation described in this booklet. TKA can be a fixed bearing knee replacement or a mobile bearing knee replacement. The goal of TKA is to relieve pain and improve function. TKA is the most common type of knee replacement. Unicompartmental Knee Replacement (UKA) Unicompartmental Knee Arthroplasty or Unicompartmental Knee Replacement resurfaces part of the knee joint. This operation may also be called a partial knee replacement. Either the medial (inside) or the lateral (outside) tibiofemoral joint is resurfaced. This operation is less common than total knee replacement. Minimally Invasive Knee Replacement (Minimal Incision/Less Invasive) A Minimally Invasive Knee Replacement operation (TKA or UKA) is performed through a small incision with less tissue dissection. Some patients are not candidates for minimally invasive knee replacement. Revision Total Knee Arthroplasty Revision total knee arthroplasty is an operation which revises or fixes a knee replacement which has developed a problem such as loosening of fixation, wear of bearing surfaces, fracture, or instability. Bilateral Total Knee Arthroplasty Some patients with two equally symptomatic arthritic knees may be candidates for Bilateral TKA on the same day. 4 Bathing While your skin staples or sutures are in your knee incision, please use sponge baths for personal hygiene. Please do not get your knee replacement wound wet. You may shower or bathe after your skin staples or sutures are removed. Bathing is best done in the shower – getting in and out of a tub can be difficult and dangerous when recovering from knee surgery. Grab bars in the shower/tub area may be helpful. A longhandled sponge, can be helpful for bathing your lower body. Some patients find a tub seat in the shower to be helpful. Be cautious when walking on slippery bathroom floors. Dressing Some patients will need assistive devices in order to dress independently. A stocking aid may enable you to put on your socks without bending over too far. A long-handled shoehorn will assist you in putting on your shoes. Long-handled reachers may assist you in putting on and pulling up your pants. You will be evaluated during your hospital stay for your particular needs at home. Compressive Stockings The white TED stockings should be worn on both legs when you are up during the day. They help control swelling in your legs (especially in your operated leg). At night, you can remove them and launder them, if necessary. 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This operation is one of several non-surgical and surgical options which are available for treatment of your arthritic knee. It is important for you to be familiar with all possible treatments for your knee. Non-operative treatment options for an arthritic knee include: anti-inflammatory medicine, pain medication, physical therapy, weight loss, walking aids such as a cane or crutches, nutritional supplements, injections, and restricting your activities. Many patients with arthritic knees try non-surgical treatment before choosing surgical treatment. Surgical treatments for an arthritic knee include: arthroscopy, osteotomy, fusion, partial knee replacement, and total knee replacement. Each operation has specific indications, and all surgical treatments are not appropriate for all patients. Generally, knee replacement is very successful. Knee pain is relieved, deformity is corrected, and function improves. It is not clear how long a knee replacement will last. The long-term success rate will vary, depending on your age, your weight, and your activity. “Plan on ten to fifteen years and hope for twenty”. If a knee replacement becomes loose or wears out, generally it can be fixed with a revision knee replacement operation. 2 Knee replacement is major surgery. When choosing to have a knee replacement, it is important to be aware of potential risks and complications such as: problems from anesthesia, bleeding, damage to nerves or blood vessels, instability, dislocation, fracture, ligament injury, blood clot, infection, and very rarely, death. GUIDELINES AFTER KNEE REPLACEMENT For your safety, and to ensure a successful outcome following your knee replacement operation, you should adhere to the following guidelines. FOR THE FIRST TWO MONTHS • Push to gain maximum range of motion during the first four weeks following surgery. Knee motion is critical to the success of this operation. • During the day time get up every half-hour or so and take a brief walk. Prolonged sitting may allow muscles around your knee to get stiff. • Avoid slippery surfaces which may allow your leg to give way. • When sleeping, do not place a pillow under your knee. This will prevent you from gaining full extension (straightening) of your knee. Try to sleep on your back with a towel roll under your ankle. • When your surgeon prescribes strengthening exercises, work hard to make your hip and knee muscles strong. 27 A Patient’s Guide to Knee Replacement • Stay active and bear weight on your reconstructed knee. • Airline travel within the first 2 months after knee replacement operation increases the risk of developing a blood clot. Please discuss this with your surgeon. Walking is an essential part of physical therapy. You should take daily walks, lengthening your walking distances as your strength improves. FOR THE REST OF YOUR LIFE Your knee replacement should provide mobility, stability, and pain free function for many years. You can participate in many activities with your “new knee”. However, you should protect your knee replacement from excess stress which can lead to premature failure of the artificial joint. Avoid weight gain which will increase stress on your new knee. High impact loading activities such as jumping, running, jogging, and heavy weight lifting should be avoided. Sports, such as basketball, racquetball, squash, volleyball, and tennis, increase the risk of implant loosening and implant wear. You may choose to participate in these sports, but you must accept the associated risk. Low-impact loading activities such as walking, boating, cycling, swimming, bowling, and golf are excellent activities for recreation and exercise after knee replacement. CONTENTS Choosing Knee Replacement ..............................................2 What is a Knee Replacement? ............................................3 Types of Knee Replacements ..............................................4 Innovation, Technology, and Information ..........................5 Getting Ready for Surgery ..................................................6 Scheduling Your Operation ................................................6 Informed Consent ..............................................................7 Academic Medical Center ..................................................7 Physical Examination/Tests ................................................7 Blood Management ............................................................8 Case Manager......................................................................9 Anesthesia ..........................................................................9 Personal Preparations For Surgery ......................................9 Physical Therapy ..............................................................12 Final Pre-operative Visit ....................................................14 Day Before Surgery ..........................................................15 Operation and Hospital Stay ............................................16 After Surgery: Day by Day ................................................17 Leaving the Hospital ........................................................23 To Rehabilitation Facility ..............................23 To Home ......................................................23 Important Information As You Leave Lahey Clinic ..........24 Follow-up Visits ............................................24 Knee Range of Motion ..................................24 Wound Care ..................................................24 Toileting ........................................................25 Bathing..........................................................25 Dressing ........................................................25 Compressive Stockings ..................................25 Driving ..........................................................26 Sexual Relations ............................................26 Dental Work..................................................26 Infections ......................................................26 Guidelines After Knee Replacement ..................................27 For the First Two Months ..............................27 For the Rest of Your Life................................28 A Patient’s Guide to Knee Replacement Dear Knee Replacement Patient, We hope this Patient Guide to Knee Replacement provides valuable information as you prepare for your knee replacement operation. More information about the Lahey Clinic Department of Orthopaedic Surgery is available at www.lahey.org/OrthopaedicSurgery. Enjoy your new knee! Lahey Clinic Knee Replacement Surgeons (Left to right) Brian J. Jolley, M.D., Stephen E. Lemos, M.D., Richard Iorio, M.D., John F. Tilzey, M.D., William L. Healy, M.D., Richard M. Wilk, M.D., Michael S. Thompson, M.D., Lawrence M. Specht, M.D., Mark J. Lemos, M.D., Bernard A. Pfeifer, M.D. If you have any questions or concerns about your knee replacement operation, please call your Orthopaedic surgeon at Lahey Clinic, (781) 744-8650. Lahey Clinic Department of Orthopaedic Surgery A Patient’s Guide to Department of Orthopaedic Surgery 41 Mall Road • Burlington, Massachusetts 01805 (781) 744-8650 See The Department of Orthopaedic Surgery at www.lahey.org KNEE REPLACEMENT