What to Expect

A Patient Guide
If you have been scheduled for total knee replacement surgery, there are certain things that will happen both pre-operatively and post-operatively of which you should be aware.

Normally, your surgery will take place approximately 4-6 weeks from the time of scheduling. During this time, you will be busy; you will have blood tests, urine tests, x-rays and possibly some special scans. If you are over 40 years of age, you normally will also require a chest x-ray and
Electrocardiogram. These tests will be ordered either by your surgeon or can be performed by your internist.

You will be asked to donate your own blood pre-operatively so that it may be given back to you during and after surgery. This is extremely helpful in avoiding transfusion reactions. Your surgeon will inform you whether you are a candidate for this procedure (called "autologous blood donation"). If so, arrangements will be made at a local Blood Bank to donate blood approximately once per week. A total of 2 units are usually requested.You will be given a prescription for iron pills to help you replace the blood that is taken.

You will need to have a complete history and physical examination performed by an internist or family practitioner. This can either be your own private physician or one that your surgeon recommends. It is usually best if this physician has privileges at Sutter General so that he/she can be available to manage any medical problems that may arise after surgery. The purpose of this visit will be to determine if you are medically able to undergo the surgery. Some additional consultations may be required from other specialists such as cardiologists, pulmonary specialists. and anesthesiologists. These will also be arranged prior to your surgery if they are needed.

2. The Pre-Op Visit
Within one week prior to your surgery you will return to see your surgeon. During this visit he will review all of the laboratory data and consultations from other physicians to ensure that all is well for the surgery. He will also perform his own physical examination. Some laboratory tests will need to be repeated at this visit. Also during this visit your surgeon will obtain your consent for surgery. This will involve reviewing the potential benefits, risks, and alternatives to the planned treatment.

3. Admission To The Hospital
Usually, you will be admitted to the hospital the morning of your surgery. If you are from outside Sacramento (greater than 45 miles) and you are scheduled as the first case of the day, you have the option to be admitted at 8:00 p.m. the evening before. This is extended as a courtesy by the hospital (they are not paid for this) and therefore is subject to bed availability.

If you live within the Sacramento area, or you are scheduled as a second or later case, you will be admitted the morning of surgery. Whether you are admitted the night before or the morning of your surgery, there is little time available before surgery begins.

This means that the pre-admission procedures must be arranged as an outpatient at Sutter General Hospital; this is done through the Sutter Testing Service. You will visit the service within one week of your surgery. Normally this is done on the same day as your pre-operative visit with your surgeon. Appropriate lab tests will also be done on this visit to Sutter Testing Service.

Regardless of whether you are in the hospital or at home the day before surgery, you should take a shower and use a laxative suppository which will be given to you at the preoperative office visit. It is important to clean out the lower bowel prior to surgery because initially after surgery the bowels do not function normally and you usually will not have a bowel movement for several days. Therefore to avoid constipation and impaction, it is important to use a suppository before surgery. The morning of surgery you should also take a shower. This will help to decrease the bacterial count on your skin at the time of surgery. The blood thinner pill(s) also given to you at the pre-op visit should be taken the evening before your surgery.

4. Just Prior Surgery
If you are the first case, you will be taken to the pre-op holding area in surgery between 6:30 and 7:00 a.m. If you are the second or later case, you will be taken there approximately one hour prior to your scheduled surgery. When you arrive in the operating room area, you will be seen by the anesthesiologist and an intravenous line will be started in your arm.
The type of anesthetic to be used is a joint decision between yourself, your surgeon, and your anesthesiologist. Usually, a spinal anesthetic is recommended. This will numb you from the waist down. This type of anesthesia is advantageous because it decreases blood loss at the time of surgery and also decreases the chance of clots forming in the large veins. Narcotic pain medicine can also be placed in the spinal which will provide pain relief for up to 18 hours following the procedure. This provides excellent pain relief but does not cause sedation or addiction. In addition to the spinal anesthesia, it may also be necessary to use general anesthesia if the planned surgery is longer than 3 hours. If the spinal alone is used you will be given sufficient sedation to allow you to doze through the procedure but you will be arousable.

5. In The Operating Room
Following the pre-op holding area, you will be taken to the operating room. After induction of spinal and/or general anesthesia, the leg will be prepared with sterilizing solution and the surgical drapes applied. A pneumatic tourniquet will be applied to your upper thigh and inflated during surgery to decrease blood loss. A urinary catheter will be placed into the bladder. The surgery itself takes between two and four hours depending upon the complexity of the surgery. Counting the time for induction and emergence from anesthesia, this usually represents a total time of three to five hours.

6. Immediately after Surgery
After surgery, you will be taken to the recovery room where you will gradually become more and more awake. From the recovery room you will go to the orthopaedic floor. Occasionally, one or two days is required in the intensive care unit because of pre-existing medical problems such as heart or lung disease. When you are fully awake, you will be aware of the fact that you have a dressing on your entire leg from the toe up to the groin. Coming out of the dressing will be one or more drains which will be left in place for two to four days.

7. The Post Operative Hospital Stay
On the first or second postoperative day, your knee will be placed in a continuous passive motion (CPM) device which slowly moves the knee through a range of motion. The physiotherapist will help you out of bed and you will stand at the bedside for a few moments. If you feel up to it, several steps may be attempted only touching the toes down to the floor on the operative leg. The therapist will also instruct you on certain exercises to perform in bed.

The most important of which will be trying to achieve full extension of the knee. To prevent problems with the lungs postoperatively, you will be given an "incentive spirometer", an exercise machine for your lungs which you should use at least once on hour while you are awake in the first 24 to 36 hours after surgery. This helps you to reinflate your lungs and avoid pneumonia.

On the second or third postoperative day, you will begin walking, using a walker or crutches, putting only 10% of your weight on the operated leg, taking most of your weight on the walker or crutches and the opposite leg. Each day you will progress farther and you will begin to work on getting in and out of bed by yourself, sitting in a chair and arising, as well as using the bathroom or bedside commode.

8. Learning Activities of Daily Living
Initially, after surgery you will most likely have a catheter in your bladder so that urination will not be a problem. After this is removed, however, and for bowel movements, you will need to use either a bedpan or the bathroom with an elevated toilet seat. Occasionally, a bedside commode may be necessary. By the end of six or seven days, you will become independent getting in and out of bed, using the bathroom and performing routine activities of daily living. In addition to the physical therapist, an occupational therapist and the nursing staff will work with you on these functions. The key to going home is being functionally independent, having a dry, well healing wound with no temperature elevation and adequate pain control using oral medication.

9. Going Home From The Hospital
Several days prior to release, you will be contacted by the Discharge Planner. Careful preparations must be made for going home. Prescriptions will be written for a "reacher", "sock-cone" and a long-handled shoe horn. Although you will be independent with most activities of daily living when you leave the hospital, it is important that you not be alone for the first two weeks. During this period of time, it is extremely helpful to have someone help prepare meals, clean the house and get you some of the things that you will need. It is not necessary that this person be medically trained.

If further physical therapy is required, this will be arranged and a physical therapist will visit your house. Also, visiting nurses can be arranged if necessary.

Occasionally it may be necessary to spend a short time in a rehabilitation hospital if progress with physical therapy is slow or other medical problems require more nursing care, or if you live alone and friends or family are not available. Special orthopaedic rehabilitation units at several facilities are available. Private insurance, Medicare or Medi-Cal usually pay for such services.

For the first six weeks, you will be limited in your activities. You may go out for short walks (less than a block) and short rides in the car, but most of the time you should spend recuperating. You will not have regained sufficient strength until at least six weeks to twelve weeks after surgery. Therefore, it is unwise to plan any large trips or outings during this period of time.

Riding in the car presents some difficulties. We would suggest if you have a large vehicle, you should ride in the front seat with the seat all the way back. An alternative, especially in smaller cars, is to use the back seat and sit crossways. You should not plan on driving until at least six weeks after your surgery.

10. Post Operative Office Visits
Normally, your sutures will be removed 10 days to two weeks after surgery. It will either be done by a visiting nurse, or by your referring physician. The first "official" postoperative visit will be at six weeks after your surgery, at which time you will have x-rays taken. Depending on the type of surgery, you may not be allowed to put more than 10% of your weight on the operative leg until six weeks after surgery. Your surgeon will inform you at the six week visit what restrictions can be changed and how much weight you will be able to bear on the limb.

By three months after surgery, you will usually be strong enough to resume most normal activities. Normally, 75% of the strength is gained by three months, 90% by six months and 100% by one year after surgery.
Routine post-operative visits and x-rays are at six weeks, three months, one year, two years and then every other year. It is very important that you continue to have the knee checked at least every other year for the rest of your life. Plans to return to work can be made at your three month visit. Usually, you are off work between three to six months.

11. Living With Your New Knee
Exercises such as swimming and bicycle riding are encouraged. Walking a reasonable amount (less than a mile) is also a good exercise. You should wear shoes that have a cushioned heel to avoid impact loads on the knee while walking. Impact loading activities such as tennis, racketball, jogging and jumping or lifting heavy objects (greater than 20 lbs) are to be avoided.

12. Prophylactic Antibiotics
Without appropriate precautions it is possible for bacteria from the bloodstream to settle in the knee joint causing an infection after a total knee replacement. Patients with dental infections have been known to have the infection spread to their knee joints. Similarly, infections elsewhere in the body can also spread to the knee. In addition, manipulation of areas that are known to have bacteria can also cause bacteria in the blood stream. Any dental procedure that causes some bleeding of the gum can result in bacteria in the blood stream. Therefore, it is wise to take prophylactic antibiotics before and after these procedures.

Similarly, any procedures on the bowels or bladder also require prophylactic antibiotics. The usual prescription for dental procedures is Amoxicillin 3.0 gm one hour before and 1.5 gm 6 hours after. If you are allergic to Amoxicillin, an alternative can be ordered. Simple mention of the fact that you have had a total knee replacement will usually alert your doctor or dentist, and they will take the appropriate action.

13. Summary
In summary, lots of things are going to happen both before and after your surgery. By reading this, we hope that you will be prepared for some of these things. Hopefully, this will generate some questions. Please ask your surgeon or any of the staff. Please remember that the goal of the surgery is to relieve pain and to restore function so that you should be able to perform the routine activities of daily living. Your knee will never be "normal" again, but it should give you a significantly improved level of function and pain relief as compared to your pre-operative status.