Patient’s Guide to Knee Replacement
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What is Total Knee Arthroplasty?

A total knee arthroplasty (TKA) is a surgical procedure in which the knee joint is replaced. During the surgery, the ends of the thigh bone and shin bone are  removed and replaced with an artificial prosthesis.

Frequently, severe arthritis can cause joint stiffness, pain and limited range of motion. These problems may get progressively worse and eventually interferes with a person's ability to function normally. When this occurs a total knee arthroplasty may be needed.

Following surgery, most patients experience significant pain relief and regain near normal movement in the joint. Usually, people who have a total knee  arthroplasty regain the ability to perform their normal activities of daily living.

Getting Ready for Surgery

Before surgery, your doctor may ask you to get a general physical exam or special pre-operative tests. This may include a chest X-ray, blood work, EKG of  your heart, or X-rays of your knee.

Medications

It is very important you tell your orthopaedic surgeon all of the oral and injectable medications you are taking, including vitamins, herbs and over-the-counter medications. There are some medications that must be stopped before surgery. You will receive a phone call from the pre-admission testing office approximately one week before your surgery to review the medications you should stop prior to surgery and to discuss when they should be stopped.

Donating Your Own Blood

You may donate your own blood for use during the surgery. If you are interested in doing so, talk with your orthopaedic surgeon for more information. Your blood donation must occur four to six weeks prior to surgery in order for the blood to be  processed and ready.

Diet

The doctor may encourage you to diet if you are overweight. Extra weight can put stress on your new joint. You should eat well-balanced meals for nutritional purposes and drink at least six to eight glasses of water a day.

Smoking

It is highly recommended that you stop smoking prior to surgery because it inhibits your ability to heal timely and properly.

Items to Bring with You to the Hospital

• Medications in their original bottles should be brought in the day of surgery. Once your medications are verified a decision will be made regarding when medications can be returned home.

• Comfortable, loose fitting clothes and supportive footwear will be needed for therapy sessions.

• We also ask that vou leave valuables at home as Sinai-Grace Hospital cannot be responsible for personal items.

Pre-Surgery Activity

You should strive to maintain an active lifestvle right up until surgery. If you currently exercise continue your routine. The more fit you are before surgery, the smoother your recovery will be.

Getting Your Home Ready for Surgery

Preparing your home before surgery will make recovering much easier. Consider the following safety tips:

Throughout Your Home

• Be aware of uneven surfaces. If possible make walking surfaces level.

• Remove throw rugs.

• Secure extension cords.

• Make sure lighting is good. Install night lights in the bathroom and hallways.

• Place emergency phone numbers by the phone.

• Choose footwear that is secure on your feet with non-skid soles.

• Place clothes and items needed in drawers at least waist high.

• Get a comfortable chair with armrests and a firm seat.

In the Kitchen

• Replenish your food supply and prepare some meals prior to your surgery.

• Store items within easy reach in cabinets and refrigerator.

• Use a Lazy Susan for easier reaching.

• Have a chair with armrests available to sit in at meals or when you are tired.

In the Bathroom

• Place a non-skid surface in the tub and showrer.

• Use a tub seat and a hand-held shower spray (optional).

After surgery, the Sinai-Grace rehabilitation staff will advise you of any additional equipment you may need for your specific circumstances.

Discharge Planning

You will be best prepared to return home if you start making plans for your discharge now. First, arrange for someone to take you home from the hospital. Usually, patients leave two or three days after surgery. Second, realize you may need help with the following:

• Activities of daily living (i.e.: bathing, dressing)

• Shopping            

• Transportation

• Meals 

• Laundry

The hospital stay is generally two to three days, but recovery will take longer. Arrange for family or friends to assist you with these daily necessities while you recuperate. Most patients having joint replacement surgery require continued physical therapy after discharge from the hospital. The DMC has a comprehensive  rehabilitation outpatient program through the Rehabilitation Institute of Michigan. You will be provided a prescription for outpatient therapy upon discharge from the hospital.

In the event you are unable to attend outpatient therapy immediately after discharge, arrangements will be made to provide home nursing and physical therapy services.

The Dav Before Surgery

It is important to follow the four instructions below prior to surgery:

• Do not eat or drink after midnight (unless you were told to take vour medications before coming to the hospital in the morning).

• Take a mild laxative the day before surgery if you have not had a bowel movement

• Take a bath or shower at bedtime or early in the morning with an antibacterial soap.

• Do not smoke three days prior to surgery.

Your surgery may be postponed if you develop any of the following:

• Fever

• Sore throat or upper respiratory infection

• Oral or dental problems

• Frequent urination or burning with urination

• Skin infection or insect bites that won't heal

Please call your orthopaedic surgeon if you develop any of the above signs.

The Day of Surgery

When you arrive at the hospital, a greet will meet you in the lobby on the first floor near the elevators. After registering, you will be escorted to the Pre-op Holding Area on the ground floor. This is where you will get ready for surgery.

• You will be asked to put on a hospital gown, take off all jewelry and take out your dentures. Please leave your valuables at home.

• An intravenous (IV) line will be started to give you fluids and medicine you need during surgery.

When the surgery team is ready, you will be taken by a stretcher to the operating room.

• The surgery team will hegin hy giving you medicine that will make you sleepy.

• An incision (or cut) will be made over the knee.

• Any damaged bone will be removed.

• The new joint is put into place.

• A drain may be placed by your joint and the incision will be closed with staples or sutures.

• A dressing is placed over the incision and you will be taken to recovery where you will stay for several hours.

• When the anesthetic begins to wear off and you start to become alert, you will be taken to your room.

The surgery will last approximately one and a half to two hours. Your orthopaedic surgeon will talk to your family after the surgery to update them on your condition.

After Surgery

Breathing Exercises

It is important to begin taking deep breaths and coughing after surgery. These simple exercises should be done every hour while you are awake. This helps to  prevent serious illness, such as pneumonia. You will also have an Incentive Spirometer to encourage deep breathing. You should perform 10 breaths on the Incentive Spirometer every hour. The nurse will assist you, if needed.

Managing Your Pain

An anesthesiologist will discuss the variety of pain management systems available with you in detail on the morning of surgery. Some of the different types of pain medications/systems include:

Patient-Controlled Analgesia (PCA)

With this system, you may receive a continuous dose of medication and be able to give yourself booster shots through your IV when you have pain. You do not  need to worry about giving yourself too much medicine because there is a lockout feature that prevents you from giving too much medicine.

Patient-Controlled Epidural (PCE)

An epidural (similar to an IV) is placed in your back to allow for small continuous doses of pain medication through your back. This system can also have a  continuous dose and/or booster shots. There is a lockout feature on this system too.

IV Medication

If you do not have a patient-controlled system, medication can be given through your IV when you ask for it.

Femoral Nerve Block

This block involves the application of a local anesthetic to the femoral nerve, which is located in your groin. This will reduce pain and sensation in the  operative leg. The anesthetic would be applied in the pre-operative period before your surgery takes place.

 It is normal to feel pain after surgery, but rest assured it can be controlled. It is also normal for pain medication to make you feel sick to your stomach. If this happens, tell vour nurse or doctor so you can get something to help  decrease the nausea. As you start to feel better, you will start to take pain medications by mouth.

Diet

Usually, the first meal you get after surgery will be soft foods like gelatin, ice cream and liquids. As soon as you are feeling better, you can eat solid foods. If you were on a special diet before your surgery, talk to your orthopaedic surgeon  about continuing it after surgery.

Preventing Blood Clots

To improve blood circulation and decrease the risk of blood clots, you will be asked to wear foot pumps on both legs. Foot pumps inflate and deflate with air  to compress your feet and help circulation. Wiggle your toes and pump your ankles up and down every hour. You may also be given medicine to thin your blood. Your nurse will tell you which medication you will be taking.

Incision Care

After surgery, you will have a large dressing over your incision. This will be taken off in a day or so. The doctors and nurses will be checking your  incision regularly for drainage and signs of infection. You may have a drainage tube placed in your joint during surgery. This will be removed a couple days after surgery.

Foley Catheter

There will also be a foley catheter in your bladder to monitor how much urine your body is making. This will usually be removed in a day or two.

Starting to Move After Your Surgery

• You may move in the bed to reposition yourself.

• A machine called a continuous passive movement (CPM) may be placed on your leg. This machine will slowly bend and straighten your knee to begin increasing the motion in your joint.

• A trapeze bar will be placed over your bed. This will help you to move more easily in bed.

• The day of or the day after surgery you will begin your rehabilitation. This will include physical therapy and possibly occupational therapy. You will be expected to get out of bed, and begin walking as soon as possible.

Physical Therapy (RT.)

• A physical therapist will be by to start treatment the day of surgery or the morning after surgery.

• You will have physical therapy twice a day.

• In physical therapy, you will begin learning how to get out of bed, walk with a walker or crutches and begin exercising your new knee.

• The amount of weight that you can put on your knee depends on what your orthopaedic-surgeon recommends and the type of surgery you had. Your physical therapist will help to remind you of your weight-bearing status.

Occupational Therapy (O.T.)

• If necessary, an occupational therapist will see you and instruct you in the use of specialized techniques and tools to perform bathing, dressing, home management and other activities of daily living with your new knee.

• Occupational therapists may also help you to arrange the purchase of any specialized medical equipment you may need after discharge. The specialized items may include a raised toilet seat, shower chair or reacher.

When at home, follow these instructions:

• After a shower, dry and clean your incision.

• Keep your incision clean and dry throughout the day.

• Watch for signs of infection, including redness, tenderness and swelling.

• Make sure you take all medication as directed. Call your orthopaedic surgeon if your medication is not working well.

• When you are lying down, elevate your leg above the level of your heart to decrease the swelling and ease the pain. However, do not use a pillow or other support directly under your knee; any support used needs to be under the whole leg or just the heel.

• Do not drive until you are fully recovered and your doctor has permitted you to do so.

• Pain medications may cause drowsiness. Do not drive or operate machinery.

• You should continue to perform your Home Exercise Program as instructed by your physical therapist.

Call your orthopaedic surgeon if you have any of the following:

• Fever - temperature higher than 101 degrees Fahrenheit

• Increased pain in your leg

• Redness, swelling or drainage from your incision

• Numbness or pins and needles in your leg

• Pain in the calf

• Questions about medications, the amount of activity or follow-up care

Follow-Up Visit

You will follow up with your doctor about two weeks after your surgery. The orthopaedic surgeon will check your knee and see how you are doing. If you have any questions about activities you would like to start doing, such as swimming, golfing or driving, please talk to your doctor before beginning  them.

Everyone knows good dental health is important. But for people with artificial joints, a visit to the dentist can be especially significant. The bacteria  that causes infection in the teeth or gums can easily travel through the bloodstream and settle in the artificial joint which can cause even more problems  than a toothache.

Representatives from the American Dental Association and the American Academy of Orthopaedic Surgeons developed the recommendations belo\v for people with  joint replacement who are planning to have some dental work done. Because there is little data on this topic, these recommendations are guidelines only.  Working together, your dentist and your orthopaedic surgeon will determine an appropriate course of treatment for you.

Preventative Antibiotics

You won't need to get preventative antibiotics for most dental procedures, but because you have an artificial joint, your risk of contracting a blood-borne infection is higher than normal. Therefore, preventative treatment is advised if the dental procedure involves high levels of bacteria.

Preventative antibiotics are recommended before dental procedures if:

• You have an inflammatory type of arthritis such as rheumatoid arthritis or systemic lupus erythematosis.

• Your immune system has been weakened by disease, drugs or radiation.

• You have insulin-dependent (Type 1) diabetes.

• You had a joint replacement less than two years ago.

• You had previous infections in your artificial joint.

• You are undernourished or malnourished.

• You have hemophilia.

It is also recommended to get preventative antibiotics for the following dental procedures:

• Dental extractions

• Periodontal (gum disease) procedures

• Dental implant placement and re-implantation of teeth that were knocked out

• Endodontic (root canal) instrumentation or surgery

• Initial placement of orthodontic bands (not brackets)

• Injection of a local anesthetic into the gums near the jaw

• Regular cleaning of teeth or implants where bleeding is anticipated

These guidelines are designed to help doctors and dentists make decisions about preventative antibiotics for dental patients with artificial joints. It is  not a standard of care or a substitute for the practitioner's clinical judgment, because it is impossible to make recommendations that would cover everv  situation. Practitioners must exercise their own clinical judgment in determining whether or not preventative antibiotics are appropriate.

Your New Knee        

Taking care of vour new knee will allow vou to return to a functional lifestyle. If you have any questions or concerns regarding the type of physical activity your new knee can endure, talk with your orthopaedic surgeon. You should be able to enjoy your new knee for many years to come. In the event that vou receive a metal component in your joint replacement, vou will receive a wallet identification card during your post-op visit with your  orthopaedic surgeon. This card identifies the exact metal component you received. You will be able to present it if you activate a metal detector in a store  or airport.