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Total Knee Replacement (TKR)

This information has been designed to give you a basic understanding of your knee replacement operation and what to expect during your hospitalisation. Please keep in mind that this is a guideline only and that each individual has different needs so you may progress at a different rate to that which is outlined.

Your Orthopaedics SA specialist will be happy to address any questions which might arise after reading this information.

 

A total knee replacement is an operation performed on a knee joint damaged by osteoarthritis, rheumatoid arthritis, accidents or sports injuries. It is carried only after other forms of treatment have no further benefit.

The knee is commonly referred to as a hinge joint. It is a major weight bearing joint that is supported by cartilage, ligaments and muscles that allow it to move smoothly as you bend and straighten your leg.

  • In a healthy knee the cartilage is the material that "cushions" the joint and evenly covers the surfaces of the thigh bone and tibia allowing it to move smoothly. The knee cap is held in place by the muscles and ligaments and helps to protect the joint.
  • In a "damaged knee" the cartilage is worn and the roughened bones rub together causing pain and stiffness.
  • By replacing your problem knee with an artificial knee (prosthesis), all parts will have smooth surfaces allowing for more comfortable movement, symmetrical alignment and less pain.

In South Australia over 1,500 people have knee replacement surgery each year.

The different types of knee replacement

There are many different types of knee replacement available but all have the same basic design.

The knee replacement components are used to resurface the damaged surfaces of the thigh bone, shin bone and sometimes the knee cap. The resurfacing components are secured either by using a bone cement or some components have a special porous surface that the bones grow into giving a "biological fixation". Often one component may be cemented and the other component may have the porous surface. As a result of the resurfacing the knee alignment is restored, pain is decreased and the knee becomes more functional.

The risks involved

  1. Infection – (1-2%) Fortunately, with good surgical technique and the use of antibiotics this is a rare complication but if it does occur it is serious and may result in the need to remove the artificial joint components.
  2. Blood clots – after joint replacement surgery are common. Giving blood-thinning medication that starts the night after surgery, reduces the risk. These clots can rarely break off and go to the lungs leading to severe breathing problems or even death.
  3. Stiffness – (5-10%) In some patients, persistent stiffness is a problem and may require manipulation under anaesthetic.
  4. Loosening – is the major long-term problem but usually is not significant for 10-15 years. Occasionally the knee may loosen earlier than this and may require revision, i.e. removal and replacement with new artificial joint.
  5. Nerve damage – Occasionally nerves that run close to the knee can be bruised, leading to weakness of the toe or foot movements.

Remember

This operation is designed to improve quality of life and is usually undertaken when all other avenues of treatment have failed and the benefits outweigh the risks. It should never be entered into lightly!

Before surgery

Autologous blood

You may be suitable to give your own blood, have it stored and then given back to you during and after surgery. This minimizes the need for having banked blood (i.e. other people’s blood from the Red Cross). Up to 3 pints of blood is collected and the process takes three visits spread over three weeks.

Smoking

If you are a smoker it is advisable to stop smoking or at least reduce the number of cigarettes that you smoke, in order to reduce the risk of chest and circulation problems after surgery. The hospital is a SMOKE FREE ZONE.

Anti-Inflammatory Medication

Anti-Inflammatory medication including VOLTAREN, FELDENE, NAPROSYN, CELEBREX and ASPIRIN should NOT be taken for seven days, prior to your surgery, as they affect the way your blood clots.

Anti-Platelet Medication

Anti-platelet medication including ASTRIX, CARTIA, CLOPIDOGREL (eg. PLAVIX, ISCOVER) and TICLOPIDINE (eg. TICLID, TILODENE) can also affect the way in which your blood clots. These medications should NOT be taken for seven days prior to your surgery.

If you are unsure about your current medications and the possible complications, please speak with your Doctor prior to surgery.

Orthopaedic Liaison Nurse

The Orthopaedic Liaison Nurse will phone you prior to your admission to hospital to arrange a suitable time for you to visit the Pre-Admission Clinic. During this visit the nurse will discuss details of your hospital stay and the recovery process and answer any questions that you or your family may have. To streamline the admission process a nursing history and health assessment will be carried out. The aim of this visit is to provide information that will better prepare you for surgery and to commence planning for your recovery.

  • During your hospital stay, the Orthopaedic Liaison Nurse may visit you on the ward to check on your progress.
  • This service offers ongoing support and assistance as required after discharge from hospital.

The Orthopaedic Liaison Nurse can be contacted at any time if you or your family have any concerns or queries – phone (08) 8267 8267.

Before Hospitalisation

This is a good time to make sure your home will be a safe environment for you, upon your discharge from hospital.

Position furniture to give clear walkways and roll up any rugs, which might cause you to slip.

Put commonly used items within reach in your bathroom and kitchen to prevent you needing to kneel.

It is also a good time to commence some gentle exercises to tone up your muscles, especially the quadriceps. Not all exercises will be possible because of pain or stiffness. You will find examples of some recommended exercises included in this information. Your physiotherapist will advise which of these exercises will be suitable after your operation.

Most hospitals encourage a pre-admission visit to show you the hospital, streamline the admission process and explain the hospital stay.

You are also encouraged to see the Anaesthetist prior to surgery.

You will usually be admitted to hospital on the morning of surgery and will be seen by the Nursing Staff and your Anaesthetist.

Please bring with you any medication that you take regularly and your X-rays, along with your pyjamas, toiletries etc.

Length of stay

The length of hospital stay is usually between 5-7 days. We aim to plan your length of stay and have discharge arrangements in place prior to your admission.

On the day of surgery

The Nursing Staff will:

  • Explain hospital routine and orientate you to your new surroundings.
  • Record your temperature, pulse rate, blood pressure.
  • May shave your knee and wash it with Betadine.
  • Answer any questions you may have.

Fasting

  • You will be required to fast about 6 hours before your surgery. The nursing staff will remind you when to stop eating and drinking.
  • You will be asked to shower about one hour before your surgery and will be given a hospital gown to wear.

The Anaesthetist will:

  • Discuss your medical and surgical history and current medications.
  • Check your heart and lungs.
  • Request that a specimen of your own blood be taken, to be matched and available should you require a transfusion. (You may have donated some of your own blood, but a specimen is still required to check your haemoglobin level).
  • Order your premedication (drugs which are given about an hour before surgery to relax you.
  • May order other tests, eg. Chest X-ray etc.
  • Discuss the type of anaesthetic, eg. general or spinal.

Premedication

A premedication may be given to you in the form of tablets or an injection. This is to relax you and make your mouth dry. Once this is given you will be asked to stay in bed. The nurse call button can be used if you need anything. You will then be put on a trolley and taken to the operating theatre by a nurse and an orderly.

The Operation

The operation usually takes about two hours with some time spent in the recovery room.

After surgery

From the operating room you will be taken to the recovery room where you will wake up and remain for about one hour before returning to your room.

  • You will have an intravenous line in your arm. This is to ensure you receive adequate fluids, intravenous antibiotics and it can also be used to administer pain-relieving medication. Your nurse usually removes this after 48 hours.
  • You will have a large dressing on your knee and there will be a drainage tube. This will drain any excess fluid from your knee and help to keep the swelling down. The nursing staff will also remove this after your operation, at the direction of your surgeon.
  • You may have an oxygen mask on your face.
  • If you are feeling fine, you may commence drinking fluids after about 3 to 4 hours.
  • There will be a monkey bar (self-help pole) above your bed to assist you with movement around the bed.
  • It is important for you to do deep breathing and coughing exercises to enhance lung capacity and circulation.
  • Movement of your toes and ankles is important to promote good circulation while you are confined to bed.
  • Rarely, you may be commenced on a CPM (continuous passive movement) machine, depending on your surgeon’s instructions.
  • The joint is stable immediately after the procedure, but the weakened muscles and soft tissue surrounding the joint require a longer-term program of physiotherapy and exercise to be restored to normal functioning.

Pain Control

During the first few days you will experience some pain. This will be controlled by intravenous or epidural medication for the first 24-48 hours. After removal of the drip, you may require injections and/or tablets. It is important initially, to take the pain relieving medication on a regular basis. This will allow you to exercise and move more freely. It may also be necessary to continue taking pain relief tablets when you return home. The nursing staff or pharmacist will instruct you on appropriate doses.

Mobility

The Physiotherapist will:

Assist you to become mobile again following your operation and teach you specific exercises.

Usually you will stand and begin walking the day after surgery. All the "tubes" are removed by two days after surgery. A physiotherapist will assist you with exercises and walking. The aim is to walk early and often. This minimizes complications.

Your mobility will gradually increase and with it, your independence. Physio continues and once your wound has healed you may go to the hydrotherapy pool with the physiotherapist to perform exercises in water.

Ice

Ice helps to reduce pain, swelling and stiffness. The nurse may apply ice to your knee. You may also apply ice at home by using crushed ice inside a damp towel. Leave the ice on for 15 minutes, then remove for 15 minutes, then reapply for another 15 minutes. This can be applied a few times a day if necessary.

Never apply ice directly to the skin.

Anti-Coagulant

A small injection under the skin of anti-coagulant is usually administered once a day for your stay in hospital. This helps to thin your blood and helps prevent the formation of clots in your legs.

Suture Line

You will have a suture line along your knee that requires a dressing while you are in hospital. The nursing staff will attend to this.

Sometimes you may have sutures that lie underneath the skin surface. These do not need to be removed and will dissolve in about 2 weeks.

Removable staples may be used and removed in about 10 days.

Prior to discharge your nurse will speak to you regarding care of your suture line once you are home. Wash your suture line daily and pat it dry with a clean towel. Avoid using any powders until the healing is complete as they may "clog" the suture line and cause bacteria to grow.

Observe your suture line for any signs of tenderness, redness, swelling or discharge. If you have any problems, contact your Surgeon, Orthopaedic Liaison Nurse or Local Doctor.

Sleep Disturbances

As you might expect, wound discomfort and restriction of position will mean adopting a sleep position which is unnatural for you. This may result in a disturbance to your sleep pattern and/or restlessness.

You may sleep on your side with a pillow between your legs (NOT UNDER YOUR KNEE). Oral analgesia and warm drinks before going to bed may assist in relaxation.

Constipation

Your decreased activity level, limited appetite, reduced fluid intake and some medication may lead to bowel irregularity. You will be encouraged to drink fluids, increase the fibre content of your diet and, if necessary, take mild laxatives.

Sexual Activity

Resumption of sexual activity depends on when you feel comfortable. There are no restrictions if you keep to the guidelines given to you by your surgeon and physiotherapist for your daily activities.

Doctors Appointment

Your surgeon will want to see you about 6 weeks after your surgery. The appointment will be made before you leave hospital by the nursing staff. It is important that you keep this appointment, as your surgeon will want to check on your progress. You will also be able to ask the surgeon questions regarding increasing your level of activity.

Exercises

These exercises are recommended before surgery to help build up muscle tone and during rehabilitation after surgery. You may not be able to complete all exercises due to stiffness or pain. Your physiotherapist will advise which of the exercises are suitable for you after your operation.

Do the following exercises 10 times each and at least 3 times per day.

  1. Gently bend your feet up and down to help circulation in your legs.
  2. Gently bend your knee so that your foot moves along the bed towards your buttocks. A mild stretching over the front of your knee is normal.
    Hold for 5 seconds then relax.
  3. Tighten the muscles on the top of your thigh by pushing your knee down onto the bed. Keep your knee as flat on the bed as possible.
    Hold for 5 seconds, then relax.
  4. With your knee over a bolster, straighten you knee by tightening the muscles on the top of your thigh. Be sure to keep the back of your knee pressed onto the bolster.
    Hold for 5 seconds, then relax.
    NB. DO NOT SLEEP OR REST WITH THE BOLSTER UNDER YOUR KNEE.
  5. Tighten the thigh muscle so your knee straightens. Now lift your leg to 45 degrees, keeping it as straight as possible.
    Hold for 5 seconds, then relax.
  6. Sit with your legs out straight and the operated leg on a rolled towel. The toes and knee of your operated knee should be pointing up. Relax the muscles in your leg and gently push with your hands to straighten the knee as much as you can, without causing pain. Hold for up to 5 minutes.
  7. Bend your knee while sitting on a chair. Gently push your operated leg back with the other leg until you feel a stretch on the front of the knee.
    Hold for 5 seconds.
  8. Sit on a chair so that your operated knee forms a right angle (90 degrees). Tighten your thigh muscle to straighten the operated knee, lifting the foot off the floor. Hold the operated leg straight for 5 seconds and then gently lower the leg.

Discharge advice

This information and instruction is meant to be used as a guide as you return home.

  • Continue with your exercises as described by your physiotherapist.
  • Continue to take short and frequent walks, gradually increasing the distance in a slow progressive manner. This will be based upon your strength and pain level.
  • Allow time for resting – frequently.
  • Do not kneel.
  • Avoid placing a pillow under your knee.
  • Do not drive a motor vehicle until advised by your doctor. (You may be a passenger however).

Call your Orthopaedic Surgeon if you notice any of these symptoms:

  • Increased pain not controlled by medication.
  • Increased redness, swelling or drainage around the incision.
  • Elevated or persistent temperature.
  • Tenderness, redness or swelling of your calf.
  • Chest pains or shortness of breath.

Visits to the dentist

  • If you ever suffer a gum infection or abscess your dentist will need to prescribe antibiotics.
  • This is not necessary for routine dental care – eg. fillings or cleaning.

IF YOU HAVE ANY ADDITIONAL QUESTIONS, FEEL FREE TO CONTACT THE ORTHOPAEDIC LIAISON NURSE. PHONE: (08) 8267 8267

Information regarding your planned surgery

It is in your interest to read this carefully. It concerns what is going to happen to you in hospital. If you do not understand, you should approach your specialist or his secretary, for clarification of any point.

  • If you are not correctly fasted for your anaesthetic, the operation may be cancelled or postponed until you are correctly fasted.
  • If you are taking regular cardiac medications, please do not stop taking them (with the exception of aspirin and anti-inflammatory medication). Take all medications with a sip of water.
  • Please TAKE YOUR X-RAYS TO THE HOSPITAL
  • If you do not understand the nature of the operation or the possible complications of the procedure, you should arrange to again see your orthopaedic specialist.

Accounts

You will be liable for several accounts in relation to your hospitalisation and operation. An account may be received from:

  • The hospital. This will include a bed fee, theatre fee and a fee for any disposable items and surgical implants used in the operation. If covered by Private Health Insurance, you should check your level of cover and the amount of rebate with the Insurance Company and hospital.
  • The anaesthetist. If you wish to discuss the Anaesthetist"s fee, please contact the Practice secretary for his/her name. You can then contact him/her directly.
  • The assistant. An assistant is required for all major cases and some lesser cases. You may find out if an assistant is required from the Practice secretary.
  • The pathologist. If pathology is required. (Not all cases require pathology).
  • The radiologist. You will require an x-ray of your new knee.
  • The physiotherapist.
  • The surgeon’s fee. There is sometimes a difference between the fee charged by the doctor and the amount you can obtain from the Health Insurance Commission or your Health Fund. The difference is the "gap". You should find out if your surgeon is using an "EZI CLAIM GAP" COVER SYSTEM, where the Private Health Fund pay for some or the entire "gap" on your behalf.