Knee Replacement

Preparation

The knee, the largest joint in the body, is a hinge joint consisting of three parts. The lower end of the thigh bone, called the femur, rotates on the upper end of the shin bone, called the tibia, and the knee cap, or patella, which slides in a groove on the end of the femur.

Total Knee Replacement

Common diseases, such as arthritis, can damage your knee bone surfaces and surrounding cartilage, causing great pain and impairing joint function. Total knee replacement can lead to dramatic improvements in your quality of life and health. More than 90 percent of people who undergo total knee replacement surgery experience a significant reduction of knee pain and are able to return to their normal daily activities. However, the decision to have total knee replacement surgery should be made very carefully after consulting your doctor and learning as much as you can about the knee joint, arthritis and the surgery.

Most patients who undergo total knee replacement are between the ages of 50 and 80, although people of all ages successfully undergo this procedure. Recommendations for surgery are based on a patient's level of pain and disability, rather than his or her age. If after undergoing an orthopedic evaluation, you and your surgeon decide that knee replacement surgery is the best possible treatment for you, our team of medical experts will provide you with information on how to prepare for the procedure.

If you would like to learn more about the procedure, please see the illustrated piece on Total Knee Replacement.

Minimally Invasive Techniques for Partial Knee Replacement

In certain cases, arthritis may be localized to a single compartment in the knee. If your surgeon believes that your knee has this type of localized arthritis, you may be a candidate for a partial knee replacement. This type of knee replacement is done through a smaller incision and a less invasive approach, which may result in a shorter hospitalization and earlier return to function following surgery. Your surgeon will discuss these techniques with you if he thinks you might be a candidate for a partial knee replacement.

Medical Evaluation

A few weeks before your procedure, you will need to have a complete physical by your primary care physician to rule out any other medical problems that may interfere with your surgery. At this time, your doctor also will take your medical history and order various tests that must be performed before surgery, such as blood tests, urinalysis,chest X-rays and electrocardiograms (EKG or ECG).

Be sure to tell your orthopedic surgeon about all medications that you are taking. They will then advise you on which medications you should continue or stop taking prior to surgery. In addition, if you develop any kind of infection prior to surgery, such as a cold or the flu, notify your surgeon immediately.

You should be in the best possible health before your surgery. If you are overweight, your doctor may suggest that you lose weight. If you smoke, it is highly recommended that you stop prior to your surgery because smoking can change blood flow patterns and delay healing and recovery.

Seven days prior to surgery, you should stop taking all aspirin or other non-steroidal anti-inflammatory drugs, such as NSAIDS like Aleve, Motrin, Ibuprofen, Advil and Naproxen. You may continue taking Cox-II inhibitors such as Vioxx, Celebrex and Bextra. You may take Tylenol for pain and discomfort.

Blood Donation

Total knee replacement can result in blood loss that may require a blood transfusion. Therefore, it is suggested that you donate your own blood before surgery. If you are unable to donate blood for yourself, your family or friends may donate for you. They must have the same blood type and meet criteria for donation. Otherwise, banked blood is available. Banked blood, which is from volunteers, is screened for viral diseases and is matched to your blood type.

If you are having surgery due to an infected prosthesis, you are not allowed to donate your own blood for surgery. In these cases, you must have family or friends donate blood or receive blood from a volunteer.

Dental Evaluation

Significant dental conditions and problems should be treated prior to surgery. Although uncommon, an infection can occur as a result of these dental procedures if bacteria enter your bloodstream. If necessary, be sure to schedule an appointment with your dentist before your joint replacement surgery to treat any problems you may have.

Insurance

Once your surgery has been scheduled, call your insurance company and inform them of your upcoming procedure. You will need to provide them with the date of your surgery, procedure type and the phone number for our office. You also should discuss what type of post-surgery services, such as rehabilitation hospital care and home physical therapy, as well as equipment, such as a commode and walker, your insurance carrier covers.

Home Preparations

It is recommended that you plan for your return home prior to your admission to the hospital so that you are as comfortable as possible. We recommend that a family member or friend be with you 24 hours a day for the first week. In addition, make sure you have rides planned from the hospital and to all follow-up visits, which will be at three, six and 12 weeks after surgery.

If you have crutches or a walker, bring them to the hospital. If you don't already have walking aids, let us know and we will help you to either rent or purchase these and other recommended devices, such as a raised toilet seat, bedside commode, tub chair and stock aid, at the hospital.

After surgery you will need help caring for yourself at home. Figure out ahead of time who will be able to assist you and talk with them about your concerns. If no one is available to care for you, please let us know and a discharge-planning nurse can help make arrangements for skilled nursing or caregivers to help you at home.

In addition, arranging meals that can be stored and frozen and stocking up on prepared foods will eliminate extra work for your caregiver. It also is highly recommended that you organize your home with safety features to prevent accidents. These include making pathways in crowded areas, eliminating all throw rugs, securing extension cords and telephone cords strung across the floor, securing handrails in your bathtub and stairways, and placing all needed items at a level so that you can easily reach them. You also should be sure that your house is equipped with the following:

• Raised toilet seat
• Stable shower bench or chair for bathing
• Long-handled sponge or shower hose
• Reaching device that will allow you to grab objects without bending your hip
• Firm pillows to sit on that keep your knees lower than your hips

Pack a small suitcase for your hospital stay that includes a list of all medications you are taking, personal hygiene items, comfortable and loose clothing, a knee-length robe and slip-on shoes. Please leave all of your valuables, including jewelry, wallet and watches, at home. It is not necessary to bring your actual medications, however do bring a list of your medications and their dosages, as the hospital will provide you with your medications. Also, we recommend you to bring a phone card.

The Day Before Surgery

Our hospital staff will call to notify you of your surgery and scheduled admission times. You may not eat or drink anything after midnight the night before your surgery. Please take a shower or bath and wash your body thoroughly. Try to rest and go to bed early.

Procedure

In total knee replacement surgery, the damaged bone surfaces and cartilage are removed and replaced with artificial surfaces made of metal and a plastic material. These surfaces are called "implants" or "prostheses" and restore the alignment and function of your knee.

Typically, a total knee replacement takes about two hours. For a complete overview of this procedure, please see the illustrated piece on Total Knee Replacement.

You will be admitted to the hospital on the day of your scheduled surgery. You will be asked to arrive to the hospital two hours before the start of your surgery. After admission, you will move into the pre-operative area where you will be evaluated by an anesthesiologist. The most common type of anesthesia is general, in which you are given anesthesia through an intravenous (IV) drip that keeps you asleep for the entire surgery. Your anesthesiologist also may offer you an epidural or spinal injection or a combination of the above. You will discuss this with your anesthesiologist prior to your surgery.

Computer Assisted Surgery

Our experts are trained in computer-assisted orthopedic surgery, which uses special cameras and intra-operative imaging tools that project images of the area being operated onto a television screen. On-screen prompts help guide surgeons to the ideal alignment of the implant and provide real-time vision of the surgical site. High-precision alignment may extend the long-term survival of the implanted artificial hip or knee, thus reducing the need for future corrective surgeries. UCSF Medical Center surgeons are currently involved in studying these new technologies to determine their impact on total knee replacement.

Recovery

After surgery, you will be moved into the recovery room where you will stay for several hours. During this time, you will be monitored until you awaken from anesthesia, at which time you will be taken to your hospital room. Typically, you will stay in the hospital for three to four days, but this depends on each individual and how quickly they progress. After surgery, you may feel some pain that will be managed with medication to make you feel as comfortable as possible. To avoid lung congestion after surgery, you should breath deeply and cough frequently to clear your lungs.

Possible Surgical Complications

The rate of medical complications following knee replacement surgery is extremely low. Serious infections, such as a knee joint infection, occur in less than 2 percent of patients. The most common cause of infection occurs when bacteria enter the bloodstream during dental procedures, urinary tract infections or skin infections. After your surgery, you should take antibiotics before having any dental work or surgical procedures performed.

Physical Therapy

Walking and knee movements are very important for recovery. Usually the first day after surgery, you will begin to work with a physical therapist who will teach you specific exercises to regain full leg and knee movement. During your hospital stay, you will attend physical therapy one to two times per day. An occupational therapist and nurse discharge planner also will help you prepare for your homecoming.

Your doctor may recommend using a continuous passive motion (CPM) machine that is strapped onto your operated leg and then bends and straightens your knee for you. You will probably be given special elastic stockings, called TED hose to be worn on your operated leg that helps to reduce swelling. An anticoagulant medication, such as lovenox, also may be given to help circulation and prevent blood clots.

Post-Hospital Care

Once you have returned home, it is very important to follow your orthopedic surgeon's instructions during the first few weeks after surgery.

• Caring for Your Incision -- You will have stitches or staples running along your wound or suture beneath your skin on the front of your knee. These will be removed two to three weeks after your surgery. Call your surgeon immediately if your incision swells, drains, becomes reddened or painful, or you develop a temperature over 101 degrees Fahrenheit.

  Before leaving the hospital, your incision will be covered with a dry dressing. You should change the dressing as instructed and avoid getting it wet until your wound has completely healed.

• Physical Activity -- Being physically active is an essential part of recovery. Within three to six weeks, you should be able to resume most normal physical activities of your daily routine. During the first few weeks of recovery, a physical therapist may teach or help you perform specific exercises to strengthen your knee and leg. Other recommended physical activities include graduated walking and normal household activities to increase your mobility. However, it is important that you do not push yourself and avoid falling, which can damage your knee and require further surgery. It is recommended that you use assisting devices, such as a cane, crutches, walker and hand rails, or the help of caregiver until your knee is strong and mobile.

  Six weeks after surgery, when you regain full hip movement, you can probably resume driving. At this time, your surgeon also may allow you to return to work, depending on how much physical activity is involved in your occupation. Sexual activity can be resumed at this time as well.

• Follow-Up -- During the first year following your surgery, routine follow-up visits are scheduled with your orthopedic surgeon. Your follow-up appointments will be at three weeks, six weeks, three months, six months and 12 months after your surgery. You will be asked to return for annual visits thereafter to assess the status and function of your implant.