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Total knee replacement

Welcome

At Mater Hospital Brisbane, we understand that being hospitalised can be a very stressful experience. In keeping with our Mission to offer compassionate, quality care that promotes dignity whilst responding to patients' needs, this booklet aims to alleviate some of your concerns. It explains the general day to day events that may occur during your visit and the things to expect when you are discharged from the hospital.

It is, however, only a guideline as each person may require differing treatments.

If you have any questions about your treatment please speak to your doctor or nurse. Our pastoral care team offers a caring support network to all patients. The dedicated members of this team will visit you during your stay and are available at your request to discuss any anxieties or problems that you may have.

What is a total knee replacement?

kneeWith a total knee replacement operation, a prosthesis replaces the damaged knee. The knee has usually been damaged by arthritis.

No implant can make your knee feel totally normal again, but in most cases the operation will help to:

  • decrease pain
  • decrease stiffness
  • improve your ability to get around and to perform tasks.

The knee joint is a hinge joint, formed by thigh bone (femur) and the shin bone (tibia). Usually the surfaces of the bones are covered with a smooth coating (articular cartilage). When arthritis occurs this coating wears away. The joint surfaces become rough, which causes pain and stiffness.

A total knee joint replacement operation removes the damaged areas of bone and replaces them with metal and plastic parts.

Surgery complications and risks

You could end up with an infection

Despite every possible precaution, including the use of antibiotics during the operation, infection occurs in approximately one per cent of knee replacements. Infection is a major potential complication, and may need further surgery and hospitalisation. This would severely affect the success of your operation.

You could develop blood clots

  • The risk of blood clots occurring in the deep veins of the leg is more than 20 per cent.
  • Risk is reduced through circulation exercises and medication. The risk of a clot travelling to the lungs (pulmonary embolism) is approximately one per cent and may be fatal.
  • Total knee replacement is major surgery and there is a small risk of heart attack or other generalised medical problem.

You could have problems with the anaesthetic

  • Problems can occur, but serious problems are very rare.
  • Most knee replacements are done under a spinal and/or epidural anaesthetic with a light general anaesthetic. If you have had previous problems with an anaesthetic please tell your surgeon or the preadmission nurse.

Your new knee could fail

  • Your new artificial knee will slowly wear out and/or loosen. A revision joint replacement may then be required. Your hip could also dislocate. Breakage of the artificial hip joint is possible, but rare. If this happens a second operation will be required. Other reasons your knee may fail are instability and painful, stiff artificial knee.

There may be other complications

  • Many other complications are possible but the risk is only around two per cent. These include nerve injury, vessel injury, superficial infection, haematoma and others. These are not life threatening and generally are treatable. During the operation, problems may occur with weak bone breaking or nerve injury. These can usually be overcome with appropriate treatment. You may wish to discuss these with your doctor.

Anaemia due to blood loss during your operation

  • A blood transfusion may be needed during or after your operation. This is rare.

Home visit by the DART occupational therapist

The DART occupational therapist may visit you in your home before your operation depending on your identified needs and where you live. This is to ensure that your home environment is optimal for when you return home. They will phone you to make an appointment at an appropriate time if necessary. The occupational therapist will have some suggestions about preparing your house for when you come home from the hospital to maximise your safety and independence.

Specific preparation for total knee replacement surgery

Diet, nutrition and health

diet

A healthy diet is particularly important for you before your operation so your body is well prepared for your surgery.

 

If you are overweight, the strain on your joints is greater and it is much harder to get mobile after the operation. Being overweight may also increase arthritis in your joints and increase the risk of anaesthetic complications.

If you lose weight:

  • your arthritis should cause you less pain
  • your arthritis should progress more slowly
  • your chances of long term success with joint replacement are greatly increased.

A healthy diet and regular exercise can help you lose weight.

  • It is highly recommended not to smoke cigarettes or tobacco products for at least 24 hours prior to your operation. Smoking is a factor that can impair healing and increase the likelihood of infection. Smoking also increases the chance of complications related to your anaesthetic which may sometimes be serious. Whilst it is best to give up smoking permanently, giving up smoking at least six weeks before your anaesthetic would reduce many of these potential complications.
  • It is important not to drink alcohol (including beer) for at least 24 hours prior to your operation.
  • It is necessary that you have nothing to eat or drink (including water, lollies and chewing gum) at least six hours before your operation. Please follow instructions provided by your doctor or preadmission nurse.

Exercises—lower limb exercise class with physiotherapy

(Please refer to the exercise plan below)

  • This class is a Mater initiative to help you get the best result from your operation. These sessions are an ideal opportunity to start some gentle exercises under the supervision of a physiotherapist. The exercises specifically strengthen your muscles in preparation for your operation and assist recovery afterwards.
    • Class times: Tuesday and Thursday from 11 am to 12 noon.
    • Where: Physiotherapy department, level 2, Mater Hospital Brisbane, (phone 07 3163 8787)

Please book your class time if it has not been prearranged for you. If you are not able to make the class, please phone 07 3163 8787 during business hours.

Remember: If your joints swell or stiffen after exercising you may have done too much. It is important not to stop exercising but rather reduce your amount of exercise. If you continue to have problems discuss this with the physiotherapist. Ice packs are a good way to reduce joint swelling (remember to have a wet towel between the ice pack and your skin so you do not get an ice burn).

After your operation

  • You will stay in the recovery room within the theatre suite after the operation. When you have woken from the anaesthetic and are stable you will be transferred on your bed to your room. The total time you will be in theatre and recovery will be approximately four hours.
  • Your nurse will frequently monitor your vital signs (e.g. temperature, pulse, respirations, blood pressure) drains, your dressing and the colour, warmth, sensation and movement of your leg for several hours after the surgery. As you become fully recovered, these observations become less frequent but remain regular until you leave hospital.
  • You will be resting in bed following your surgery. You will have a dressing and maybe a splint on your knee. You will not be allowed to have a pillow under your knee. It is important to regularly do your breathing and circulation exercises. These exercises help prevent complications such as chest infections and blood clots in your legs.

foot

The following exercises help prevent complications suchas chest infections and blood clots in your legs. You should do these every hour that you are awake while resting in bed.

Breathing exercises: take five long and slow deep breaths. Each breath should be deeper than the previous breath. Think about getting the air to the very bottom of your lungs.

Circulation exercises: firmly move your ankles up and down to stretch and contract your calf muscles.

  • Following your surgery, because it is not possible for you to turn yourself from side to side, nursing staff will assist in doing this for you. This will help circulation to all body parts and stop sore, red areas developing, especially on your bottom or heels.
  • Your nurse will assist you to have a wash sometime after you return to the ward and assist you with hygiene cares.
  • Anaesthetics can cause nausea. To reduce this side effect your oral fluids and diet is introduced slowly following surgery. Begin with sucking on ice chips or sipping small amounts of water then progress slowly to eating and drinking normally.
  • To maintain your fluid intake you will be receiving fluids via a drip (IV). This will be removed when you are tolerating adequate amounts of oral fluids.
  • You may continue some of your usual medications as ordered by your doctor. You may also be given an injection once or twice a day of blood thinning medication. This helps to prevent blood clots.
  • Pain relief: you will have either a Patient Controlled Analgesia (PCA) or an epidural
    • A PCA allows you to manage your own pain. PCA involves specialised equipment which is connected to a drip (IV). You will have a button to push which allows a small amount of pain relieving medication to be delivered directly into your vein via the drip. The equipment has a specialised safety programme to reduce the risk of you receiving too much medication. You will remain on PCA until you are able to eat and drink. Your pain will then be managed with tablets. There is no risk of becoming addicted to strong pain relieving medication when it's used appropriately.
    • An epidural delivers pain-relieving medication into the space in your spine where the nerves carry pain signals from your operation site to your spinal cord and brain. The epidural usually remains in for two to three days depending on your type of surgery. Some patients will experience little or no pain with an epidural and may feel numb around the operation site. This is quite normal as this is its intended effect and means that the epidural is working, however if pain is moderate or severe you must notify the nurses straight away. You must also notify the nurses if you have any feeling of numbness or tingling around your mouth or upper limbs.
    • If you have a PCA or epidural, you will more than likely be prescribed paracetamol (Panadol) four times a day. Paracetamol works well when used on a regular basis and helps to reduce the amount of stronger pain-relieving medication you require which therefore reduces their side effects.
  • You will be given oxygen via nasal prongs or a mask while you have the epidural or PCA in place. It is important to always keep this on when sleeping.
  • While we try to relieve your pain as much as possible, some times it is not possible to take your pain away completely, however, your pain must be controlled well enough for you to move, do your physiotherapy exercises and to sleep. If your pain relief is not adequately controlled for this please tell your nurse. Also tell your nurse if you have an itch, you feel nauseated or feel like vomiting. These may be side effects of the pain relieving medication and are usually easily managed.
  • After the operation your nurse will assist you with toileting needs.
  • The stockings and compression sleeves will remain on. These also help in the prevention of blood clots in your legs.

Post operative phase—days one to three and rehabilitation

Discharge planning

  • Your discharge needs will be reviewed daily. Your nurse will continue to talk to you about any special needs you may require once you are discharged. By day three it will be determined whether you are ready for discharge home, with or without home care support, or continue with rehabilitation.

You will be ready to go home when you will have achieved the following recovery milestones:

  1. you will be able to walk independently and manage stairs, with a walking aid
  2. you will be able to transfer safely (e.g. get in and out of bed on and off the toilet)
  3. your pain will be controlled with oral pain medication
  4. your hygiene requirements will be met by yourself, your carer or community home care assistance.

Teaching and emotional support

  • Your nurse will review this booklet with you daily and discuss any concerns you may have. Pastoral carers are also available if you would like to speak with them.
  • Throughout your stay and as you are ready to meet the next challenge, your nurse/ physiotherapist/occupational therapist will discuss with you activities that can help you in your rehabilitation.
    Discussion topics
    • Precautions for your new knee
    • Exercises and techniques from your physiotherapist
    • Transfer techniques
    • Managing stairs safely
    • Managing with activities of daily living (Advice from you occupational therapist)

Consults

  • The medical team will visit with you throughout your stay in hospital.
  • Your physiotherapist will also see you the day following your surgery and will continue to see you each day, guiding you through your exercises and assisting you to progress with your walking.
  • Your occupational therapist will visit you from day two and if necessary complete a shower assessment. The purpose of this is to show you how to modify your hygiene cares to manage with your operated knee.

Tests and procedures

  • You will have a check x-ray taken of your knee the day following your surgery. Blood tests will be ordered by your doctor as necessary.

Observations

  • The monitoring of your observations (e.g. temperature, pulse, respirations, blood pressure, drains, dressing and the colour, warmth, sensation and movement of your leg) will continue, but become less frequent, throughout your hospital stay.

Medication

  • You will be given your medications as ordered by your doctor, plus any required for pain relief.
  • Epidural or PCA: this will continue through day one and is usually removed on day two depending on your doctor's orders.
  • Oral pain relief: it is a good idea to take pain relieving tablets regularly to ensure that your pain remains well controlled. This enables you to rehabilitate faster.
  • Drip (IV): the drip will continue through day one and is usually removed on day two.

Mobility

  • Throughout your stay in hospital it is important for you to continue your breathing and circulation exercises regularly while resting in bed.
  • You will commence the exercises at the end of this section knee extensions, straight leg raise, bridging heel slides) the first day after surgery and will continue them throughout your rehabilitation.
  • Your doctor may request CPM treatment. After extensive joint surgery, attempting to move your joint can cause pain resulting in you not wanting to move your joint. In not moving your joint the tissue around the joint will become stiff and form scars resulting in limited range of motions and often may take months of physical therapy to recover the full movement. Continuous Passive Motion (CPM) is a machine that provides joint movement post-operatively without the patient's muscles being used.
  • While you are either sitting in a chair or on the side of the bed, your physiotherapist will provide some support as you start to bend your knee. The aim is to have between 65 and 90 degree knee flexion by the time you go home.
    • mobilityDay one: the physiotherapist and nurse will help you transfer from bed to chair. The physiotherapist will assist you in walking, using a frame, for at least three metres. You will also sit out of bed for at least 30 minutes depending on how you are feeling. A higher chair with arm rests will be provided.
    • Day two: you should be able to transfer independently using the transfer techniques outlined above. Your physiotherapist will walk you at least 15 metres and you will be encouraged to sit out of bed for at least 30 minutes.
    • Day three: the aim today is for you to be walking independently with your walking aid for a distance of 30 metres. If you have stairs at home your physiotherapist will teach you how to go up and down stairs safely.
    • Rehabilitation phase: you will be walking independently with your walking aid. The hospital staff are available to provide assistance if needed.
  • With all your activities it is important to adhere to the knee precautions discussed below.

Hygiene

  • You will be assisted to have a shower for the first couple of days and by day three you will be encouraged to shower, sitting on a chair, with minimal or no assistance from your nurse. The occupational therapist will complete a shower assessment if necessary, providing you with skills to manage with hygiene care while protecting your new knee.
  • Rehabilitation phase: you will be encouraged to be independent with your showering and will be provided assistance as required.

Nutrition

  • You can continue with your normal diet as tolerated.

Continence state

  • continenceYour nurse will assist you with your toileting needs as necessary. An over toilet frame may be recommended to make getting on and off the toilet easier. Getting on and off the toilet is the same procedure as getting on and off a chair. Use the armrests of the over toilet frame to help you stand and sit, slide your operated leg slightly forward.
  • By day three and throughout your rehabilitation phase you should be independent with meeting your toileting needs. Your bowel patterns should be returning to normal. If you are having trouble with constipation please let your nurse know.

Treatment

  • TEDS and SCDs: The stockings are to be worn continually throughout your rehabilitation. They are taken off when you shower and then replaced immediately after your shower. The foot pump or compression sleeves are to be used while ever you are on bedrest until about day three. By day three you are more independent with mobility and it is not likely they will be required
  • Drains and dressing:
    • Day one: your wound drain will be removed and the dressing you have on your wound will be reduced.
    • Day two: the dressing on your wound will be replaced with a lighter dressing
    • Day three and rehabilitation phase: the dressing on your would will remain in place and will only be changed if necessary.

Precautions for your new knee

For three months after your operation there is a risk that your new knee could dislocate in some positions. Dislocation is when the parts of your knee separate. To avoid dislocation you should adhere to the following precautions:

  • avoid sitting in low chairs
  • avoid squatting, jumping, running and high impact sports
  • do not drive for at least six to eight weeks according to your doctor's instructions.

Exercises and techniques from your physiotherapist

You will do all these exercises in hospital and when you go home after the operation. It is important to practise them every day so that your muscles will get accustomed to exercising in this way.

Remember: If your joints swell or stiffen after exercising you may have done too much. It is important not to stop exercising but rather reduce your amount of exercise. If you continue to have problems discuss this with the physiotherapist. Ice packs are a good way to reduce joint swelling. (remember to have a wet towel between the ice pack and your skin so you do not get an ice burn).

Exercises

Regime: Do each exercise 10 times, twice per day

Knee extensions

  • knee extensionsPlace a rolled towel under your knee and slowly straighten your leg by lifting your heel up off the bed
  • Hold for six seconds with the knee as straight as you can.

Straight leg raise

  • leg-raiseTighten the muscle on the front of your thigh and pull up your toes to straighten your leg
  • Lift your leg 10 centimetres keeping your knee straight, then lower slowly.

Bridging

  • bridgingBend both knees
  • Lift your bottom off the bed, hold and lower slowly.

Knee bending

  • knee-bendingSlide heel towards your bottom to bend your knee
  • Straighten slowly—bend this far only.

Hip control

hip-controlIf you have had a previous hip replacement, wait until the lower limb class before trying this exercise.

Do not attempt this exercise after your operation until advised by your physiotherapist.

  • Lie on your good side with your hips and knees bent a little
  • Keep your heels together and on the bed
  • Lift your top knee only and hold for six seconds then lower slowly.

Standing exercises

standing-exerciesHold on to something steady initially. As your confidence increases and your balance improves, try letting go.

Hamstring curls

  • hamstring-curlsSlowly bend your knee bringing your heel towards your bottom.
  • Slowly lower your leg.

Mini squats

  • mini-squatsStand with your feet shoulder width apart.
  • Bend your hips and lower your hips a small amount then return.

Caution: You should not bend your knees deep enough to cause pain

Lunge

  • lungeStand with one foot forward and your feet shoulder width apart.
  • Lunge forward slowly to take your weight over the front foot.
    Hold for six seconds.
  • Repeat this with the other foot forward.

Hip abduction

  • hip-abductionKeep your trunk straight and tall with your toes pointing forward.
  • Slowly lift your leg out to the side and then lower it keeping your hip straight. You do not have to lift your leg very far.

Hip extension

  • hip-extensionWith your trunk straight and tall and keeping your knee straight, slowly lift your leg behind you keeping your knee straight and then lower it.
  • Squeeze the muscle in your bottom tightly while you do this.
    You do not have to lift your leg very far.

Balance

balanceWhen you have arthritis your balance in this joint is disturbed. Hold onto something steady. To exercise your balance, stand on the leg that is having the operation and try to let go and balance. Aim for 10 seconds.

Transfer techniques

To sit down after your operation:

  • transfer-techniquesstand so that the chair is directly behind you and touching your legs
  • keep your feet apart
  • slide your operated leg slightly forward
  • lower yourself using your arms and legs.

To stand up after your operation:

  • move your bottom forward to the edge of the seat
  • keep your feet apart
  • slide your operated leg slightly forward
  • use the armrests of the chair and push up to standing using your arms and good leg.

At home it is important for you to:

  • walk frequently throughout the day
  • sit for short periods of time only, in the first few weeks after the operation
  • take several rests periods throughout your day. Resting will help to keep the swelling in your leg to a minimum. The physiotherapist will discuss the safe use of ice packs which may also help reduce the swelling of your wound.

Managing stairs safely

managing-stairsOnce you are walking safely the physiotherapist will teach you how to go up and down the stairs.

Going up:

  • step up with your good (non-operated) leg first
  • then step up with your bad (operated) leg
  • move the walking stick up last.

Going down:

  • place the walking stick down first
  • then step down with your bad (operated) leg
  • step down with your good (non-operated) leg.

On discharge

A total knee replacement is an extensive procedure, and it may take up to three months for you to regain full independence. However, whilst in hospital with us we will aim to:

  • have you walking independently with a walking aid
  • have a family/community support network in place before you leave
  • discuss and help with any safety requirements needed in your home. Any home modifications or equipment recommended by your occupational therapist should be in place or arranged

Advice from your occupational therapist

The occupational therapist (OT) can give you details of ways to manage around the house and the equipment available to help you. These may include some long handled aids to make picking up things easier and also make showering and dressing yourself safer. You should continue to use this equipment at home after the operation until you have regained your full strength and movement.

Getting dressed:

  • Sit down to dress yourself.
  • Use the long reaching aid (dressing stick). A dressing stick allows you to put on your trousers and underwear pulling them up to your knees/thighs and is useful for picking up clothing and other objects off the floor. These temporary devices will be shown to you at the DART preoperative visit or by the occupational therapist while you are in hospital.
  • Dress the operated leg first and undress it last.
  • When you stand to pull up clothes, steady yourself before pulling the garment up.

Lifting and carrying

The muscles around your knee will have lost strength after the operation so you should avoid heaving lifting or carrying for the first six weeks after your surgery.

  • Avoid bending over—ensure commonly used items are stored at waist height or above.
  • Move things in small loads.
  • Use a lightweight kitchen trolley to move items around the home.
  • Only carry loads easily managed in one hand if you are using a stick.

Housework

You should be able to do light household jobs soon after you return home. You may tire more easily when you first return home. This is normal.

  • When doing housework, work in short sessions with frequent rest breaks.
  • Use a washing basket and trolley when hanging out clothes. If you do not have a trolley, only carry small loads, as wet clothes are heavier than dry clothes. Place the laundry basket on a stool or table to avoid bending.
  • Avoid standing on anything unstable to reach high windows or shelves.
  • Avoid vacuuming or washing floors.

Advice from your physiotherapist

Gardening

You can still do gardening after your operation but you will need to use long handled gardening tools. Please discuss this with your physiotherapist or occupational therapist.

Getting stronger

Your muscles will not regain full strength while you are in hospital. To strengthen your muscles and gain the best results it is vital to continue your exercise program at home for at least three months or as directed by your physiotherapist. You can expect improvements in your knee up to four months after your operation if you persist with your exercise program.

A physiotherapist may visit you at home to progress your exercises and mobility. As you improve you will be able to manage more challenging exercises. Plan to exercise about half an hour after you take your usual pain medications.

Further exercises

lunge-stepLunge onto a step:

  • Keep both hips facing the front when you do this one
  • Step onto the step with your operated leg
  • Hold onto the rail/s for support
  • Hold 10 seconds, then release.

bottom-slidesBottom slides:

  • Plant your foot on the floor in front of you
  • Slide your bottom forward in your chair
  • Try to increase the bend in your knee.

terminal-extensionTerminal extension

  • Lie on your back with a rolled up towel under your heel.
    This helps to stretch the back of your knee.

Fitness

Walking is one way of improving your fitness. You should find it easier with your new knee. Swimming is a good form of exercise where your body weight is supported. Seek advice from your doctor or physiotherapist before commencing swimming. Whichever activity you choose, set yourself a time or distance to aim for and try a small increase every few days.

Discharge advice following your total knee replacement

What to do:

  • Maintain precautions for your new knee
  • Continue your wound care:
    • If your wound dressing has been removed before you go home, you can pat dry the wound with a clean towel following your shower. Remember to dry the wound before the rest of your body.
    • If you have a waterproof dressing, leave it on until the clips are removed. After this you can let clean water flow over the wound area.
    • Follow the instructions on the wound care sheet provided on discharge. Your staples need to be removed by your general practitioner (GP) between 12 and 14 days after your operation.
  • You can expect some swelling and bruising to area and some associated pain after doing your exercises in the initial period after your discharge.
  • Continue to take tablets for pain relief as required.
  • Maintain your daily exercise program as advised by your physiotherapist and continue regular walks.
  • Maintain a well-balanced diet as good nutrition is important to the healing process and can assist in preventing constipation.
  • Continue to wear your compression stockings (TEDs), as advised.
  • Check with your doctor about stopping anticoagulants if you are undergoing dental or other procedures.
  • Follow the advice given to you by your occupational therapist and physiotherapist regarding:
    • dressing, showering, lifting, carrying, housework
    • exercises, transferring, getting in and out of a car, managing stairs, gardening, getting stronger and fitness.
  • Follow your doctor's advice as to when you can commence driving again. This will usually be more than six weeks after your surgery.
  • Follow your doctor's advice as to when you can return to work. This will depend on the type of work you do and your recovery.

Contact

Please contact your GP (office hours) or attend your local emergency department (after hours) if you experience any of the following after discharge:

  • any new wound ooze
  • fever (high temperature)
  • increased swelling, redness or warmth around your wound
  • swollen calf or thigh that are red and warm to touch
  • a dramatic increase in pain.

Down the track—get back into life!

After three months you should be back to most of your usual activities. You may find that you can return to activities you have not been able to do for some time because of your knee pain. Make the most of these improvements by getting back to activities you enjoy.

Having prepared yourself well and participated actively in your treatment, you will be able to return quickly to a more active and independent lifestyle.

Mater Hospital Brisbane

Raymond Terrace, South Brisbane Q 4101

Telephone: 07 3163 8111

Acknowledgments

Staff of Mater Hospital Brisbane, South Brisbane; Domiciliary Acute Care and Rehabilitation Team (DART)

The Royal Brisbane Hospital Orthopaedic Transitional Care Project Sponsored by Queensland Health, A Guide to Total Hip Replacement

© 2010 Mater Misericordiae Ltd. ACN 096 708 922.

Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: PI-CLN-420038
Last modified 16/11/2015.
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