Total Knee Replacement

Before You Come To The Hospital

• Important Phone Numbers
• Schedule of Follow-up visits
• A Closer Look at Total Knee Replacement
• Before You Come to the Hospital
• When You Come to the Hospital

Your Surgery and Hospital Stay

• The Day of the Surgery
• Recovering in the Hospital
• Managing Pain
• Rehabilitation in the Hospital
• Do's and Don'ts in the Hospital
• Preventing Blood Clots
• Diet
• Preparing to Return Home

Final Steps: At Home

• Guidelines for Home Recovery
• Preventing Infection
• Sports Activities
• Home Recovery Exercise Program
• Home Recovery Program
• Sexual Relations

Important Telephone Numbers

Ortho Excel - 9920053334
Other Important Numbers http://www.orthoexcel.in/contacts.htm

Schedule of Follow-Up visits

Expect to have routine follow-up visits at the Ortho Excel as follows:

• Suture removal 10-14 days from surgery
• 6 weeks following day of surgery
• 3 months following total knee replacement
• 1 year following total knee replacement
• 3 years following total knee replacement
• 5-6 years following total knee replacement
• 8-10 years following total knee replacement

This follow-up schedule may vary from patient to patient. You must call the Ortho Excel Staff to schedule all appointments. Please notify us if you have a change of name, address, telephone number or insurance carrier.

A Closer Look at Total Knee Replacement

To understand total knee replacement, you should be familiar with the structure of the knee, a complex joint consisting of three bones: the femur (thigh bone), the tibia (shin bone), and the patella (kneecap). When you bend or straighten your knee, the end of the femur rolls against the end of the tibia, and the patella glides in front of the femur.

With a healthy knee, smooth, weight-bearing surfaces allow for painless movement. Muscles and ligaments provide side-to-side stability. A membrane lines the joint. Cartilage acts as a cushion between the femur and tibia and is lubricated by synovial fluid.	With an arthritic knee, the cartilage 'cushion' wears out. The bones rub together and become rough. The resulting inflammation and pain cause reduced motion and difficulty in walking.

The weight-bearing surfaces of a total knee replacement are smooth, as in a normal knee. A femoral component covers the end of the thigh bone, a tibial component covers the top of the shin bone, and the patellar component covers the underside of the kneecap. The femoral component is made of a super alloy (chromium cobalt ) and is held in place by a cement methylmethacrylate). The patellar component is made of plastic (polyethylene) and is held in place with cement. The tibial component is made of either polyethylene or titanium covered by polyethylene.

Clinical and biomechanical research has steadily refined knee replacement methods and materials. Prosthesis durability can vary from patient to patient because each patient's body places slightly different stresses on the new knee. However, the average patient can expect to obtain greater mobility and freedom from pain, which will, in turn, improve ability to walk.

• The femoral component is a cobalt chromium alloy
• The patellar component is polyethylene
• The tibial insert component is polyethylene
• The tibial tray component can be made of the following materials (alloys):
 ø Cobalt chromium
 ø Titanium
 ø Polyethylene

Before You Come to The Hospital

Total knee replacement can enhance your quality of life by providing many years of improved mobility and reduced pain. Each year many people benefit from total knee replacement. In the last decade remarkable advances in technology have transformed total knee replacement into an efficient and widely performed procedure.

Things To Do

• You may be asked to donate your blood for the surgery. If the donation is required, the Ortho Excel staff will make an appointment for you at Lenox Hill Hospital's Blood Donor Center.

• The Ortho Excel staff will make an appointment for you for pre-surgical testing fourteen (14) days prior to surgery.

• Social workers will help facilitate your discharge planning. The Home Care staff will help you plan your home care and physical therapy needs following discharge from the hospital. If you wish to consult a social worker or a member of the Home Care staff to help plan for your return home, you may call the Social Work Department or the Home Care Department before your admitting date to the hospital.

• Before your surgery, the Ortho Excel Staff will make an appointment for your examination.
- Review and/or perform any necessary diagnostic tests
- Provide medical clearance for the surgical procedure

• Unless you are told otherwise, continue to take medicines already prescribed by your own physician. Fish oils should be discontinued two (2) weeks prior to surgery. Also, anti-inflammatory medications and anti-oxidant vitamins such as C and E should be discontinued ten (10) days prior to your surgery.

• You should begin taking ferrous sulphate 325mg twice a day beginning 1 month before your surgery.

• Prepare for your return home from the hospital (see Preparing to Return Home).

• Before your admission, please complete the Health Care Proxy form authorizing another person designated by you to make decisions with your physician about your care, should this become necessary.

• To obtain your admission time and location, please call Same Day Surgery Admissions at 9833309818 between 2pm and 4pm one business day before your scheduled surgery.

• If possible, give yourself a Fleet ® enema the night before surgery.

EXTREMELY IMPORTANT: PLEASE BRING A LIST OF YOUR CURRENT MEDICATIONS AND THEIR DOSAGES SO THAT THE CORRECT MEDICATIONS AND DOSAGES CAN BE ORDERED FOR YOU WHILE YOU ARE IN THE HOSPITAL. ALSO BRING MEDICAL INFORMATION FROM YOUR PHYSICIAN, INCLUDING DETAILS ABOUT ANY PAST REACTIONS TO ANESTHESIA.

DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT ON THE NIGHT BEFORE YOUR SCHEDULED SURGERY, UNLESS OTHERWISE INSTRUCTED.

Be sure you understand all pre-operative instructions. If you have questions or concerns, please discuss them with your surgeon or call the Ortho Excel at 9920053334.

Recovering in the Hospital

After surgery, your IV (intravenous) line will remain in your arm for approximately 48 hours. The IV line delivers fluids, antibiotics and other medications, and can also deliver blood, if necessary.

At the bandaged surgical site, a thin tube inserted into the site and attached to a drain that prevents blood from accumulating under the muscles and bones of the knee. The tube and drain are removed the day after surgery, and the bandage is removed the second post-surgical day.

The day after surgery, your knee will be placed in a continuous passive motion machine (CPM), which helps it to regain flexion and extension. A nurse will position you in bed and help you turn until you are able to move on your own.

Because anesthesia may temporarily inhibit urination after surgery, a catheter may be inserted into the bladder to remove urine. When the patient regains function, usually within one or two days after surgery, this catheter is removed.

In collaboration with you and your family, the hospital staff, including a physician, physician assistant, nurse, physical therapist, and social worker will plan, provide and monitor your care.

Exercise

Gentle exercises to improve your range of motion can help prevent circulation problems as well as strengthen your muscles. As soon as you are able after surgery, a physical therapist will teach you the necessary exercises.

Deep Breathing

After surgery, regular deep breathing, to rid your air passages of mucus, is vitally important. Normally, you take deep breaths almost every hour, usually without being aware of it, whenever you sigh or yawn. When you are in pain, or are drowsy from anesthesia or pain medication, your breathing may be shallow. To ensure that you breathe deep daily, the nursing staff will provide you with a device called an Incentive Spirometer, along with instructions on its use.

How to use the Incentive Spirometer

1. With the unit in an upright position, place your lips tightly around the mouth-piece and exhale normally.
2. To achieve a deep and sustained breath, inhale at a rate sufficient to raise the ball in the chamber.
3. Exhale. After performing the exercise, remove the mouthpiece from your lips.
4. Relax and breathe normally for a moment after each deep breath.

Repeat this exercise 10 times every hour.

Managing Pain

How does it feel?

Recovering from any surgery involves pain and discomfort. The hospital's team approach to pain management can help reduce your discomfort and thus speed your recovery.

Pain management, however, begins with you. Since no objective tests exist to measure what you are feeling, you must help the staff by describing the pain, pinpointing its location, and judging its intensity, as well as reporting any changes in these. Pain may be constant or sporadic, as well as sharp, burning, tingling, or aching.

The scale can help you gauge the level of pain.

The Pain Scale

Worst Pain                No Pain
10  9  8   7   6   5   4    3    2   1
•  •  •  •  •  •  •  •  •  •  •  •  •  •  •

Always report any increases or changes in pain. As we discuss below, there are several approaches to pain relief. To fully reap their benefits, you must use them before pain becomes severe.

Pain management after total knee replacement will be decided by the surgeon and the surgical team. The main methods of pain control after surgery include:

• Approach 1: Epidural Anesthesia
Epidural anesthesia, for one to two days post-surgery, will keep your pain at a low level on the pain scale. After the epidural is discontinued, your pain can be managed by oral or injectable medication. An epidural pump and a PCA pump look similar.

• Approach 2: Patient Controlled Anesthesia (PCA)
Patient controlled anesthesia (PCA) will be provided if necessary, or if the epidural wears off or is stopped for medical reasons.

Approach 3: Oral Medication
Approximately 24 to 48 hours after surgery, as pain decreases and your activity level increases, you will be given oral or injectable pain medications, which control discomfort without restricting activity or mobility.

Cold Therapy

During your hospital stay, ice packs applied to the surgical site by the nursing staff while you are at bed-rest, will aid in reducing swelling and pain.

Rehabilitation in the Hospital

Your participation in a physical therapy program is essential to the success of your surgery. The more committed and enthusiastic you are, the quicker your improvement will be.

The day after surgery, a physical therapist will visit you with an exercise program to increase your increase range of motion and strength in your leg muscles. In the first few days after surgery, you may benefit from taking pain medication one hour prior to your physical therapy session. Check with your nurse and/or therapist.

The physical therapist will assist you in the following activities:

• Sitting at bedside with your legs dangling
• Standing with the aid of a walker
• Climbing stairs
• Arranging attendance to Activities of Daily Living Class, where you will learn how to live and thrive with your total knee replacement.

Before leaving the hospital, most patients progress to forearm crutches and can get in and out of bed unassisted.

Do's and Don'ts After Your Total Knee Replacement

Below is a general list of precautions to follow after your total knee replacement. If additional precautions are warranted, the staff will provide instructions.

Do

• position your knee comfortably as you go about your daily activities.
• walk and perform range-of-motion exercises every day.
• use an ice pack if your knee begins to swell.
• elevate your leg one hour twice a day if your knee, calf, ankle or foot begins to swell.
• Compression stockings above the knee can be purchased at any medical supply store
• At home, you can use a grab bar or shower chair for added safety, comfort, support and stability.

Don't

• Twist your knee. Turn your entire body instead.
• Jump or otherwise put sudden, jarring stress on your knee.

Preventing Blood Clots

After total knee replacement surgery, clots, called deep vein thromboses (DVT), may form in the leg veins. In rare cases, these leg clots travel to the lung, where they may cause symptoms. To prevent and reduce the incidence of clot formation, mechanical devices are used to squeeze the leg muscle, thus maintaining blood flow in the veins. Also, a medication to minimize clot formation, such as LMWH is prescribed.

Ultrasound Doppler

Before your discharge from the hospital, you will receive a noninvasive test to detect blood clots. The test relies on sound waves generated by moving blood cells. You will be asked to lie in a semi-upright position. The procedure causes no discomfort, and no special preparation is required. If no clots are found, you will be discharged on Aspirin 325 mg a day for one (1) month. If your doppler results are positive, your surgeon will determine the necessary treatment.

Leg Swelling

Following knee replacement, most patients develop swelling in the operated leg. Although the amount of swelling can vary from patient to patient, the swelling itself in the leg, knee, ankle or foot is normal, and will usually resolve gradually over several weeks.

For the first month after your operation, sitting, which tends to worsen the swelling, should be 30 TO 45 MINUTES ONLY. Periods of walking should be alternated with periods of elevating the swollen leg. When elevating the leg, the ankle should be above the level of the heart. You should lie with one pillow under your head and four to five pillows under your foot and leg to elevate your leg above your chest. While sitting in a chair, DO NOT ELEVATE YOUR FEET.

Try to spend an hour in this elevated position in the early afternoon to help diminish the swelling that may have developed during your morning walks.

To prevent or reduce leg and ankle swelling:

• Elevate operated leg
• Avoid sitting for more than 30 to 45 minutes at a time
• Perform ankle exercises
• Use elastic compression socks

FINAL STEPS: AT HOME

Caring for Surgical Site

1. Leave the Primapore Dressing until your sutures are removed.
2. After removal of your sutures, leave the incision open unless instructed otherwise.
3. Please inform ROC of increasing redness of or drainage from your incision.

Pain Medication

1. Take your pain medication as prescribed.
2. To control pain, take your pain medication before the pain becomes severe.
3. If your pain medication seems weak, or if you are experiencing unpleasant side effects, do not hesitate to call the Ortho Excel.
4. If you are taking pain medication, avoid alcoholic beverages and recreational drugs.
5 .If you experience discomfort during your ongoing physical therapy, take your pain medication at least 45 minutes prior to your subsequent therapy sessions. This will allow enough time for the medication to take effect.

Preventing Infection

Having undergone surgery increases your risk of infection. However, antibiotics can help protect you and should be used in the following situations:

• With any medical or surgical procedure, performed by your physician or dentist.
• During certain diagnostic procedures, such as catheterization and endoscopy, or those involving intestines, lungs, bladder and kidney.
• With serious infections elsewhere in your body.

Tell your internist and dentist that you have an artificial joint so that they can prescribe antibiotics. If you have questions or concerns, please call the Ortho Excel.

Total knee replacement patients who require dental work on gums or roots must adhere to the following antibiotic procedure regimen:

For patients not allergic to Penicillin: Cephalexin, Cephradine or Amoxicilin: 2 grams orally 1 hour prior to the dental procedure

For patients allergic to Penicillin: Clindamycin: 600mg orally 1 hour prior to the dental procedure.

Patients should adhere to this regimen for the first two years following joint replacement. Immunocompromised patients, including those with inflammatory arthropathies, rheumatoid arthritis, drug or radiation-induced immunosuppression, insulin-dependent diabetes or any other major medical problem should follow this antibiotic routine indefinitely.

Antibiotics can reduce the risk of infection but cannot completely eliminate that risk. Preventing infection must be the concern of all the healthcare professionals who treat you. MAKE SURE YOU INFORM YOUR PHYSICIAN AND DENTIST THAT YOU HAVE HAD A TOTAL KNEE REPLACEMENT.

Sports Activities

After full recovery, some patients enjoy light sports activities. Activities you can enjoy after total knee replacement include walking, bicycling, bowling, swimming, golf and doubles tennis. Avoid high impact activities, such as:

• Jogging
• Running
• Jumping
• Skiing

Home Recovery Exercise Program

Knee Flexion 1. Sit on the edge of a table or chair. 2. Try to bend your operated knee as much as you can, assisting with the opposite leg. 3. Hold for 10 seconds. 4. Do 15 repetitions, 3 times per day.

Quad Sets / Extension

1. Sit or lie on your back with your leg straight.
2. Press the back of your knee downward. This will tighten the muscle on top of your thigh and move your kneecap.
3. In a sitting position, press your knee down using both hands to apply additional pressure.
4. Hold for 10 seconds.
5. Do 15 repetitions, 3 times per day.

Knee Flexion 1. Place your foot on a low stool. 2. Lean your weight forward to bend the knees so that you can feel a stretch. 3. Hold for 10 seconds. 4. Do 15 repetitions, 3 times per day.
Calf Raises 1. Stand up, holding on to a sturdy surface, such as a table. 2. Raise yourself up onto the balls of your feet. 3. Hold for 10 seconds. 4. Do 15 repetitions, 3 times a day.

Your New Knee is Different

You may experience skin numbness around your incision, and knee stiffness, particularly with excessive bending activities, such as getting in and out of a low chair or a car. Though possibly uncomfortable, kneeling is not harmful. At times, you may notice soft clicking. These symptoms will gradually improve over several weeks and months. The benefits of total knee replacement usually become fully evident 6-8 months after surgery.

Climbing Stairs

The following are instructions (NOT exercises) for climbing and descending stairs.

If you have one (1) total knee:

UPSTAIRS

• The non-operated leg goes first.
• The operated leg goes second.
• The crutches go last (at the same time as the operated leg).

DOWNSTAIRS

• The crutches go first.
• The operated leg goes second.
• The non-operated leg goes last.

If you have two (2) total knees:

UPSTAIRS

• The stronger leg goes first.
• The weaker leg goes second.
• The crutches go last(at the same time as the weaker leg).

DOWNSTAIRS

• The crutches go first.

Sexual Relations

The following questions, answers and illustrations respond to the common concerns of patients and their partners after knee replacement surgery.

Will I be able to resume sexual relations now that my knee has been replaced?

The vast majority of patients are able to resume safe and enjoyable sexual intercourse after knee replacement. Patients whose sexual function had been impaired by preoperative knee pain and stiffness welcome their new pain-free mobility. However, gaining full confidence with your new knee may take several weeks.

When can I resume sexual intercourse?

In general, intercourse can be resumed safely approximately eight weeks after surgery. Though individual recovery time varies greatly, this timeframe allows the incision and the muscles around the knee to heal. If you recuperate rapidly, you will be able to resume sooner, as long as you are free of pain.

What positions are safe during intercourse?

Total knee replacement precautions need to be observed during all activities, including sexual intercourse. In general, follow the do's and don'ts on pages 26-27 and the positions illustrated on page 29. As advised in the discharge instructions, you should avoid excessive knee flexion (knee toward chest), adduction (leg towards center of body), and internal rotation (toes turned inward).

Most patients, male and female, prefer 'passive' intercourse in the 'bottom' position, an option some find less fatiguing. As your knee heals, you may resume a more active role. After a few months, patients can resume sexual activities in any comfortable position.

What should I tell my partner?

As good communication is essential, you may want to share information in this booklet with your partner. In addition, you can discuss the knee precautions that the hospital staff reviewed with you.