Total Knee Replacement

Thank you for choosing The Orthopedic Specialty Clinic for your knee replacement surgery. Certainly, the prospect of having your knee replaced is a daunting one. The purpose of this handout is to answer as many potential questions about the process as possible, so that with a clearer idea of what is ahead, you will be better able to navigate the next few months of recovery. The problem at hand is that your joint surface cartilage has worn down to the point where bone is touching bone without a cushion. Total knee replacement involves resurfacing the joint at the femur (thigh bone), tibia (shin bone), and patella (kneecap). At most, only a centimeter of bone is removed from each surface and is replaced with metal and plastic components which create a new bearing surface for the knee. Your muscles, tendons, and ligaments remain, and are crucial to the function of your new joint. Multiple long-term studies show well over 90% survival of the implants beyond 15 years, and there is not a known limit to how long they can last. Though the results are generally excellent, some implants can fail over time, requiring a second surgery.

We prefer to do the surgery under a spinal anesthetic, also using a long-acting sensory nerve block and IV sedation. This helps avoid the postoperative nausea and grogginess often seen after a general anesthetic and lowers the risk of a blood clot after surgery. The operation usually lasts about an hour and requires an incision on the front of the knee of about 6-7”. A physical therapist will have you up and walking on your new knee within hours of the operation, and we hope to have you home by the next day, at the latest. Pain management is an integral part of successful knee replacement. You will be prescribed opioid pain medications upon discharge. Although opioids are a necessary tool for controlling pain after surgery, we seek to limit their use (and attendant side effects) to the immediate postop period. Please read the attached information on opioid pain medications.

Various complications have been reported in the total knee literature. The main ones to consider include infection, blood clots, and joint stiffness. Generally, our infection rate is .5% or less, and measures taken to prevent infection include the use of perioperative antibiotics, wearing space suits during surgery, and minimizing traffic into and out of the OR. Further, diabetics (who are at higher-than-normal risk) should have their sugars under good control (HbA1c<7), and overweight patients must get their body mass index (BMI) below 45. For blood clot prophylaxis, we utilize sequential compression devices on your legs, as well as medicine (baby aspirin or Eliquis, depending on your risk profile). Getting up and walking around is also an important measure to prevent clots. Joint stiffness is a result of scarring, which is the natural process by which we heal wounds. Physical therapy and home exercises are key to preventing a stiff knee. Constipation is common postoperatively and is a byproduct of opioid medication use and relative immobility. Please read the attached information on bowel care management. Other complications reported in the literature include implant loosening, nerve or vascular injury, fracture, or excessive bleeding.

Once you are ready for discharge, it is essential that you have plans in place to return home. Although in the past we have utilized inpatient rehab centers after discharge, studies have clearly shown higher rates of complications such as infection and stiffness. Best results are obtained with quick return to your home, and early engagement in outpatient physical therapy. PT begins once or twice per week with a well-defined program of home exercises. Initial goals include swelling control, regaining motion, muscle activation, and gait training (we hope to have you off assistive devices within two to three weeks. Once you have reached these basic goals (usually 4-6 weeks), we want to transition you to the Arthrofit exercise class (or some similar organized fitness program) for long-term conditioning. Improving your overall fitness is key to maximizing the results from your knee replacement surgery. Overall, you can expect change and improvement in your knee function for up to a year; in this sense, it is important for you to prepare mentally for a marathon, not a wind sprint. A positive mental attitude is key to a successful recovery. We look forward to helping you through the process.

TIMELINE

Surgery is scheduled

• Read the entire packet of information. Call our office with any specific questions.
• Call (801) 442-8600 or (888) 269-8674 (M-F 8am-8pm, Sat 8am-4pm) as soon as possible to register for Let them know your date. Please be prepared to give your personal and insurance information.
• Call (801) 314-4062 (M-F 9am-4pm) to schedule a prescreening clinic visit for 2 weeks before your scheduled surgery date. Blood will be drawn for labs (no need to fast). Be prepared to discuss your health history and home medications (bring a comprehensive list including names and dosages). Bring your insurance card and a photo ID. The presurgical screening clinic is located at entrance #6 on the northwest side of the TOSH campus (see attached map)
• Obtain written medical clearance for surgery from your primary care (or other providers), if instructed by your surgeon’s office.
• Register for a preoperative total joint class at ORG/JOINTREPLACEMENT. In this 1-hour class you will learn how to plan for your surgery and recovery, and what to expect while in the hospital. In-person attendance is preferred, but you can also watch online. You can contact our Total Joint Coordinator for a link: Janel Katter at (801) 314-4017 or [javascript protected email address]
• Exercise regularly (as your knee can tolerate). The better shape you are in before surgery, the easier your recovery will be. We encourage preoperative engagement in the Arthrofit exercise class at TOSH to help facilitate this. Also, take a multivitamin that includes iron, folate, and vitamin D, daily.

Before Surgery

• Two weeks prior to surgery you will be contacted to arrange your postop physical therapy.
• Stop all anti-inflammatory medications (aspirin, ibuprofen, diclofenac, etc.) one week prior to surgery
• If you are on aspirin, Plavix, Coumadin (or any other blood thinners) because of a heart or clotting condition, please contact your provider for instructions on when to stop these medications before surgery.
• Make plans for someone to bring you to the hospital for surgery (and take you home upon discharge). You will need someone to stay with you for at least 24 hours after surgery.
• Packing list for your hospital stay: Bring a comprehensive list of all medications you take. Bring your insurance card and photo ID. Pack toiletries for overnight stay. Pack loose-fitting clothing that will slip over bulky dressings, as well as a robe and comfortable shoes. You will be reading and signing documents before surgery. If you wear glasses, bring a case for them (contact lenses must be removed prior to surgery). There may be unforeseen delays in the surgery schedule, so we recommend bringing a book or iPad for the preop waiting period (do not forget a charger). If you use a CPAP machine at home, please bring it.
• For two days prior to your surgery, shower with Hibiclens (chlorhexidine gluconate) wash. Pay particular attention to the area you will have surgery, but do NOT use Hibiclens on your face, head, or genitals (use your normal shampoo or soap on these areas). We also recommend using Differen (benzoyl peroxide) wash or wipes over the surgical area after the Hibiclens wash. These items are readily available at any Walgreens or CVS and are an inexpensive means to reduce bacteria on your skin, and thus your risk of infection. Also, do NOT shave below the neck for two days prior to surgery. On the day of surgery, do NOT apply lotions, perfumes, or deodorant after showering
• Call (801) 314-4090 the day prior to your surgery (Friday for Monday surgery) between 2- 3pm to find out your arrival time.
• Do not eat or drink anything after midnight before your surgery (no chewing gum, breath mints, water, coffee, or other liquids). You may brush your teeth before surgery.

Day of surgery

• Leave all valuables and jewelry at home. Remove all body piercings
• Wear loose-fitting clothing that will fit over bulky dressings
• Do not forget your glasses! And if you use a CPAP at home, bring it
• Bring your insurance card and photo ID
• Bring a complete list of your medications and dosing schedule. Take your blood pressure medication, seizure medications, and asthma medications with a small sip of water the morning of surgery. DO NOT take oral diabetic medication or insulin the day of surgery unless instructed to do so by the pre-admissions nurse or your nurse or your surgeon.

**Failure to comply with these instructions may result in cancellation of your surgery**

What to expect

• After checking in, you will be shown to a preop room, where you will change into a gown, an IV will be started, and labs may be Hair around the surgical site will be clipped.
• You will be visited by your surgeon and anesthesiologist, and any questions you may have will be answered. Consent forms will be signed, and the surgical site will be marked.
• IV antibiotics will be given within the hour your surgery starts. A short-acting spinal anesthetic as well as a long-acting sensory nerve block will be administered. You will then receive IV sedation so you can relax and/or sleep during the procedure (no tube will be placed down your throat, and you will breathe on your own during the operation.
• Your surgery will take around an hour. The incision down the front of your knee will be about 6-7”. The implant is sized precisely to your anatomy. A light dressing will be placed on your knee, as well as an ice pack.
• You will be in the recovery room for approximately 45 minutes, then you will be taken to floor, where specialized joint replacement nurses will care for you.
• You may resume a normal diet as tolerated.
• A physical therapist will have you up and walking as soon as your spinal has worn off.
• Important tasks for the day of surgery:
  • Sit up in bed, eat regular food, and drink plenty of liquids
  • Urinate on your own (if not within 4 hours of arrival to floor, notify the nurse)
  • Deep breathing exercises
  • Stands get out of bed and walk the halls with assistance
• If you complete these tasks, and are medically stable, you may go home the day of surgery if you would like to
• The outer dressing may be removed the day after surgery if the incision is not draining
• We ordinarily schedule you to begin outpatient physical therapy within the week of surgery. Our discharge planner will meet with you to ensure that your therapy needs are met.
• A physical therapist will work with you on going up and down stairs before discharge.
• Upon discharge home, you will receive prescriptions for pain medication, as well as nausea medication and a stool softener. You will also be given a prescription for either aspirin or another blood thinner (depending on your risk profile) for blood clot prevention. You will receive instructions regarding incision care, medications, bathing, etc.