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The purpose of this document is to better prepare you for your upcoming knee replacement surgery (also called TKA). It is not intended to be a definitive document, but rather to provide some guidelines for the surgery. The patients that generally have the best overall experience after this surgery are those who are best prepared and know what to expect. Each patient is different, and has different needs. You might have many other questions, so please ask us to address any concerns that you might have. You can ask questions by phone, in person or via email at drkimball.com. This document is divided into three categories: preoperative (before surgery), perioperative (in hospital), and postoperative (out of hospital).
What is the chance of success?
"Success" should not be measured in a quantitative knee score, but rather in the ability to answer "yes" to the following three questions:
Are you glad you had the operation?
Did it fulfill your expectations?
Would you do it again?
Approximately 98% of patients at 1 year will answer "yes" to all three questions.
What is the recovery time?
Patients heal from surgery at a different pace. In most cases, however, you will be restricted to the use of a walker, crutches, or a cane for distances for the first month after surgery. You will then be allowed to advance to a cane outdoors and no support around the house for several weeks. You will gradually return to normal function without any assistive devices. This usually takes approximately 3 months, but may take longer.
Will I go to a rehabilitation facility or home?
It depends, most patients are able to go home after their operation. However, you may go to a rehabilitation facility to gain the skills you need to safely return home. Many factors will be considered in this decision, including availability of family or friends to assist with daily activities, home environment and safety considerations, postoperative functional status as evaluated by Dr. Kimball and the physical therapists at the hospital, and overall evaluation by the hospital team.
When can I drive?
If you had surgery on your right knee, you should not drive for at least 1 month. After 1 month, you may return to driving as soon as you feel comfortable. If you had surgery on your left knee, and drive a vehicle with an automatic transmission, you may return to driving as soon as you feel comfortable. Do not drive if you are taking narcotic pain medications.
When can I travel?
You may travel as soon as you feel comfortable. It is recommended that you get up to stretch at least once an hour when taking long trips. This is important to help prevent blood clots, and will also decrease stiffness/soreness in your knee. Recent published data suggests you should not travel by air for 6 months following joint replacement because of the increased risk of blood clot associated with air travel.
When can I return to work?
This depends on your profession. Typically, if your work is sedentary (sitting), you may return to work in 1 month. If your work is more rigorous, you may require up to 3 months before you can return to full duty. In some cases, more or less time is necessary. This decision will be determined, to a large degree, by what you do and how you feel.
What activities are permitted following surgery?
You may return to most activities as tolerated, including walking, gardening, and golf. Some of the best activities to help with motion and strengthening are swimming and use of a stationary bicycle. You should avoid high-impact stresses such as running and jumping and vigorous sports such as singles tennis, racquetball, or squash.
How long will my knee replacement last?
This varies from patient to patient. 20-year outcome studies show a 96% survival when using Rotating Platform components. The longevity of your knee is, to a large degree, determined by how it is put in and the type of prosthesis used. I use computer navigation to assure the best possible alignment and balance of your knee components. I use rotating platform technology because these knees have demonstrated some of the best long term survival statistics.
What happens after I schedule surgery?
You will need to have some blood test and an EKG, and possibly a chest x-ray. These are coordinated either through the hospital where you are having surgery or the Central Utah Clinic. Please bring a current list of all medications that you are currently taking when you come to the hospital.
What do I do if I am taking blood thinners?
Coumadin(Warfarin), Lovenox, Plavix, and Aspirin are examples of blood thinners. These will need to be stopped prior to surgery. Please discuss with Dr. Kimball or his staff at least 1 week prior to your surgery. Also, some herbs and alternative supplements may cause increased bleeding after surgery. Please inform Dr. Kimball or his staff of any of these supplements or herbs that you might be taking.
Should I get clearance from my primary care physician?
This depends on the individual patient and their pertinent medical issues. In general, however, it is best to notify your primary care physician and/or cardiologist of your plans to have surgery. If you are having: chest pain, shortness of breath, unexplained headaches, periods of unexplained numbness or weakness, or abdominal pains, it is best that these are evaluated thoroughly prior to surgery. The previous are examples of some symptoms that require evaluation, but notify Dr. Kimball or his staff if there are changes in your medical condition.
What time will my surgery begin?
The operating room schedule is not finalized until the day prior to surgery. The hospital will contact you to tell you what time you need to report to the hospital. Obviously, every patient cannot be the first case of the day. Cases are scheduled in specific order based on a patient's medical needs, age, length of procedure, and inpatient/outpatient issues. Availability of special equipment in the operating room also is a factor in scheduling. We will attempt to honor your request, but cannot guarantee where you will be in the operating room schedule. Some procedures take longer than expected, and you might have to wait longer than originally expected for your procedure. Please be patient and understand that Dr. Kimball and the hospital staff are working to do their best for all patients.
Although I often have a busy schedule, I only treat one patient at a time and I do not watch the clock. I do what ever it takes to produce the best possible result. Sometimes that requires more time than anticipated.
What type of anesthesia will I have?
There are two general types of anesthesia for knee replacement surgery: general and regional(spinal, epidural). Dr. Kimball generally recommends regional anesthesia when possible. Regional anesthesia is generally associated with less nausea and mental status changes than general anesthesia. The anesthesiologist will discuss these alternatives with you prior to surgery. The final decision is yours to make however I use a very specialized "multimodal" approach to pain management. This includes various oral medications given shortly before surgery in order to block pain receptors prior to stimulating them at the time of surgery. It also includes combining a spinal anesthetic with a femoral nerve block/catheter for a combined regional anesthesia. Post operative pain management will include a continuation of the femoral nerve catheter usually for 48 hours in combination with anti-inflammatory medication and oral pain medication. This combination usually works extremely well and most patients have a pain level of 1-2 out of 10 for the first 2 days following surgery. Additionally this type of anesthesia is associated with a lower incidence of blood clots and pulmonary embolis.
Even though your anesthesia is regional, you will be given sedation so you are not awake for the procedure. I am happy to discuss the details of this approach. It is extremely important to me that you experience as little pain as possible following this procedure. If I can adequately control your pain, you will be able to recover faster and accomplish the goals we both are seeking.
When can I shower (get the incision wet)?
You may shower three days after your operation if no drainage is present at your incision site. Initially, try to keep the incision dry with a plastic wrap. If your incision gets wet, pat it dry.
What kind of pain medication will I receive after surgery?
Post operative pain management will include a continuation of the femoral nerve catheter usually for 48 hours in combination with anti-inflammatory medication and oral pain medication. This combination usually works extremely well and most patients have a pain level of 1-2 out of 10 for the first 2 days following surgery. The type of pain medication(s) used varies from patient to patient based in part on your prior experience with medication and allergies you may have.
When will I start blood thinner medication?
A blood thinner will be started on the day of surgery after the procedure if you are able to tolerate the medication. The type of medication used varies depending on your medical conditions and needs. Typically I start coumadin on the day of surgery. This medication takes 2-3 days to become effective. 24 hours after surgery I start Lovenox injections. This medication works immediately to thin your blood. I continue the Lovenox until the coumadin levels have become therapeutic.
How often should I use the continuous passive motion (CPM) machine?
The CPM will be started after surgery. Generally, it will be used 4-6 hours per day. You may use it more if you wish. It is not a substitute for physical therapy. In fact, many hospitals and orthopedic surgeons do not use the CPM machine at all. Dr. Kimball uses it as an adjunct to your therapy. The amount of bend will generally increase as you improve. If the machine is rubbing against the sides of your leg or knee, please notify your nurse or therapist or adjust your position to avoid irritation. One of the goals following surgery is to regain functional range of motion. CPM machines can be helpful in accomplishing this goal.
Do I need a catheter in my bladder?
Most are more comfortable with a urinary catheter for 1-2 days when a spinal anesthetic is used. I will discontinue the catheter as soon as possible.
How long will I have an IV?
You probably will have an IV in your arm for your entire hospital stay. The fluid may be stopped on the second postoperative day if you laboratory studies are doing OK and you are eating and drinking well.
How long will I be in the hospital?
Most of my total knee patients are in the hospital for 3 days. You will not be discharged from the hospital until it is safe to do so. Hospital and insurance rules do no allow for us to keep you in the hospital for convenience. Your stay in the hospital needs to be supported by your medical condition. Generally speaking, if you can make it to the front door, you probably can go home. The decision to discharge you will depend on your medical status and your functional status and not merely the length of time you have been in the hospital.
How long do I need a bandage on my incision?
I generally remove your drain (a small tube left in the knee for drainage) 24 hours after surgery. Don't worry, it doesn't hurt. I then discontinue the bandage 48 hours after surgery unless there is some additional drainage.
When will my sutures be removed?
I do not use sutures that need to be removed. I close wounds with a "plastic" subcuticular closure where biodegradable sutures are positioned just under the skin. These dissolve and need not be removed. Steri-strips are also used to cover the incision line for the first week following surgery.
Who makes all of the arrangements for rehabilitation or equipment?
A social worker at the hospital is part of the hospital team, and will help to coordinate your needs as you are discharged from the hospital. They are an invaluable asset in helping you and your family make the transition from inpatient to outpatient. They also are quite helpful in addressing questions regarding insurance coverage. This will include home physical therapy and a CPM machine at home for the first 1-2 weeks following discharge.
How long will I be on pain medication?
It is not unusual to require some form of pain medication for a few weeks to a few months. Initially, the medication will be strong (such as a narcotic). Most people are able to wean off their strong pain medication at 2-4 weeks after surgery. Some switch to an over-the-counter medication like acetaminophen or ibuprofen. Ice is also very helpful to decrease pain and swelling. You will have a Polar care unit on your leg after surgery. You will take this home with you and most find it very effective in pain relief. (this is a motorized type of ice chest which circulates cold water through a pad which is wrapped around your knee) Please make sure that you have stopped the blood thinner medication before taking ibuprofen.
How long will I be on a blood thinner?
I generally continue the blood thinner for 2 weeks from the day of surgery. If you develop any bleeding (nose bleeds, bloody stools, etc.), please contact the office or go to the emergency room. At discharge from the hospital, we will arrange to intermittently test your blood to measure the effectiveness of the medication.
Can I drink alcohol during my recovery?
While you are on a blood thinner, you should avoid alcohol because it modifies the effect of the medication, and can lead to gastrointestinal bleeding. You should also avoid alcohol while taking narcotic pain medication.
What are good and bad positions for my knee during recovery?
You should spend some time each day working on both flexion (bending) and extension (straightening) of your knee. It is a good idea to change positions every 15-30 minutes while awake. Avoid a pillow or roll under your knee as this can contribute to the development of blood clots. Excessive use of a pillow behind the knee can contribute to greater difficulty getting the knee to straighten out completely. A roll under your ankle helps improve extension of the knee.
Should I apply ice or heat?
Initially, ice is most helpful to reduce swelling. The Polar Care unit will facilitate this. After several weeks, you may also try using heat and choose what works best for you.
Can I go up and down stairs?
Yes. Initially, you will lead with your nonoperated leg when going up stairs, and lead with your operated leg when coming down. As your muscles get stronger and your motion improves, you will be able to perform stairs in a more normal fashion.
Do I need physical therapy?
Yes. The physical therapist plays an important role in your recovery. You will be seen by a physical therapist soon after your operation and throughout your hospital stay. Once home, a therapist will probably visit you 2-3 times a week to assist you with your exercise program. You will also be taught a series of exercises that you can do on your own without supervision. In addition, swimming and riding a stationary bicycle are good exercise options. These exercises can be continued indefinitely even after your recovery is complete.
I am constipated, what should I do?
It is very common to have constipation after surgery. This is due to a number of factors and is aggravated by the need to take narcotic pain medication. A simple over-the-counter stool softener is the best prevention for this problem. In rare cases, you may require a suppository or enema or other medication.
I feel depressed, is this normal?
It is not uncommon to have feelings of depression after TKA. This may be due to a variety of factors, such as limited mobility, discomfort, increased dependency on others, and medication side effects. Feelings of depression will typically fade as you begin to return to regular activities. If your feelings of depression persist, consult your primary care physician.
I have insomnia, is this normal? What can I do about it?
This is a common complaint following TKA. Nonprescription remedies such as diphenhydramine (Benadryl) or melatonin may be effective. If this continues to be a problem, prescription medication may be necessary. Most who have difficulty sleeping following TKA do so because their knee hurts rather than an actual sleep disorder. Often merely taking a pain pill at bed time will help solve this problem.
POSTOPERATIVE (Long Term)
How much range of motion do I need?
Most people need 70° of flexion to walk normally on level ground, 90° to ascend stairs, 100° to descend stairs, and 105° to get out of a low chair. To walk and stand efficiently, your knee should also come to within 10° of being fully straight.
What range of motion should I expect from my own knee at 6 weeks? At 1 year?
Range of motion varies and depends on many individual factors. Your potential will be determined at surgery. My average patient achieves approximately 120° of flexion by 6 weeks postoperatively. Some patients achieve less, and some much more. The range of motion you have prior to surgery has a significant impact on what you might achieve following surgery.
I think my leg feels longer now, is this possible?
In the majority of cases, your leg length will essentially be unchanged. In some cases, however, the leg is slightly lengthened. This usually is the result of straightening out a knee that had a significant bow preoperatively. At first, the increased length may feel awkward. Most people become accustomed to the difference, but occasionally a shoe lift may be necessary in the opposite extremity. If you make a bowed leg straight it will become slightly longer.
Can I use weights when I exercise?
Generally, weights are not used for the first 6-8 weeks. As you progress with your physical therapy program, your physical therapist may recommend the use of weights. These should be limited to light weights.
Will I set off the security monitors at the airport? Do I need a doctor's letter?
You will probably set off the alarm as you progress through the security checkpoint. Be proactive and inform the security personnel that you have had a TKA and will most likely set off the alarm. Wear clothing that will allow you to show them your knee incision without difficulty. A letter from your physician or a wallet card is no longer of any help when passing through security checkpoints.
Do I need antibiotics before dental work or an invasive medical procedure?
Yes. Inform your dentist that you have had a knee replacement. Avoid any dental cleaning of non-urgent procedures for 6 weeks after surgery. Current thinking is that antibiotics on the day of dental or other invasive procedures is useful at least for the first 2 years following joint replacement.
Can I kneel?
Yes. After several months, you can try to kneel. It may be painful at first but will not be harmful or damaging to your knee. Much of the discomfort comes from kneeling on your recent incision and the healing local tissues. Kneeling generally becomes more comfortable as time passes.
Can I return to downhill skiing?
Downhill skiing poses a risk. This comes not from the act of skiing, but rather from potential injury due to a serious fall or collision with another skier. You should definitely avoid skiing black diamond slopes. If you ski, be aware of the risks and ski only in good conditions.
When do I need to follow up with Dr. Kimball?
Follow-up appointments are usually made 10-14 days, 6 weeks, and 3 months postoperatively, followed by 1 year, 2 years, 5 years, 7 years, and 10 years. Follow-up is necessary to monitor the prosthesis fixation and potential wear of the plastic articulation. If you have any other problems, you should seek additional follow-up as needed.
If you have questions, please ask them. You can call the office and speak to me or to Doug Fillmore my P.A. For non-medical questions you may speak to Chyleen Phillips, my assistant or Alison Nickle, my executive assistant.
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