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A Complete Guide for
Patients Having Knee Replacement Surgery
Choosing to have a total knee replacement is a big decision. For
many patients, the prospect of the greater mobility and reduced
pain of a “new knee” is exciting. But, as with any major
surgery, patients also have questions and concerns.
This handbook provides much of the information you need to prepare
for your upcoming surgical experience. You should read the entire
booklet and share it with your family and primary caregiver –
the person who will be helping you at home after surgery. Gaining
as much knowledge as possible ahead of time will help both of you
be relaxed and ready for the experience that lies ahead.
Before Your Surgery
Preparing for a total knee replacement begins weeks before your
actual surgery date. First, you will want to prepare yourself physically.
It is important to be in the best possible overall health to help
ensure the best possible surgical experience. Activities that will
increase upper body strength are of special importance because you
will be using a walker or crutches after the operation. Talk to
your physician for specific recommendations.
Many times, knee replacement results in the need for autotransfusion,
a safe and effective procedure in which the blood that you lose
during surgery is salvaged and recycled. During surgery, the blood
you lose is collected under sterile conditions and filtered of all
impurities. The collected blood is then washed to remove bacteria
and other contaminants, resuspended in clear crystalloid fluid,
and transfused back into your body.
It is also possible that your knee replacement will necessitate
a blood transfusion. While autotransfusion uses your own blood,
a blood transfusion requires that you be given someone else’s
donated blood – unless you donate your own blood ahead of time.
Because a blood transfusion may be necessary, you may want to consider
donating several pints of your own blood. In the weeks before surgery,
you should talk with your physician about these procedures.
In the weeks before surgery, talk with your surgeon about blood
transfusion and autotransfusion.
Before your surgery, the physician may order blood tests and a urinalysis
to check for any infections. Also, your teeth need to be in good
condition as an infected tooth or gum could be a source of infection
for the new knee. For these reasons, your orthopaedic specialist
may ask you to see a medical doctor and/or dentist for a check-up.
You may be instructed to stop taking any anti-inflammatory medications
(aspirin, ibuprofen) a week or two before surgery. You may take
Tylenol® (acetaminophen), but if you need stronger pain relief,
call your surgeon.
Pre-Surgery Checklist
Night Before Surgery Pack a small
suitcase with personal hygiene items, non-skid slippers, and comfortable
loose clothing Do not eat or
drink after midnight Take a bath or
shower Review this booklet
Day of Surgery Take medications
only as instructed by your anesthesiologist Arrive at the
hospital at the appointed time and check in at the registration
desk.
Pre-Op Visit
Prior to your surgery, you will have a pre-op visit to the hospital.
This educational visit can last several hours, and will provide
a great deal of helpful information for you and your caregivers.
Be sure to prepare a list of questions ahead of time and bring it
with you.
The pre-admission nurse will inquire about your past medical history
and current medications, have you sign a permit for surgery, and
provide some basic pre-op teaching concerning diet. Be sure to provide
complete and accurate medical information; it will help for you
to bring a list of past surgeries and current medications and dosages
you normally take.
Your anesthesiologist will conduct a teaching session to explain
your anesthesia options for surgery. He or she may also ask for
more detailed medical information, and may order some basic pre-operative
testing for you, such as a blood test, EKG, and/or chest x-ray,
to confirm that you are in optimal health for surgery.
The orthopaedic nurse educator will discuss your “patient pathway”
– our specific plan for your personal care during your hospitalization.
Areas covered in detail will include pain management, use of the
continuous passive motion (CPM) machine, use of assistive devices,
breathing exercises, and blood clot prevention.
Pain Management
Your surgery and ensuing activity will likely cause you some discomfort.
Our goal is to help you manage your pain so that it doesn’t
inhibit your recovery. Do not delay taking your pain medication
until the pain becomes unbearable. Taking the medication will help
you breathe easier and move sooner, which will help you progress
more quickly.
Following surgery, you will be asked to rate your pain on a 0-to-10
pain scale, where 0 is no pain and 10 is the worst pain you’ve
ever had.
After your surgery, your pain
will be controlled in one or more of the following ways: PCA (Patient-Controlled Analgesia) – a pump connected
to your IV that you control. You determine, within safe limits that
we set, how often you receive your pain medication. It is important
to have adequate pain relief before walking and physical therapy
so that you will not be inhibited in your activity. Oral – medication given by mouth, usually after
you have stopped the PCA. Shots – medication given by injection.
For some patients, temporary nausea and vomiting can be caused by
anesthesia or medications for pain (ie, PCA). Anti-nausea medication
may be given to help ease this effect.
Our goal is to help you manage your pain so that it doesn’t
inhibit your recovery.
What to Expect the Day of Your Surgery
On the day of your surgery, you will be admitted to the hospital.
Once the admission process is complete, you will then be taken to
the presurgical unit and asked to change into a hospital gown. A
final presurgery assessment of vital signs and general health will
be performed. After this, you will be transported to a “holding
area” near the operating room. At this time, your family will
be instructed to wait in the designated surgery waiting area while
you are away. They will be updated on your progress.
In the holding area, you will have an IV (intravenous) catheter
(tube) inserted into a vein in your arm so that you can receive
the necessary medications during surgery. You will be given an antibiotic
through your IV to reduce the risk of infection. (All surgery carries
the risk of infection because of the bacteria that are normally
present in the body.)
Your anesthesiologist and operating room nurse will meet with you
in the holding area. At this time, be sure to ask any last-minute
questions. When your surgeon is prepared and all of the presurgery
tasks are complete, you will be transported to the operating room
on a stretcher.
After your surgery, you will be taken to the Recovery Room where
you will stay for about 1 hour. A nurse will frequently check your
vital signs and surgical dressing. When your condition is stable,
you will be transferred to your room on the surgical unit.
Once you are in your room, a nurse will continue to check your progress
and help you get oriented to your surroundings and the routine of
your stay. You can expect the nurse to: Examine you and
listen to your heart and lungs Check your vital
signs Check your surgical
dressing and drain; reinforce the dressing as needed Reinforce use
of the patient-controlled analgesia (PCA) pump for pain management Record what you
eat and drink and monitor how much urine you produce (you will have
a Foley catheter in your bladder attached to a urine collection
bag; this monitoring of intake and ouput is called I&O) Apply cold packs
to your operative leg Apply TED stockings
to your nonoperative leg to help prevent blood clots Apply foot pumps
to help prevent blood clots Assist you in
turning, coughing, deep breathing, and using incentive spirometry
to help prevent complications, such as congestion or pneumonia,
due to decreased activity Maintain your
IV Reinforce pre-
and post-op teaching; answer any questions you and your family members
may have
Another crucial part of your recovery is physical therapy (PT).
A physical therapist will promptly visit you in your room to: Evaluate your
condition Place you on
the CPM machine as directed by your physician Instruct you
in an individualized program of rehabilitation exercises
During the rest of the day, you will: Be able to have
clear liquids or soft diet as tolerated Have blood drawn
to further monitor your condition Be encouraged
to do the post-op activities you were taught during your pre-op
visit and physical therapy (PT)
What to Expect: Post-Op Days 1 to 4
Most patients who have a knee replacement stay in the hospital 3
or 4 days. Your doctor will visit you each day to evaluate your
progress and make any needed changes to your plan of care. These
pages provide an outline of what else you can expect in the days
following your surgery.
Post-Op Day 1
The nursing staff will: Continue to monitor
and assess, making no major changes Maintain the
PCA pump for pain control Continue to apply
cold packs to your operative leg Maintain the
TED stockings and foot pumps Adjust the CPM
when PT is not available Assist you in
getting out of bed Reinforce Coumadin
teaching (see section of this booklet titled “Use of Coumadin”) Assist you with
bathing Reinforce pre-
and post-op teaching
The physical therapy staff will: Adjust the CPM
as you can tolerate Teach you to
perform knee exercises Teach you to
use a walker or crutches and assist you with walking
The occupational therapy staff will: Meet with you
to discuss home equipment needs Assist and instruct
you in daily living activities, such as dressing, bathing, toileting
The case manager will: Discuss your
plans for returning home Start making
any necessary arrangements for care or equipment
Post-Op Day 2
The nursing staff will: Check your surgical
dressing and drain (physician may discontinue the drain); change
the dressing Discontinue the
PCA pump and provide oral pain medication upon your request Change your IV
to a Heparin-lock, a small sterile tube that will allow for easier
movement while keeping a vein accessible for antibiotics Discontinue the
Foley catheter Monitor your
bowel function Continue to apply
cold packs to your operative leg Maintain the
TED stockings and foot pump Assist you in
moving around Answer questions
and continue discharge teaching
The physical therapy staff will: Adjust the CPM
as you can tolerate Assist you 2
or 3 times a day with your knee exercise program, range of motion
(ROM), and walking Teach you how
to safely go up and down stairs Discuss how to
get in and out of a car Reinforce instruction
Post-Op Day 3
If you have not experienced any complications, it is likely that
you will be discharged today. As you prepare to return home, you
should feel comfortable with ambulation (walking with a walker or
crutches) and should understand your pain medication and Coumadin®
therapy regimens. Make sure that you understand all of the instructions
you have been given and ask any questions you may have.
The nursing staff will: Check your surgical
dressing; change the dressing if needed Continue to provide
oral pain medication upon your request Continue to monitor
your bowel function Continue to apply
cold packs to your operative leg Maintain the
TED stockings and foot pump Review the medicines
you are to take home Answer questions
and review discharge teaching
The physical therapy staff will: Continue the
CPM as ordered Assist you 2
or 3 times a day with your knee exercise program, ROM, and walking Reinforce instruction
The case manager will: Finalize discharge
arrangements Arrange for home
equipment needs
Post-Op Day 4
For patients who are not yet discharged, the remaining day(s) in
the hospital will follow much the same course as Day 3.
The nursing staff will: Continue to monitor
your vital signs and other physical indicators Remove your surgical
dressing, unless you prefer to leave it covered Maintain pain
medication, cold packs, TED stockings, foot pump
The physical therapy staff will: Continue the
CPM as ordered Assist you 2
or 3 times a day with your knee exercise program, ROM, and walking Reinforce instruction
The case manager will: Review your discharge
plan and make any needed changes
Getting Moving Again
It may come as a surprise to you that you will be encouraged to
get up and start moving around as soon as possible after your surgery
– sometimes even the day of your surgery. When you are medically
stable, your physical therapist will teach and assist you to perform
certain knee exercises.
Physical therapy is a key part of your recovery. The more quickly
you get moving again, the more quickly you are likely to progress.
To ease the
discomfort the activity will initially cause, remember to take your
pain medication prior to therapy.
In addition, your physical therapist will discuss your longer-term
rehabilitation plans. You will also see an occupational therapist
who will teach you how to use certain devices to help you put on
socks, reach for household items, and bathe in a safe manner. Your
therapist can also recommend ways to make your recovery at home
as easy – and safe – as possible. A case manager will
talk with you about your plans to go home and to ensure that you
have all the necessary help to support you in your recovery. If
needed, the case manager can help arrange a visiting nurse.
Your Diet
After surgery, your physician will limit your diet to liquids for
the first 6 to 8 hours. Many people will experience some nausea
due to the anesthesia and pain medication. Your food selection will
be limited to clear liquids such as apple juice, ginger ale, tea,
broth, and gelatin. Once any nausea has passed, you will be able
to select from our dining menu. Any member of the patient care staff
can assist you with making meal selections.
Constipation can also be a side effect of the inactivity following
surgery and of certain
medications. If you experience constipation, try these suggestions: Eat 5 to 7 servings
of fresh fruit and vegetables daily Eat a hot breakfast
with a hot beverage daily Increase fiber
in your diet by eating whole grain cereals and breads Drink at least
6 to 8 8-oz. glasses of water daily Increase your
physical activity as much as you can tolerate
Preventing Complications
Patients who undergo total knee replacement are at risk for certain
complications, including infection, lung congestion, and blood clots.
To help reduce these risks, you will be given medications, materials,
and instructions for use in the hospital and at home: Antibiotics – Following surgery, you will receive
antibiotics to prevent infection. However, for the rest of your
life you will need to follow the Antibiotic Regimen to reduce risk
of infection (see section in this booklet titled “The Antibiotic
Regimen”). Incentive spirometry – a series of deep breathing
exercises to keep the lungs clear
of congestion. Foot pump – felt sleeves that fit over your feet
and are connected to a machine that pulsates. This promotes blood
flow in your legs and decreases the chance of blood clots. Controlled passive motion (CPM) machine – an
apparatus that assists you in moving your leg gently and frequently. TED stockings – elastic support stockings
that improve blood circulation in your legs. These must be worn
correctly each day in order to prevent blood clots (see section
titled “Use of TED Stockings”). You should continue to
use your TED stockings until your physician says otherwise. Coumadin®– a medication that thins your blood
to reduce the risk of clot formation. Elevation – raising your feet and legs helps
keep blood from pooling in the lower extremities.
Use of TED Stockings
Blood clots are a serious concern for knee replacement patients
because your decreased activity level following surgery puts you
at risk. TED anti-embolism (anti-blood clot) stockings improve the
flow of blood in your legs. During activity, your muscles help pump
blood from your heart to your legs and back again by applying pressure
to the veins. During long periods of decreased activity, the muscles’
involvement in assisting in blood circulation is decreased. As a
result, there is an increased risk of blood pooling and clotting
in the legs.
TED stockings create pressure that helps push blood out of the legs
and back to the heart. The pressure is strongest at the ankle –
the lowest part of your leg. By wearing your TED stockings as instructed
by your doctor, you are reducing your risk of blood clots forming
in your legs. You must wear your stockings correctly each day for
them to be effective. These pages provide instructions for proper
use of your TED stockings:
Before You Begin
1. Make sure your legs and feet are clean. Gently bathe them daily.
Do not massage the skin on your legs. Do not apply cream or lotion
to the skin.
2. Make sure your legs are dry. You may lightly powder your legs
to decrease irritation and help the stockings slide on more easily.
3. Make sure you put the stockings on straight. Twisted stockings
will not provide the proper pressure.
How to Apply Your Stockings
1. Insert hand into stocking as far as the heel pocket. Do not roll
up stocking before putting it on. (Stockings are interchangeable
for either leg.)
2. Grasp center of heel pocket and turn stocking inside-out to heel
area.
3. Carefully position stocking over foot and heel. Work the stocking
with the flat of your hand until the foot and heel are in place.
Be sure the heel is centered in the heel pocket.
How to Remove Your Stockings
1. Remove your stockings once daily while you wash your legs and
feet.
2. Take hold of the upper edge of the stocking and pull toward the
heel. With the flat part of your hand, work the stocking over the
heel and remove.
3. After removing the stocking, check your legs and feet for changes
in color, temperature, sensation (numbness), irritation, abrasions
of the leg, tenderness, or pain. These are signs of decreased blood
flow.
How to Care for Your Stockings
1. Clean your stockings every 3 days. Wear your clean pair while
the other pair is being washed.
2. Machine- or hand-wash your stockings. Do not use bleach—only
soap and water.
3. Dry your stockings by laying them flat or by machine-drying them
on a low setting. When done, remove from the dryer immediately.
4. Do not use ointments, oils, lanolin, or creams on your legs.
These can cause the elastic in the stockings to wear out.
5. Be careful of fingernails; they can puncture the stockings.
6. Do not stretch or pull on the stockings more than necessary;
the elastic will begin to weaken.
When to Call Your Doctor
1. If you notice any of these conditions on your legs or feet: rash,
open sores, reddened areas, changes in skin color or temperature,
numbness, tenderness.
2. If your stockings become loose, torn, or if they fit improperly.
The Antibiotic Regimen
After knee replacement, you must – for the rest of your life
– follow the Antibiotic Regimen outlined below. This is because
any infection that develops in your body can spread bacteria to
your artificial joint, putting it at risk. Early treatment of the
infection will prevent this complication. The following is the Antibiotic
Regimen:
1. Any time – even years after your surgery – that you
develop an infection such as strep throat or pneumonia, or if you
think you have developed an infection anywhere in your body, you
must notify your doctor. This includes infections in the gums, skin,
bladder, etc. In such cases, it is recommended that your family
doctor promptly prescribe antibiotics and culture any drainage.
2. It is also important that, for the rest of your life, you advise
any physicians and dentists you visit that you have had a joint
replacement. Oral antibiotics are recommended for all routine dental
procedures, including teeth cleanings and treatment of dental cavities.
IV antibiotics are recommended for extensive surgical procedures
of the gums or jaw.
Use of Coumadin®
Coumadin is a prescription medication that thins your blood to prevent
clot formation. When taking Coumadin, you should follow the instructions
below.
Special Instructions for Patients Taking Coumadin: Take the exact
dosage of Coumadin that your physician prescribes for you. Take Coumadin
at the same time every day. Note that the
amount of the drug you take may vary over time. Your physician will
determine the dosage schedule based on the results of a routine
blood test (prothrombin time or PT). This test may be taken on a
weekly basis until your physician discontinues the medication. Because Coumadin
thins your blood, it can cause excessive bleeding. Take special
care not to bruise or cut yourself. If you do get a cut, apply pressure
over the area and apply a bandage. If you need any
dental work or other surgical procedures, inform the dentist or
physician that you have had a joint replacement and are taking Coumadin. Follow the dietary
guidelines sheet for foods that may affect the medication. Do not take Ecotrin“,
aspirin, or any arthritis medications without talking to your physician.
Medications such as these can thin your blood. Only use pain medication
prescribed by your physician or take Tylenol“. Continue to take
Coumadin until your physician tells you to stop. While on Coumadin,
take the following precautions to reduce your risk of bleeding:
– shave with an electric razor
– use a soft-bristled toothbrush
– wear shoes at all times
– arrange furniture and rugs to reduce your risk of bumping
or tripping Call your physician
if you develop any of the following conditions:
– excessive bruising
– red or black stools
– nosebleeds
– red or dark urine
– bleeding gums
– unexplained swelling
Exercising Your New Knee
Be sure to exercise your knee as instructed by your surgeon or physical
therapist after your total knee replacement. Exercise builds leg
strength and improves the knee’s range of motion.
Quad Sets Sitting, place
your leg with the new knee joint straight out in front of you. Slowly tighten
thigh muscles of straight leg while counting to 10 out loud. Relax. Heel Slides Sitting, place
both of your legs straight out in front of you. Slide your leg
with the new knee joint toward your chest while keeping your heel
on the ground. Grasp your leg behind the thigh if necessary. Hold the position
when you feel a gentle stretch in your knee. Repeat 20 times.
Heel Prop Lie with pillow
under RIGHT/LEFT heel. Tighten the muscles
on the top of the leg while trying to push knee toward the floor.
Hold ____ seconds. Short Arc Quad Sets Place a rolled
towel under your operated knee, keep your knee on the towel, and
lift the foot of your operated leg several inches. Try to straighten
your knee. Lower your foot
back to the ground. Repeat this 10
times. Do this exercise
twice a day, and build up to 25 repetitions. Straight Leg Raises Bend your unoperated
leg. Keep your operated
leg as straight as possible and lift it up as high as your bent
knee. Slowly lower
your leg, then rest. Repeat this 10
times. Do this exercise
twice a day, and gradually build up to 25 repetitions.
Long Arc Quads While sitting
in a straight chair, slowly straighten your operated leg as much
as you can. Hold your leg
out for a count of 5. Bend your leg;
bring it back as far as you can, then pause and return to the starting
point. Hamstring Strengthening While holding
support, lift RIGHT/LEFT heel toward buttocks. Hold ____ seconds.
Partial Knee Bends Hold on to a
stable object. Slightly bend
knees and slowly straighten.
Range of Motion Place RIGHT/LEFT
foot on smooth surface. Slowly slide
foot back as far as possible. Hold ____ seconds.
Stationary Bike Slowly pedal
the bike forward and then backward. Lower the seat
a bit for improved range of motion.
Avoid Risky Movements
Because some movements put a lot of strain on the knee, you will
want to keep the following in mind to protect your new joint: Do not twist
your knee, as can happen when you turn your body without moving
your feet. Do not perform
high-impact activities, such as running or jumping.
How to Use a Walker/Crutches Holding your
crutches in place, put pressure on your hands, but not on your armpits. Move your crutches
forward, then the operated leg. Looking straight
ahead, step through your crutches with your unoperated leg.
How to Go Up and Down Steps
To Go Up Stairs: Using your crutches
for support, place your unoperated leg on the step. Lean on the crutches
and lift yourself up with the same leg.
To Go Down Stairs: Place your crutches
and your operated leg on the lower step. Use your crutches
for balance and lower yourself down the step. Move the crutches
as you would the operated leg. When you can,
use a railing.
Important Reminders for the First Month
You will eventually be able to return to your usual activities,
but during the first month, please follow these instructions: Put as much weight
as you like on your surgical leg while walking, but continue to
use your crutches or walker until your 1-month visit. Walk as much
as you like. Continue with
all your exercises – especially straight leg raises and bending.
Sitting in a rocking chair helps with bending. You may use ice packs
for 20 minutes at a time on the knee. No jumping, lifting,
or kneeling activities yet. Use a toilet
seat riser if needed. Wear your TED
stockings until your 1-month appointment. Note that you may leave
them off for short periods of time and at night. Do not lift any
weights with your surgical leg. You may lie on
either side in the bed; placing a pillow between your knees may
make it more comfortable. You may engage
in sexual activity whenever comfortable – 4 to 6 weeks post-surgery.
Be more passive in the beginning. Do not drive
prior to your 1-month follow-up appointment or until the doctor
allows you to drive. Follow the Antibiotic
Regimen for the rest of your life. Expect to be
tired and need rest periods. Lying down a few times a day will help
reduce leg swelling. If you go home
on Coumadin®, do not take any aspirin products or arthritis
medications unless you have discussed it with your doctor. Keep the incision
clean and dry. If you have staples or stitches, you must not shower
until they are removed. Make an appointment to have them removed
approximately 2 weeks after surgery. Use pain medication
as directed to minimize discomfort while exercising. Do not drive
or drink alcohol while taking narcotics for pain. Call if signs
of infection develop: redness, increased swelling or pain, fever,
chills, or drainage (other than the clear, yellow drainage you may
have had while in the hospital). Call your physician’s
office if you have any questions or problems.
Jeffrey R. Ginther, MD, FACS | Servicing Central Indiana | 317-770-4100
