Total Knee ReplacementBy
Sarah Lewis, PharmD
What is a total knee replacement?
A total knee replacement is the surgical removal of the entire knee joint and replacement with an artificial joint called a prosthesis. Your knee joint is formed where your thigh bone (femur) and your shin bone (tibia) meet. It is the largest joint in your body and also contains ligaments, tendons, cartilage, the kneecap (patella), and lubricating fluid. Total knee replacement can help restore pain-free range of motion and full function in a diseased knee joint. Another name for it is total knee arthroplasty.
A total knee replacement is a common but major surgery with serious risks and potential complications. You may have less invasive treatment options. Consider getting a second opinion about all of your treatment choices before having a total knee replacement.
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Why is a total knee replacement performed?
Your doctor may recommend a total knee replacement to treat a variety of diseases, disorders and conditions of the knee. Your doctor may only consider a total knee replacement if other treatment options that involve less risk of complications have not worked. Ask your doctor about all of your treatment options and consider getting a second opinion before deciding on total knee replacement surgery.
Your doctor may recommend total knee arthroplasty to treat severe knee joint damage caused by:
Knee joint infections, also called septic arthritis
Knee joint injuries, including fractures, torn ligaments, and torn cartilage, which may lead to irreversible joint damage
Osteoarthritis, or degenerative joint disease, which is the breakdown of cartilage and bones within the joint, resulting in pain, stiffness and swelling. It is the most common reason for a total knee replacement.
Osteonecrosis, or death of bone. Osteonecrosis is a rare condition.
Rheumatoid arthritis, which is an autoimmune disease characterized by joint inflammation, and other inflammatory causes of arthritis
Who performs a total knee replacement?
An orthopedic surgeon performs total knee replacement. An orthopedic surgeon specializes in surgical treatment of diseases and conditions of the bones and connective tissues.
How is a total knee replacement performed?
Your total knee replacement will be performed in a hospital or surgical center. Your orthopedic surgeon will perform the procedure by making an incision in the knee to remove damaged cartilage and bone and replace it with plastic or metal surfaces.
Surgical approaches to a total knee replacement
A total knee replacement may be performed using one of the following approaches:
Minimally invasive surgery involves inserting special instruments and an arthroscope through a 3- to 4-inch incision in your knee. The arthroscope is a thin, lighted instrument with a small camera that transmits pictures of the inside of your body to a video screen. Your surgeon sees the inside of your knee on the video screen while performing surgery. Minimally invasive total knee replacement generally results in a quicker recovery with less pain than open surgical procedures. This is because it causes less trauma to tissues. Your surgeon will make a smaller incision than the incision used in open knee surgery. Surgical tools are threaded around muscles and tissues instead of cutting through or displacing them as in open surgery.
Open surgery involves making an 8- to 10-inch incision in the knee. Open surgery incision allows your doctor to directly view and access the surgical area. Open surgery generally has a longer recovery and more pain than minimally invasive surgery. Open surgery requires a larger incision and more cutting and displacement of muscle and other tissues than minimally invasive surgery. Despite this, open surgery may be a safer or more effective method for certain patients.
Sensor-assisted surgery uses a device during surgery to help your surgeon properly balance the soft tissues in the knee. This includes ligaments, tendons and muscles. The sensor helps avoid making the new joint too tight, which limits the range of motion, or too loose, which makes the knee unstable. Sensor-assisted surgery may also shorten your recovery time. However, using the sensor does not change the type of implant or the surgical method your doctor can choose.
Minimally invasive techniques may be combined with an open procedure. Your surgeon may also decide after beginning a minimally invasive technique that you require an open surgery to safely and most effectively complete your surgery.
Your surgeon will advise you on which procedure is best for you and how long you need to stay in the hospital or surgical center based on your diagnosis, age, medical history, general health, and possibly your personal preference. Learn about the different procedures and ask why your surgeon will use a particular type of procedure for you.
Types of anesthesia for knee replacement
A total knee replacement may be performed using either general anesthesia or regional anesthesia.
General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You may also have a peripheral nerve block infusion in addition to general anesthesia. A peripheral nerve block infusion is an injection or continuous drip of liquid anesthetic. The anesthetic flows through a tiny tube inserted near your surgical site to control pain during and after surgery.
Regional anesthesia is also known as a nerve block. It involves injecting an anesthetic around certain nerves to numb a large area of the body. You will likely have sedation with regional anesthesia to keep you relaxed and comfortable.
What to expect the day of your total knee replacement
The day of your surgery, you can generally expect to:
Talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form.
Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. Your care team will give you blankets for modesty and warmth.
Talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will have.
A surgical team member will start an IV.
The anesthesiologist or nurse anesthetist will start your anesthesia.
A tube will be placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the surgery as they happen.
The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the procedure and during your recovery until you are alert, breathing effectively, and your vital signs are stable.
What are the risks and potential complications of a total knee replacement?
As with all surgeries, a total knee replacement involves risks and possible complications. Most surgeries are successful, but complications may become serious and life threatening in some cases. Complications can develop during surgery or recovery.
General risks of surgery
The general risks of surgery include:
Anesthesia reaction, such as an allergic reaction and problems with breathing
Bleeding or hemorrhage (heavy bleeding), which can lead to shock
Blood clot, in particular a deep vein thrombosis that develops in the leg or pelvis. A blood clot can move to your lungs, heart or brain and cause a pulmonary embolism, heart attack, or stroke.
Infection and septicemia, which is the spread of a local infection to the blood
Potential complications of a total knee replacement
The vast majority of total knee replacements are successful. However, complications can be serious. Potential complications of a total knee replacement include:
Dislocation of the new joint
Loosening of the new joint causing pain and the possibility of additional surgery to secure the new joint
Nerve, muscle, or blood vessel damage
Wear and tear of the new joint requiring another replacement
Reducing your risk of complications
You can reduce the risk of certain complications by following your treatment plan and:
Following activity, dietary and lifestyle restrictions and recommendations before surgery and during recovery, including physical therapy, occupational therapy and other rehabilitation treatments
Informing your doctor if you are nursing or there is any possibility of pregnancy
Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
Taking your medications exactly as directed
Telling all members of your care team if you have any allergies
How do I prepare for total knee replacement?
You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome.
You can prepare for a total knee replacement by:
Answering all questions about your medical history and medications you take. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.
Getting preoperative testing as directed. Testing will vary depending on your age, health, and specific procedure. Preoperative testing may include a chest X-ray, EKG (electrocardiogram), blood tests, and other tests as needed.
Losing excess weight before the surgery through a healthy diet and exercise plan. This will also decrease the weight load on your new knee.
Not eating or drinking before surgery as directed. Your surgery may be cancelled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.
Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.
Questions to ask your doctor
Facing surgery can be stressful. It is common for patients to forget some of their questions during a brief doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before surgery and between appointments.
It is also a good idea to bring a list of questions to your appointments. Questions can include:
Why do I need a total knee replacement? Are there any other options for treating my condition?
What type of total knee replacement procedure will I need?
How long will the procedure take? When will I be able to go home?
What restrictions will I have after the surgery? When can I return to work and other activities?
What kind of assistance will I need at home?
How should I take my medications?
How will you treat my pain?
When should I follow up with you?
How should I contact you if problems arise? Ask for numbers to call during and after regular hours.
What can I expect after total knee replacement?
Knowing what to expect can help make your road to recovery after a total knee replacement as smooth as possible.
How long will it take to recover?
You will stay in the recovery room after surgery until you are alert, breathing effectively, and your vital signs are stable. You may have a sore throat if a tube was placed in your windpipe during surgery. This is usually temporary, but tell your care team if you are uncomfortable.
A total knee replacement generally requires a hospital stay of several days. Some people need to stay in a rehabilitation center after discharge from the hospital to improve mobility and joint function so they can safely return home.
Recovery after surgery is a gradual process. Recovery time varies depending on the procedure, type of anesthesia, your general health, age, and other factors. Recovery time for total knee replacement is 2 to 3 months, but a full recovery may take up to a year.
Will I feel pain?
Pain control is important for healing and a smooth recovery. There will be discomfort after your surgery. Your doctor will treat your pain so you are comfortable and can get the rest you need. Call your doctor if your pain gets worse or changes because it may be a sign of a complication.
When should I call my doctor?
It is important to keep your follow-up appointments after a total knee replacement. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:
Breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing
Change in alertness, such as passing out, unresponsiveness, or confusion
Chest pain, chest tightness, chest pressure, or palpitations
Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor's specific instructions about when to call for a fever.
Inability to urinate or have a bowel movement
Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot
Numbness or tingling in the affected extremity
Pain that is not controlled by your pain medication
Unexpected drainage, pus, redness or swelling of your incision
How might a total knee replacement affect my everyday life?
A total knee replacement may cure your condition or significantly reduce your symptoms so you can lead an active, normal life. For example, a total knee replacement may help relieve pain and allow you to move around more easily and be more active.
A total knee replacement usually results in very few limitations or restrictions to everyday activities. Most people enjoy a return to activities they were no longer able to do before surgery.
A total knee replacement can also cause significant changes to your body that may affect your everyday life, such as restrictions on:
High impact activities such as running
Joint overloading activities such as heavy lifting
Sports requiring lateral movements such as skiing
Vigorous walking, hiking, or stair climbing
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