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ORTHOPAEDIC SURGERY


The Day of Surgery and Postoperative Course
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It is normal to feel anxious on the day of surgery, but try to relax. You will meet several members of the hospital staff, be checked-in, and asked to change into a hospital gown. You will meet your Consultant and the Anaesthetist.

You will be taken to the pre-anaesthesia room where the Anaesthetist will discuss the anaesthesia options. Two types of anaesthesia are commonly used for knee replacement surgery. The first is a general anaesthesia, which puts you in a deep sleep and therefore requires assistance with your breathing. The risks are small and usually are related to the heart or lungs. The second type of anaesthesia (epidural anaesthesia) works by numbing your legs so you do not feel the operation. This is done by placing numbing medicine around the nerves that go to your legs using a small catheter in your lower back. You are also given medicine to relax you and you may fall asleep, but you can still breathe on your own. The potential advantages of the epidural anaesthesia include less blood loss and less risk of lung problems and blood clots in the legs. Also, the epidural can be continued after your surgery to help control the pain. If you are young and/or without vascular disease, your surgeon and Anaesthetist may employ methods to lower blood pressure (hypotensive anaesthesia) to conserve blood loss, and to assist in obtaining optimal fixation when acrylic bone cement is used. Following your discussion with the Anaesthetist, you will then be taken to the operating room and devices will be placed on you to monitor your heart, blood pressure, breathing and temperature. The anaesthesia will be administered.

The total knee replacement procedure takes about two hours. Some additional time is required for the Anaesthetist to prepare you for surgery and then following surgery to transport you from surgery to the recovery room. Depending upon the type of anaesthesia that you receive, you may have no recollection of the operation. You may awaken in the recovery room. There will be a nurse by your side to help you awaken and recover from anaesthesia.

It is very likely that you will have pain in your knee. This is normal and you should not be surprised or concerned. Remember, total knee replacement is major surgery. Most of the pain that you experience right after surgery is from the surgical incision and dissection. You will be given strong pain medication through your I.V. line. The pain will decrease over the first couple of days. You may feel somewhat sick or nauseous. This is not unusual and medication can be given to relieve these symptoms. Most patients spend about an hour in the recovery room and then they are moved to the nursing floor. Recovery from anaesthesia is highly variable. Some patients are awake and alert within a couple of hours while others remain groggy until the next day.

You will be given fluid and medication through the I.V. line until you are able to drink and eat without upsetting your stomach. Most patients are ready for breakfast or lunch the day after surgery. Pain pills can be taken as needed. The most important aspect of your recovery after knee replacement surgery is mobilisation. Starting the day after surgery, the nurses and the physical therapists will work with you and assist you in getting out of bed, sitting up in a chair, and starting to walk. The knee is initially quite tender and most patients use a walker to get started.

Physical Therapy
The fundamental goals of physical therapy and rehabilitation following total knee replacement are :
  1. Full extension. Get the knee to straighten-out, all the way!
  2. Flex (bend) more than 90 degrees, and preferably to 120 degrees!
  3. Strengthen the quadriceps muscle to be able to actively extend (straighten) the knee all the way!
  4. Progressively increase your walking!
The therapist will work with you to be sure that you make progress with every session. While you're in the hospital, the therapist will try to work with you once in the morning and once in the afternoon. Your doctors will check you each day to be sure that you are getting better, as expected.

Each patient progresses at their own rate. In general, we expect that the knee has full extension the day after surgery and has 90 degrees of flexion by three days after surgery. Quadriceps strength and walking ability continue to improve over several months. Most patients are able to walk without cane or crutch by three months. Many are able to do so in less than six weeks. The use of continuous passive motion (CPM) machines, which automatically bend and straighten the knee following surgery, has relative advantages and disadvantages, depending upon the individual patient and their knee. Your doctor will decide whether or not CPM is beneficial for you.

You are ready for discharge from the hospital when you are able to drink and eat without upsetting your stomach and you don't require any medications that need to be administered through an I.V. line. You need to be able to sit in a chair, stand up, and walk about 30 feet. In order to be discharged there cannot be any evidence of infection, blood clots, or other complications. Obviously, you have only just begun to recover from your knee replacement surgery and there is much more work to be done in order to regain your functional independence!

Most patients are able to go home from the hospital in 3 or 4 days, however, our hospitals will take care of you for considerably longer, up to 10 days. When you do return home, you should continue, to do the exercises for your knee that you learned in the hospital. It can also be arranged for a physical therapist to visit the home and work with you. When at home, it is preferred that the patient wear regular clothes and spend most of the day out of bed. You will continue to wear TED hose for a minimum of two weeks following surgery and until your leg/knee is not swollen. By three days after surgery, it is all right to shower and get the incision wet. The surgical staples are usually left in for about 10 days. While you are recovering, you may go outside, go to the store, visit family and friends, etc. if you feel well enough. Remember, the idea is to live your life!

Some patients may have medical conditions or other arthritic joints that make it difficult or impossible for them to go directly home from the hospital. In other cases, there may not be family or friends available to help the patient at home after surgery. In these situations, the hospital staff should be notified in advance as they can assist in making arrangements with a rehabilitation facility or an extended care facility where the patient can stay for a week or two.

Usually, about 2-3 weeks after surgery, patients can go to a physical therapy facility on an outpatient basis. Continue on your own with the physical therapy exercises that you learned in the hospital. Remember, there are really only 4 goals for rehabilitation following total knee replacement. The knee must come out completely straight in full extension as shown in Figure 4a; the knee must bend to at least 90 degrees and preferably to 120 degrees as shown in Figure 4b; the quadriceps muscle must regain strength to actively extended the knee as shown in Figure 4c; and you should be able to walk as far as you want without a cane or crutch. Your doctor and your physical therapist may work with you, but you are ultimately responsible for the rehabilitation of your knee.
Physical Therapy Physical Therapy Physical Therapy
Fig 4a Fig 4b Fig 4c

Follow-up Examinations
It is preferred that a doctor or nurse check your wound and remove your skin staples at about 10 days after surgery. The next visit is usually around 4 weeks later. Most patients are able to drive at about 6-8 weeks after surgery. Try driving in an empty parking lot to ensure that you can control the car before driving on a busy street. You should also see your Doctor for an evaluation 3 months after surgery. We generally recommend an evaluation at 6 months after surgery and then at one year after surgery. We recommend that total knee replacement patients have evaluations on an annual basis with a standard series of x-rays, for the rest of their life. If you have concerns about your total knee replacement at any time, then you should call the doctor's office as soon as possible to schedule an appointment.

Medication Issues
Infection may localize at the site of the artificial implant and can cause major complications. Therefore, if at any time you should contract an infection anywhere in your body, especially those which cause high fever, you should have it treated immediately by your physician. Special precautions should be taken for bladder infections, ingrown toenails, prior to having dental work for tooth and gum infections, and before undergoing surgical procedures. In general, Amoxicillin 3 grams is recommended 1 hour before and 1.5 grams 6 hours after any dental root canal or major dental procedure. If you are allergic to Amoxicillin or Penicillin, Erythromycin stearate is recommended (1 gram 1.5 - 2 hours before and 500 mg 6 hours later). The need for special precaution during routine dental check-ups is controversial. If your gums tend to bleed during the cleaning process, antibiotics are recommended as described above. If possible, all dental work should be delayed until four months following surgery. Antibiotic coverage for other surgical procedures or infections is individualised according to the possible bacterial contamination and, therefore, you should notify the respective physician or surgeon so they can prescribe the appropriate medication.
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How long does the replacement last? And then what?
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In many ways, a total knee replacement is similar to a set of automobile tyres. How long a set of tyres lasts depends on how much the car is driven, on what types of roads the car is driven, how heavy the car is, and whether or not the car is properly serviced and maintained. Similarly, how long a total knee lasts depends on how much it is used, what types of activities it is used for, how heavy the patient is, whether the patient has regular check-ups with the doctor and whether the patient is staying in good physical condition.

No two patients are exactly the same and there is tremendous variability in patient activity. A set of automobile tyres can last for many years if the car is not driven very much. Alternatively, a set of automobile tyres can wear out in less than one year if they are driven many miles over rough roads. In many patients, their total knee replacement will last their lifetime. In others, it may last less than a year. Total knee replacements are designed to provide painless and unlimited standing, sitting, walking, and other activities of normal daily living. They do very well for golf, cycling and swimming. They are not designed for jogging, or sports like tennis and skiing - although there are patients with total knee replacements that do these things! Total knee replacement surgery is done to improve quality of life. Each patient must decide for themselves what makes life worth living for them, and then pursue happiness through those activities. You should be aware, however, that the longevity of a total knee replacement may be shortened by frequent, vigorous activities.

In the event that a total knee fails, it is possible to implant another knee replacement. Such revision total knee replacement surgery may be a lesser or greater operation than the original total knee surgery. Similarly, recovery from revision total knee surgery may be easier or more difficult than it was from the original total knee surgery. In general, the results of revision total knee surgery are not quite as good or predictable as for primary total knee replacements. The results of revision total knee replacement depend on what the problem was that necessitated surgery. Following revision total knee replacement, most patients have good relief of pain and are able to walk as far as they desire.
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Conclusion
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Total knee replacement has proven to be extremely successful and beneficial and a significant contribution to modern surgery. As with all major surgeries, there are risks that the patient must be willing to accept in order to obtain the benefits of pain relief and functional independence provided by a total knee replacement. Immediately following surgery, the patient will have pain from the operation and will have to diligently perform a number of exercises in order to rehabilitate the knee.

Recovery takes about 3 months and then most patients enjoy many years of painless knee function with no limits on their ability to stand, walk and perform other activities of normal daily living. We hope that your surgery is a success and that your hospital stay is as pleasant as possible. We are confident that this page of information will help to familiarise you with our procedures and answer many of your questions. However, please feel free to contact us should you have any further questions or require additional information. Bibliographic or patient references can be provided upon request.

If you have any further questions, please feel free to contact us.
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Orthopaedics Surgery

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