Preparing for knee replacement - practical issues

Knee replacement patients are generally in the 'autumn of their days'. It's important to ensure your family is part of the education process when knee replacement surgery is pending.

Their support is critical for a successful rehab which can take months after surgery. Ask that they attend the pre-op clinic with you so any questions they have can be answered. Like you, they will want to know about the risks involved in surgery, the medications you will find it necessary to take, the rehab protocol and in general, how they can assist your recovery.

Questions relating to admission

Here is a list of questions you might consider asking before you commit to surgery. You will probably find the hospital staff and the surgeon's secretary helpful if you feel uncomfortable putting all these questions to the surgeon himself -

• How much time do I need to take off work?
• What if I get sick (fever, flu, sore throat) before surgery?
• I currently take xxx medication...should I continue taking it up to surgery time?
• What kind of knee replacement does the surgeon think is right for me?
• What type/brand of protheses will he use? Why?
• How long will my scar be?
• Will I have sutures or staples?
• How long will I stay in the hospital?
• What are the anaesthetic options available to me?
• How will my pain be managed?
• What limitations will I have immediately after surgery, during rehab and in daily activities after I've healed?
• How long after the operation will I need to attend a physiotherapist?
• What are the common complications of knee replacement?
• What if the surgery is not successful?
• How many knee replacements does the surgeon do each year?
• What is the infection rate in the hospital?
• Will I need to purchase a walking stick/crutches?

Special Medical Risks

The surgical team expect and are used to dealing with medical conditions common in this age group, but a number of conditions stand out as particularly important and efforts should be made in this age group to bring these within optimal control before surgery:

• Obesity - Of these disorders, obesity has the highest risk of post-operative complications, with 3.7% of post op complications compared to 2.6% in patients with normal weight. But obesity is itself pushing up the demand for knee replacement and this poses a real dilemma for the surgeon.
• Diabetes - Whenever one talks of diabetes, it is important to distinguish between insulin dependent and adult onset diabetes. Most older patients with diabetes have the 'adult-onset' type. It is important to tell the surgeon about this early on in the process, so that the diabetes can be effectively managed before surgery. Also you need to inform the ward staff on admission, and bring your medicines in with you you to ensure that medication can be uninterrupted. Special diets will need to be arranged with the dieticien and kitchen staff. The overall complication rate in diabetic patients is 2.9% compared to 2.6% in non-diabetics. One paper reported a rate of deep infection of 1.2% in diabetic patients having knee replacement compared to 0.7% in non-diabetic patients (all of these were of the insulin-dependent type of diabetic).
• High Blood Pressure - Patients with high blood pressure have a 2.8% complication rate compared to the 2.6% in patients with normal blood pressure.

Pre-Admission tasks before knee replacement surgery

You will need to pay attention to sort these out well before your admission, as you will be most disabled the first week after surgery and will need to be sure that your house is ready for you.

• The first thing you will need to do when you get home is to get out of the vehicle and into your home. Stairs will be a problem. You will need to discuss with your family the best way to tackle this. It may be best to sleep downstairs if a toilet is nearby.
• Bouncy pets will be a problem for the first week after surgery. There are many stories of exuberant dogs being the cause of failure of knee surgery. If you have a bouncy dog you need to ask a friend to keep it for you for a week after you get home, or arrange for it to go to kennels.
• If you have a good firm armchair with a high seat, it may be best to have this moved to your bedroom before you come home from hospital. Also prepare a footstool with a good cushion he admissto keep the leg up. Even better is a recliner chair, particularly if the seat is high. A phone in the bedroom is important - a mobile phone would be fine. If there is no toilet in easy access a commode is needed, with a sturdy base and armrests. A 'pick up reacher' with pincers for picking things up off the floor is lkely to be very helpful, and will need to be ordered in good time before you get home. You will find links to many of these here.
• If your bedroom is only accessed via stairs, it would be best to sleep downstairs for a few days, preferably near a bathroom (otherwise use a commode). After a knee replacement many people find that the toilet seat is too low (toilet or commode). One can buy raised toilet seats which simply go over the old toilet seat. Even better is a seat with arm rests on either side, which allow you to elevate yourself.
• You will probably be using the shower rather than the bath after surgery. Useful here are non-slip mats in and outside the shower, a very well-fitted grab bar (which will not come out of the wall if you pull on it), and a waterproof seat with armrests.
• In preparing the kitchen the freezer is a good place to start. If you are likely to be alone at home you could stock up on prepared meals for the freezer. Check the grocery cupboard to make sure you will not run out of essential items for a few weeks. Have a firm chair in the kitchen. Move the dishes you use most often into a handy place so that you do not need to bend down to find them in a cupboard.

Pre-admission exercises

The first few weeks of a knee replacement can be a trying time.

Although it is an objective to get the knee bending easily again, swelling, fluid in the joint and inflammation make this nigh impossible at first and therefore the knee is straight and managing with routine things is likely to be more difficult than usual.

It is helpful to build up your upper body strength before surgery to facilitate using crutches, getting out of a chair, using a grab bar. Another factor to consider is that the thigh muscles can waste quickly after surgery. Your quads and hamstrings muscles are likely to already be weak, and it is helpful to do simple exercises at home to help improve their strength:

Practical upper body exercises include -

• triceps extension using elastic exercise bands (eg Theraband - which you can buy from Amazon)
• biceps curls using elastic exercise bands (eg Theraband)
• armchair presses (lifting your body up a few inches from your armchair, holding the position for a count of 5-10 and sitting down again) (repeat 5-10 times)
• stationary bike
• swimming

Lower body exercises include -

• static quads or quads sets
• short arc extensions

The admission process

The admission forms will, of course, document your personal details and those of your next-of-kin in the event of a major problem. A plastic bracelet will be put on your arm to ensure that it is easy to link you to your medical notes at all times.

Details will be taken about current medications, long term problems like diabetes, coronary troubles and previous strokes. You need to be frank about these past and current problems, so that the staff are ready to respond should there be any emergency. Of particular importance is any past problems with clots in the legs or lungs. You may be wise to take time at home to make a list of your medications and medical history, and to bring that with you to hospital, together with a bag of your medications.

The admission period is a good time to ask about the various uniforms of the nursing staff, so that you can distinguish between the grades of the persons who will be attending to you.

For a knee replacement it is general practice for a patient to be admitted 1-3 days before the scheduled surgery. This is normally to make sure that you have been visited by an anaesthetist (anaesthesiologist), who is likely to examine you fully and probably order several tests, such as a chest X-ray, an ECG (electrocardiogram or heart trace) and blood tests. It is quite common to donate some of your own blood to be refrigerated and received back during surgery.

Ready for surgery

Questions you might want to ask -

• When do you get your last meal?
• Can you drink water the night before surgery? What about on the morning of surgery?
• What can you expect if you are diabetic?
• What kind of pre-medication are you going to be given?
• What regime does the surgeon use to prevent deep vein thrombosis? Will you be put into elastic stockings after the operation? Will the hospital supply these?
• Will you have a catheter and a drip when you come back from the operating room?
• Is it likely that you will be taken directly to the intensive care unit, and if so how long is it likely that you will remain there?

There is usually a very formal routine when you are just about to go to the operating room (operating theatre) -

• Although the ward nurses already know you, they may still have to formally check your name on a wristband, with which you will be supplied.
• This may be checked again in the operating room, and you may be asked to verify your details.
• You may already have signed a form consenting to surgery, but it is likely that this will again be formally checked in the operating room.
• You may be asked to confirm which leg is being operated upon. The leg ma be marked with a black pen.
• A drip will likely be put in while you are still awake.
• A heart monitor may be attached while you are sill awake.
• If you are having a general anaesthetic, this is about all you will know before an injection is given and you are asleep.
• For a spinal or epidural anaesthetic it is more complicated. Both of these work by inserting local anaesthetic near the spinal cord, and paralysing the nerves. For this, you will likely be turned on your side and rolled up as far as possible, while the anaesthetist goes behind you. A small prick of local anaesthetic will numb the skin. Sometimes this is done in a sitting position. A spinal anaesthetic inserts the anaesthetic fluid in one go into the space around the spinal cord via a fine needle - in skilled hands it is usually quick and easy. As soon as the injection is given, the needle is withdrawn and a sticky-plaster applied. Epidural anaesthesia is a bit more complicated. The anaesthetist places the anaesthetic agent outside the casing of the spinal cord, and a bigger needle with a plastic cover is used. It may take longer to find the exact position. The needle is withdrawn and the plastic part remains in position, allowing the anaesthetic to be topped up during and even after the procedure.

After your surgery

The post-op week in hospital -

• The policy with regard to 'intensive care' (ITU or ICU) will depend on your surgeon and the hospital. The older patient having a knee replacement may be taken to the intensive care unit more or less as a routine after surgery, to make it easier for the ward staff and to be safer for the patient. It will not necessarily mean that there have been complications.

• The drip is likely to be continued for at least 24 hours, and blood may be given via the drip.

• The knee is likely to be have a drain inserted through the skin (48 hours).

• A 'CPM' (continuous passive motion) machine may be immediately applied - this gently and slowly bends and straightens the knee. It is not uncomfortable, but of course it is necessary to lie on your back and makes it hard to wiggle around in the bed.

• Pain management will initially probably be via injections into the leg or buttock. Later tablets will be given. If epidural was used, it may be continued for a while in the ward to offer pain relief.

• A bedpan will be necessary for at least 24 hours.

Managing back at home

• With regard to getting in and out of the car, hospital staff may wave you goodbye at their station without a thought to how you'll get on with this difficult task. The easiest may be to sit on the back seat with your legs supported on the seat - you can still get the seat belt on OK. Patients just need to sit on the seat first and then slide backwards, bad leg against the back of the seat.
• Household chores are probably already difficult but there are things which will be harder immediately on return from your knee replacement. Your family will need to take over some of the chores - those that require longish periods on your feet - ironing, gardening, cooking.
• In any event the family will need to make arrangements for taking over all your chores while you are in hospital, and be flexible if it turns out that you need more than the expected 7 to 10 days.
• It's sometimes as difficult for the family of a TKR patient as it is for the patient themself! Like you, their sleep may be disrupted if they are your primary care-giver. They may have the same mood swings as you do, feeling helpless when seeing you in pain. Keep the lines of communication open so they know they are an integral part of your recovery. And don’t forget to THANK them!
• It will be helpful for the family to have a grasp of the extent to which you will need car and bathroom to be modified for you once you are back home. It takes time to buy and fit bath grab bars, for example.
• Most people having a knee replacement are likely to be retired, but many will still have work commitments. Inasmuch as arthritic patients have been struggling with their daily lives anyway, they often manage remarkably well getting back to their normal routines.
• Two months is probably the least you can allow, and should allow you to get the benefit of the rehab sessions within your rehab allowance, but it will take six months or longer to really get fully confident with the knee and to take on new activities.

Rehabilitation programme for the first month

• The first month will concentrate on regaining general mobility and then on regaining flexion (bending) of the knee. The greater the effort you made pre-op in building upper body strength, the easier it will be to use crutches, sticks or other walking aids like a Zimmer frame.

After the first month and beyond

• After the first month rehabilitation will concentrate on building general fitness, and balancing the various muscle groups that support the knee.

Dental work around the time of surgery

• There appears to be a conflict between the dentists and the surgeons. Patients are usually told that any dental treatment other than the routine clean requires antibiotic treatment beforehand. Dentists on the other hand may insist they've been instructed to only give this treatment for patients with heart conditions. It's best to ask your surgeon for instructions, and for a note for the dentist.
• It might also be worth adding that any infections in addition to the knee area also need quick intervention with antibiotics.