Custom Knee Replacement FAQ’s

Do all patients get a customized knee replacement, if not why not?

There are very various specific indications for doing customized knee replacement.  Customized knee replacement cannot be done for patients who have ligament instability and for patients who have significant deformities.  In significant deformities we need to place a stem on the tibial side or on the femoral side (on one or both sides of the joint, into the bone) and customized knee replacement surgery does not have the ability to place stems.  Certain patients who have ligamentous laxity need a hinged prosthesis that affords a lot more stability to accommodate further damage of ligaments is required.  Customized knee replacement, and also regular knee replacement does not allow that kind of stability and, therefore, patients with ligamentous damage cannot have a customized knee replacement.

Why does my surgeon not do a customized knee replacement?

A major issue would be that the hospitals where the surgeon works, may not be allowing certain implants. Some hospitals restrict their orthopedic surgeons in use of implants.  I have not understood the reason for this even though I am told that implant companies match the pricing for any other implant that already exists at the hospital. Some hospitals just do not allow certain implants to be used by the surgeon, especially if the surgeon is employed by the hospital they have full control over what the surgeon can use.  I am an independent physician and I take great pride in this.  I take my patients to hospitals which allow me to use all the possible implants. This is one of the major reasons why I choose to be not employed by hospitals.  I have the independence to take my patients to the hospitals which I believe, can provide the best care for the patients undergoing joint replacement surgery. Customized knee replacement surgery does really need significant additional training.  Some surgeons may not have the desire to undergo that training to do a customized knee replacement.  The training is extremely simple and surgeons who have competence in doing joint replacement surgery, can easily learn the technique.

If a patient has one knee with a customized implant and the other without a customized implant, would the patient be able to tell the difference?

For the correct indication and if the procedure is done right, my hope is that the knee with customized implant will do better than the knee with the non customized implant.  There have been no studies that I am aware of to date (2018) which have looked at this factor and it will be an excellent study to undertake prospectively.

How long does the swelling last after knee replacement surgery?

The swelling after knee replacement surgery lasts for several weeks after the surgery. If the patient has sudden increase in swelling and pain in the calf, it is important to contact the doctor because this may be a sign of a blood clot in the calf muscle. The swelling in the knee joint can be decreased by using below-knee elastic stockings. Additionally, the patient may keep the lower extremity elevated for decreasing the swelling in the extremity that has undergone the knee replacement.

How long does the patient have pain after knee replacement surgery?

The recovery after knee replacement surgery takes at least three months and continues for several months after that. Most patients are comfortable 4 to 6 weeks after the surgery

How long do I have to take pain medications after knee replacement surgery?

Pain perception by patients is variable. Most patients need some sort of narcotic pain medications for 4 to 6 weeks after the surgery. Very few patients take only acetaminophen after replacement surgery and there are some patients who need narcotic medications for longer periods of time. If the patient is taking pain medications, the use of pain medications should decrease with time. If the pain does not get better with time or if the patient feels that the pain is worsening, the patient should contact the orthopedic surgeon immediately.

What is the most comfortable sleeping position after knee replacement surgery?

Most patients feel comfortable sleeping in supine position with a pillow under the knee joint. The knee after surgery feels better when it is slightly bent. Most patients keep ice pack over the front of the knee when they are resting.

Does meniscal surgery lead to a knee replacement?

The literature is clear for patients with arthritis who also have a “meniscal tear”. Arthroscopic surgery to take care of the meniscus alone does not suffice. The “meniscal tear” associated with arthritis is the part of the arthritic process. As the arthritis progresses there is tear of the meniscus. There is also degeneration of the cartilage and eventually erosion of the bone. If meniscal surgery is done in patients who have knee arthritis, the outcomes are poor.

 

  • If the patient has meniscal surgery in the absence of arthritis or in cases where the arthritis is not advanced, the outcomes are good. Arthroscopic surgery is typically done in younger individuals with no degenerative changes in the joint.
  • If the patient’s meniscus is removed, it is likely that the deformity in the lower extremity if present, may get aggravated leading to accelerated degeneration of the joint leading to arthritis. The patient therefore has to be carefully evaluated for arthritis before scheduling arthroscopic surgery for the meniscus.
How bad is the pain after knee replacement surgery?

Everybody’s pain tolerance is different. We give medication before the start of the surgery to help in the postoperative pain control. Additionally, in the surgery (intraoperatively) we give injections to decrease the postoperative pain. After the surgery, injections as well as medications are given to keep the pain down after knee replacement surgery.

 

  • We want the patient’s pain to be well controlled, I would say we want the pain to be below “4” on a “scale of 1 to 10” after surgery. “10” being the worst pain the pain can ever experience.
  • Surprisingly, the pain is increased on the second day of surgery. This is because of the numbing medication that was injected in the knee joint during the surgery has started to wean away.
How long after knee replacement surgery can I drive?

Most patients who have had left knee replacement surgery can drive sooner than patients who have had right knee replacement surgery (for vehicles that do not have foot clutch for gears). Driving can be resumed after being cleared by physical therapy and after the patient is off any narcotic pain medications that may interfere with the patient’s ability to drive.

What is done in knee replacement surgery?

In knee replacement surgery, the deceased part of the cartilage is surgically removed and is replaced with artificial implants. There are three compartments in the knee -two compartments between the thigh bone and the shin bone, one on each side of the joint. The third compartment is underneath the kneecap.

Why do you resurface the undersurface of the kneecap?

There are some surgeons who do not replace the undersurface of the kneecap, however, I routinely replace the undersurface of the kneecap.

 

  • Studies have shown that the patients who have not had the underneath of the kneecap resurfaced have increased incidence of pain in the front of the knee joint. I therefore do replacement on the undersurface of the kneecap routinely in all my patients who undergo knee replacement surgery. Most patients having knee replacement surgery have arthritis in all compartments of the knee joint including the undersurface of the knee. Even if the undersurface of the knee does not have arthritis, they can develop wear and tear in the undersurface of the kneecap at the later stage because of the articulation of the cartilage on the implant below it. This can lea to arthritis under the knee cap at a later stage.
  • The time to replace the kneecap does not change the invasiveness of the procedure significantly. There is a better possibility of decreasing the risk of developing the knee pain (over the front of the knee joint) after the surgery and therefore replace all three compartments when I do a knee replacement surgery.
When you replace the kneecap, is the original native kneecap completely removed?

The kneecap is not entirely removed. Only the undersurface of the kneecap is replaced. The bone of the kneecap under the skin remains untouched.

Why does my knee feel hot after knee replacement surgery?

The knee may feel hot after knee replacement surgery because of the surgical intervention and because of the inflammation that happens following the surgery. In addition, the knee may feel hot after doing physical therapy. A hurting knee feels hot!

 

  • The patients generally take anti-inflammatory medications and ice the knee following physical therapy. I also encouraged them to take their medication and ice the knee before going to sleep to help them sleep better.
  • If the knee has sudden increase in heat and redness, especially if accompanied by fever, it is important to be immediately evaluated by a surgeon because this may mean an infection has set in.
How long does stiffness last after knee replacement surgery?

Most patients feel that the knee is “tight” after knee replacement surgery. In the surgery, I try to get as much range as possible. I tried to make sure that the knee can be fully extended and fully flexed during the surgery.

 

  • However, the most important predictor of “postoperative” knee function is “preoperative” knee function. This means that if the patient did not have good range before the surgery, the patient does not get good range after the surgery.
  • The range of motion of the knee improves after the surgery. However, the preoperative range of motion is the best predictor of postoperative range of motion.
Is knee replacement surgery considered major surgery?

Yes, knee replacement surgery is considered major surgery. Although knee replacement is now a routine procedure, an entire joint is replaced and I consider that as major surgery.

Who does knee replacement surgery?

In my opinion, only orthopedic surgeons who are fellowship trained in joint replacement surgery and who do good volume of hip and knee replacement surgery should be doing joint replacement surgery. Having said this, there are general orthopedic surgeons as well as sports orthopedic surgeons who also do joint replacement surgeries.

Literature has shown that the results of joint replacement surgery are better when performed by a surgeon who does good volume of joint replacement surgeries. Additionally, some hospitals have better outcome than others and my preference is for patients to consider hospitals which do significant amount of joint replacement surgeries.

What exercises should be done after knee replacement surgery?

The patient should work very diligently with the physical therapist after knee replacement surgery. The exercises include range of motion exercises as well as strengthening exercises. When working with Physical Therapy, the physical therapist also does “pain modalities”. These modalities include numerous techniques by the physical therapist to decrease the inflammation and to help with pain.

Can I ski after knee replacement surgery?

The patients should be able to ski after knee replacement surgery. The only activity which I discourage is impact type of activity because I worry about the long-term issues that can happen with impact that can decrease the life of the implant.

Can I “get on my knees” after replacement surgery?

Patients sometimes have trouble kneeling down after knee replacement surgery. Some patients desire to kneel in church (as an example) and patients have to understand that some patients are unable to kneel after knee replacement surgery.

  • Who is able to kneel and who is not able to kneel is unfortunately unpredictable! It is not possible to prognosticate which patients can kneel in the postoperative period.
How much blood is lost during knee replacement surgery?

I do knee replacement surgery under tourniquet. This means that the field is bloodless. Esmarch tourniquet is used to exsanguinate the limb prior to the procedure and the cuff around the thigh is elevated to prevent the blood from entering that extremity.

  • The blood loss does occur after the surgery once the tourniquet is deflated. I achieved good “hemostasis” (coagulation of blood vessels) before closing the incision. Additionally, there are certain pharmacological agents that can be sprayed into the knee joint to decrease the risk of postoperative bleeding.
  • If the knee implant does not entirely cover the bone, then the raw bone bleeds. It is therefore important to achieve as much coverage as possible of the raw bone by the implant.
  • Some surgeons start the procedure without the use of a tourniquet. They use a tourniquet only for cleaning out the bone and when cementing the knee into position. The raw bone needs to be thoroughly cleaned and the field has to be bloodless to allow interdigitation of cement into the bone.
  • It is important to get a good interface between the bone and the cement as well as the cement and the implant to decrease the possibility of loosening of the implant. Interestingly, the studies have shown that the blood loss is not significantly more when surgeons do not use the tourniquet during the knee replacement surgery.
What should I expect within the first few days after knee replacement surgery?

I like my patients to make an attempt to walk the same day of surgery. Next day they are walking with a walker with the help of physical therapy. Some patients who are younger make an attempt to climb stairs the same day of surgery. Most patients go home the day after the surgery.

  • We give pain medications to stay ahead of the pain. I tell my patients it is critically important not to skimp on pain medications especially if they are hurting because then patients do not cooperate with physical therapy. Not cooperating with physical therapy can give rise to increased risk of complications like stiffening of the knee joint and also development of blood clots. It is important to keep patient’s pain very well controlled after joint replacement surgery.
Why do I feel tired after knee replacement surgery?

The patient’s knee replacement surgery takes lot out of you! The entire joint is replaced. Anesthetic drugs take a toll on you. It is quite common for patients to feel tired after knee replacement surgery. The feeling of tiredness decreases over time. The patients feel less and less tired as more days go by and after several weeks they feel back to being themselves.

When should I consider knee replacement surgery?

I follow the three-strike rule.

  1. First and the most important strike is the patient’s knee pain that interferes with their activities of daily living.
  2. Second strike is on examination I know that the pain is coming from the knee joint. Sometimes pain from the back or from the hip can also cause knee pain where the underlying problem is in the back or the hip. The clinical evaluation is therefore extremely important. It is the same nerve that supplies the back, hip and the knee and the symptoms can sometimes be confusing.
  3. The last strike is that on examination, I see arthritis on the x-ray of the knee joint.

Only if these three strikes come together, the patient is a candidate to get knee replacement surgery.

How long after knee replacement surgery should you take anti-inflammatory medications?

Anti-inflammatory medications after knee replacement surgery should be taken until the swelling and the feeling of the knee “feeling hot” goes away. This typically takes several weeks. If the patient is taking non-steroidal anti-inflammatory medications, they should be taking it with food. Patients who have gastrointestinal issues should not be taking nonsteroidal anti-inflammatory drugs. Additional contraindications for taking non-steroidal anti-inflammatory drugs should be discussed by patients with their providers. There are certain medications like celecoxib which are less irritant to the stomach and can be considered in patients who have mild gastro issues.

Can knee replacement surgery done on an outpatient basis?

There are centers that have started performing knee replacement surgery on an outpatient basis as of 2018. However, I am not yet there!I am still waiting for the data to settle down. Unicondylar knee replacement surgery (which means partial knee replacement) can be done as an outpatient basis because they are much smaller surgeries than replacement of the complete knee.

What exercises help to keep the knee straight after knee replacement surgery?

After knee replacement surgery, bump or a roll of sheets can be kept under the ankle and pressure can be applied directly over the distal part of the thigh to straighten out the knee joint. Physical therapists use various additional techniques to achieve good extension of the knee joint.

How important is it to have a good physical therapist?

It is critically important to have a good physical therapist after knee replacement surgery to get good range of motion and to achieve good strength after knee replacement surgery. Physical therapists who are not aggressive or who are not experienced with treating patients after knee replacement surgery are one of the reasons why a knee can stiffen up.

  • On the other hand “over aggressive” and inexperienced physical therapists have known to cause fracture of the bone proximal and distal to the artificial knee joint! I feel patient should go only to physical therapist who routinely take care of patients after hip and knee replacement surgery.
What causes pain after knee replacement surgery?

The pain after the knee replacement surgery is due to surgical dissection that is done for approach to the knee joint. It is also due to work that is done on the bone -as an example to remove the osteophytes (bones spurs). The surgeon may have also needed to do some “releases” (cutting of soft tissues) for straightening of the deformity. Additional surgical dissection may be needed for removal of hardware that was in the knee joint (example- screws from the anterior cruciate ligament surgery or hardware from fixation of prior fractures).

What causes shin pain and ankle pain after knee replacement surgery?

It is the same nerve that supplies the knee and the skin and the soft tissue below the knee joint. It is not uncommon to see pain over the shin after knee replacement surgery.

  • Obviously, if a patient has a separate pathology in the ankle, the pain from the ankle could be coming from this ankle pathology (which can include arthritis in the ankle joint).
What nerve block is used for knee replacement surgery?

The patient has a conversation with the anesthesiologist to talk about what nerve blocks and if nerve blocks will be used after knee replacement surgery.There are mainly two types of nerve blocks that are used after knee replacement surgery. One is using numbing medication in the nerve in the groin on the affected side. The other type of nerve block is an injection on the side of the back to numb the nerves going on the behind of the lower extremity. Most commonly both nerves are blocked by anesthetists who use blocks for knee replacement surgery.

What are the precautions that you advice patients after a nerve block is given for knee replacement surgery?

I feel it is critically important for patients to wear a knee immobilizer if a nerve block has been used. The knee immobilizer should be used in the immediate postoperative period until full function of the nerve has been restored.

  • The reason I insist on a knee immobilizer is because the patients who have had a nerve block do not realize that the muscles on that affected extremity are weak. They feel that they can walk normally because they have no pain. This is incorrect because the muscles are still weak. When they put weight on that affected extremity, that extremity can buckle leading to falls and subsequent fractures. Knee immobilizer prevents from the knee buckling in the postoperative period after getting a nerve block.
Do you do minimally invasive knee replacement surgery?

I prefer to the word “less invasive knee replacement surgery”. The surgery is done in a manner that it is “as less invasive as possible”. Interestingly, “the length of the incision” does not necessarily correlate to the “invasiveness” of the operation. Skin heals side to side, not end to end!

 

  • What I worry about is a good long term outcome more than anything else. The invasiveness of the procedure underneath the skin is what matters and I keep the invasiveness to as less as possible.
Should I be wearing a knee brace after knee replacement surgery?

I do not advise use of a knee brace after knee replacement surgery. If a patient has had a nerve block, a knee brace may be used only until the muscle function has completely restored. Knee brace is really of no use after knee replacement surgery in long term.

How many times can you have a knee replacement surgery?

The idea of a knee replacement surgery is to do one surgery that will hopefully last for the rest of the patient’s life. If subsequent revision surgeries are needed, it is important to go to a fellowship trained joint replacement orthopedic surgeon who is comfortable doing these complex cases. Each subsequent surgeries involves additional bone loss and the complexity of the surgery increases. As of 2018, I have not had to do an amputation for field knee surgery, but with recalcitrant infections, patient sometimes may need an above knee amputation.

What is the recovery time for double knee replacement surgery?

While knee replacement takes a lot “out” of the patient and two knee replacement surgeries done at the same time take “two times” more out of the patient! Only patients who have good cardiac health are able to undergo both knee replacements. The recovery especially in the beginning stages is longer because it takes time for the patients to get up and walk. The time especially in the initial few weeks are longer after double knee replacement surgery.

Do you have any recommendations on diet after knee replacement surgery?

After knee replacement surgery, we want excellent nutrition and excellent hydration. It is critically important for the surgery to heal up. This is not a good time to attempt to lose weight!

How long is physical therapy after knee replacement surgery?

Patients have physical therapy for at least 3 months after knee replacement surgery. It is critically important to do physical therapy to maintain range of motion. Range of motion that you have 3 months is what remains for life.

How long after knee replacement surgery can I walk?

I encourage my patients to walk immediately after the surgery. They can put as much weight as they want to after the surgery. If the surgery is done late during the day, then patients walk the next day. First they walk with the walker. The patients then go on walking with the cane.

What is the best age for knee replacement surgery?

There is nothing defined as “the best age” for surgery. Patients who meet the indication for the surgery can have the surgery if they are medically cleared. We have done knee replacement surgeries in patients who are in the 20s and 30s as well as in patients who are in the 80s and the 90s. The indication for doing knee replacement surgery is pain in the joint that has continued to deteriorate in a patient having advanced arthritis.

How long you off work after knee replacement surgery?

Patients have varying degree of physical activity involved in their job. Patients who are motivated and who are self-employed and who can work from home go back to work within couple of weeks. Patients who do heavy physical labor need to be off work for at least 3 months.

How do you prevent blood clots after knee replacement surgery?

Prevention of blood clots after knee replacement surgery is multifactorial. It is by doing less invasive surgery by using regional anesthesia, by using elastic compression stockings, by using sequential compression devices during and after the surgery and also by using pharmacological medication.

 

  • For most of my patients, I use aspirin as pharmacological thromboprophylaxis (which means drugs to decrease the risk of blood clots) unless the patient have contraindications to using aspirin.
  • Patients get high potent anticoagulation therapy if they are at significantly increased risk of blood clots or if they are on blood thinners prior to the surgery.
How much walking should I do after knee replacement surgery?

In the long term, I do not limit walking after knee replacement surgery. In the short term, in the immediate postoperative period, I tell my patients to let their body “talk to them”. Eventually, they are able to walk more and more. Walking is very much encouraged after joint replacement surgery.

Can I look at some pictures before and after knee replacement surgery?

I have some pictures before and after knee replacement surgery on my website.

When do you remove staples after knee replacement surgery?

Staples are removed after the skin has healed. Staple removal occurs typically happens two to three weeks after the surgery.

Who removes the staples?

If the patient is at a rehab facility, the rehab facility is able to remove staples. Staples are removed by someone who can evaluate the patient’s wound and can remove the staples. I have had patients who use surgical staple removal and have removed the staples themselves! The first time it happened, I was not aware that the surgical staple removals are available in any surgical supply store! This is absolutely “not” what I encourage.

  • Staples have to be removed by some medical practitioner who has credentials and who has experience in evaluating the wound and ensuring the wounds are well healed before removing the staples. The provider should also have Steri-Strips so that if the provider notices any gaping in the wound, the provider can apply Steri-Strips over the wound.
  • If the patient goes home after joint replacement surgery, the visiting nurse may be able to remove the staples. If the patient goes home and visiting nurse is unable to, does not feel comfortable removing the staples, the patient comes to the orthopedic surgeon’s office to have the staples removed.
Can I sleep on my side after knee replacement surgery?

It is possible to sleep on your side and there are no restrictions after knee replacement surgery. (There are several restriction on how to sit and get up after hip replacement surgery).

How long should a patient wear compression stockings after knee replacement surgery?

The patient should wear compression stockings until the knee swelling has subsided. It is a standard postoperative protocol that all patients get stockings after knee replacement surgery when they go to rehab center and or whom their continues as needed.

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