Knee Replacement FAQ’s

What are the different types of knee replacement surgery?

Knee replacement surgery entails removing the diseased part of the damaged knee joint and capping it with an artificial part. The knee joint has three compartments called medial (inside of the knee), lateral (outside of the knee) and patellofemoral (underneath the knee cap) compartments. Total knee replacement is the most common type of knee replacement that involves replacing the all three compartments. Partial knee replacement involves replacing only part of the joint-the medial, lateral or patellofemoral joint. It is imperative to be selective in choosing which knees are good candidates for partial replacements because poor selection is responsible for early failures. If there is an excessive deformity or if there is significant arthritis in other compartments, partial knee replacement does not result in good pain relief and may necessitate revision to a full knee replacement.

What is custom knee replacement technique?

A custom knee replacement is a novel technology in total knee replacement that is designed specifically to match the natural shape of the articulating surfaces of the patient’s knee.

This technique helps to ensure accurate placement and alignment of knee implant components. The procedure is less invasive as it eliminates the need to drill holes in the bones.

The technique usually requires fewer steps during the surgical procedure leading to shorter operating time, and may help enhance surgical efficiency.

What conditions require knee replacement?

Knee replacement is the last option for treating pain from arthritis. Arthritis means that the cartilage (the glistening tissue at the end of the bone) has worn out and the bone is rubbing on bone. There are numerous conditions that can cause this and there are more than a hundred types of arthritis. The most common types are osteoarthritis and rheumatoid arthritis. Orthopedic surgeons typically try a variety of injections in the joint and physical therapy before knee replacement surgery.

How to prepare for knee replacement?

The treating orthopedic surgeon coordinates care in preparation for knee replacement surgery. There are established protocols before any joint replacement surgery that involve medical clearance, dental clearance, nasal cultures, cardiac, urine and blood tests etc. It is very important to select a surgeon who specializes in joints and a hospital that does a large number of joints. Literature has shown that larger volume a surgeon and hospital performs, better are the outcomes.

How long does the surgery last?

Surgery lasts about an hour to one and half hour depending on the complexity of the case. There are many steps involved in the operating room before surgery like anesthesia, prepping and draping the knee etc. Therefore by the time the patient is wheeled into the operating room to the time patient comes out of the post-operative care unit, the time maybe more than two hours. Most patients walk full weight bearing on the same day of surgery with a walker. Most patient with partial knee replacements go home the same day. Majority of total knee replacement surgery patients go home the next day. Fewer patients are going to inpatient rehabilitation facilities.

How much pain is involved after? And how can that be managed?

We have made major advances in pain management in the post-operative period. We stay ahead of the pain by giving pain medication on a scheduled basis. Pain medication is even given before the patient is wheeled into the operating room. We use a combination of narcotic and anti-inflammatory medications orally, intramuscularly and intravenously. Additionally, we inject the joint and the tissues around it intraoperatively with anesthetic with lasts for about two days.

How long is the recovery?

The total rehabilitation after total knee replacement is about three months. Recovery after a hip replacement is very different where patients are pain free within days. After total knee replacement surgery, patients see light at the end of the tunnel at 4 to 6 weeks and at 3 months they are significantly better. Improvements continue for several months afterwards but the range of motion that exists at 3 months is what remains for life which is why rehabilitation and physical therapy is extremely important after total knee replacement surgery.

What restrictions on activities are there at each stage of recovery?

Patient can walk with full weight immediately after knee replacement surgery. They should range their knee in the post-operative period and do physical therapy to decrease the possibility of stiffness. In the long term, it’s advisable not to do any impact type of activities. Artificial joints have no ability to heal themselves and impact increases the possibility of loosening.

What does the recovery involve?

After having full knee replacement surgery, most patients go home the next day. A visiting nurse and physical therapist that visits them at home. Patients then do outpatient physical therapy three times a week for next several weeks. Most patients are pain free in 3 months after the surgery.

How much physical therapy is involved after?

Physical therapy start immediately after surgery and is required for about three months after surgery. Physical therapy starts in the hospital, then at home and then in an outpatient facility. It helps in improving range of motion, improving strength, decreasing inflammation and pain.

What are the best case scenario results?

Knee replacement surgery is done for pain and most patients are completely pain free after the surgery. Along with hip replacement surgery, it is one of the most satisfying surgeries in orthopedics. Some patients have trouble swatting and kneeling. Occasionally they may have clicking in the joint but their quality of like has improved substantially after surgery.

When and why do some knee replacements fail?

More than 90% of knee replacements last for more than 20 years. Most early failures are due to infection that may happen within few months of the surgery. Most late failures are due to loosening that happens over several years. Intermediate failures may happen because of suboptimal alignment and patient factors that include impact activities to the joint.

How long does it take to know if your knee replacement was successful?

The arthritis pain is gone immediately after the surgery. Patients immediately notice this when they place weight over the operated extremity. The surgical pain gets better with time. Most pain is gone in three months. Infection or other adverse events manifest as increasing pain, redness, swelling etc. A knee is not improving after surgery warrants further evaluation by a joint replacement surgeon.

Are follow-up surgeries (that aren't a total re-do) ever needed (say, for scar tissue), and why?

The idea of knee replacement surgery is to give the patient one operation that will last a lifetime. Follow up surgery after knee replacement will only be needed if there is a complication. Occasionally, if the knee is not progressing for range of motion with physical therapy, the knee may need to be manipulated under anesthesia to break the scar tissue. If there is an infection surgery maybe need to clean up the joint.

How long does a knee replacement last?

More than 90% of full knee replacements last for more than 20 years. Partial knee replacements may not last long if the indications are not accurate. There is growing literature to show that if the selection is correct for doing partial knee replacements and if the surgery is done in an accurate manner to insure correct alignment, the long term results may be similar to a full knee replacement.

How best to take care of one's knee following knee replacement?

Patients have an active pain free life after knee replacement. They can play golf, swim, do horseback riding, ski etc. Its prudent to avoid constant impact type of activity. Some of the worst long term outcomes are in active males who abuse their joints. Additionally, it’s imperative to take antibiotics when patients visit the dentist because bacteria can travel from the mouth to the knee through the blood and cause infection in the knee joint.

How to AVOID knee replacement.?

Arthritis leading to knee replacing is a combination of genetic and environmental factors. Modifiable factors include maintaining body weight and musculature around the joint. Patients suffering from rheumatological disorders should be diligent in taking medication. We are going significantly less joint replacement surgery for rheumatoid arthritis because of better drugs that have come out in the past few decades. Surgery can be done for deformities of the knee like bow leggedness to dramatically decrease the need for knee replacement surgery in the future.

How long does it take to recover from total knee replacement?

Total recovery time after total knee replacement is about three months. I tell my patients they are not “really happy” at four weeks because they are still taking pain medication and they are still sore from their surgery. I tell my patients they see “light at the end of the tunnel” at six weeks. At three months they are significantly better.

I also advise my patients “not” to speak with patients who have had a hip replacement because the patients’ recovery after hip replacement surgery is much sooner than after total knee replacement surgery. We do not know why recovery from knee replacement surgery is more than the hip replacement surgery. The patients have to do significant physical therapy after total knee replacement to prevent stiffness. The medical providers ensure that the process of recovery is as comfortable as possible.

How long I will be out of work after total knee replacement?

It’s important to have realistic expectations. Patients who work in heavy labor are not able to go back to work at least for three months after total knee replacement. The patients who work at home, who are able to ambulate with ambulatory devices are able to go back to work within a few days. I have several patients who are motivated, who do not do heavy labor for daily living, go back to work in their home office within a few days of surgery.

How long does it take to drive after total knee replacement?

The brake response time is an extremely important consideration to go back to driving after total knee replacement surgery. The patients who have had a left knee are able to drive as soon as they are off their narcotic pain medication that may interfere with driving. Most patients who have had right knee replacement surgery are able to go back to driving at about six weeks after the surgery if cleared by their physical therapist.

The patients need good range of motion at their ankle as well as good power and good reaction time for muscles around their ankle as well as their knee and hip to be safe drivers. Very few patients are unable to drive because of their knee three months after surgery.

Can I kneel down after knee replacement surgery?

The goal of knee replacement surgery is to make the patient better. Goal is to relieve pain from knee arthritis. Ability to kneel after knee replacement surgery is unpredictable. Some patients are not able to kneel after knee replacement surgery but are able to carry on their activities of daily living without pain. The patients who are considering knee replacement surgery should be counseled regarding this aspect of unpredictability around kneeling after knee replacement surgery. Unfortunately, it not possible to tell which patients can or cannot kneel after surgery.

Is total knee replacement surgery is painful?

Pain tolerance is different for different patients. I know some patients who had minimal pain and only took tylenol after knee replacement surgery. Others have pain for several weeks after knee replacement surgery.

We employ many modalities to decrease the pain. We start patients on medication even before the start of surgery to control the postoperative pain. Intraoperatively we give injections so that the postoperative pain is controlled after the surgery. Depending upon what the patients can tolerate, they are given a combination of narcotic medications as well as anti-inflammatory medications.

The patients who take pain medications before the surgery have a difficult time controlling their pain because “their pain thermostat is set a higher level”. These patients therefore need even higher medications after the surgery. For the patients who are taking narcotics medications prior to the knee replacement surgery, I advise them to stop the narcotic medication especially if they are taking it for the knee arthritis alone. Taking narcotic for arthritis in the knee is a bad idea because arthritis is a progressively deteriorating condition and it does not get better with time. It only gets worse because the arthritis progresses over time.

Giving narcotic medications for arthritis is a common mistake and it carries the risk of the patient getting addicted to the medication. After the surgery, the patients need higher dose of narcotic medication and they are not able to cooperate with physical therapy. Additionally, there are systemic problems of narcotic medications. The patients who are on narcotic medication prior to the knee replacement surgery for reasons not related to the knee (example- back pain), get medications from their pain management after the surgery. The patient is counseled regarding postoperative narcotic medication before the patient is booked for surgery.

Most patients do not need narcotic medication for more than three months after the surgery. If the patient does need narcotic medication after three months and the patient is not on narcotic medication before, there are probably concerns about the knee replacement that need to be evaluated by the orthopedic surgeon.

How long do you stay in the hospital after knee replacement surgery?

Most patients go home the second day after knee replacement surgery. Occasionally patients stay two nights after knee replacement surgery. Most patients go home and not to a rehab facility. Case management as well as physical therapist evaluate the patients before discharge from the hospital to ensure it is safe for them to be discharged from the hospital. Additionally, patients should not be on any IV medication or intramuscular medication for control of pain before discharge from the hospital. Additional we also ensure that the patient is not nauseous and all of the patient’s symptoms can be well addressed by oral medications after discharge.

Can you run after total knee replacement?

The patients are strongly advised against impact activities after getting a total knee replacement done. We want the patients to be active and pain-free but constant impact can deteriorate an artificial joint. The artificial joints have no ability to heal themselves and constant impact can damage the joint necessitating early revision knee replacement surgery.

How much does it cost to get knee replacement?

Most insurances cover knee replacement surgery. If the patient has Medicare, Medicare covers 80% of the cost and 20% of the cost is covered by the patient’s secondary insurance. The patients have to remember that the 20% balance that is not covered by Medicare is the Medicare 20% amount “allowed” by Medicare and not the billed amount by the physician.

Since total knee replacement is an elective surgery providers are able to give an accurate out of pocket expense prior to getting the surgery. For patients traveling from abroad we give a flat rate that covers the hospital stay, the surgeon, the medical care during the hospitalization, the cost of the implant as well as anesthesia.

Is total knee replacement an outpatient procedure?

There are some surgeons and centers that do total knee replacement on an outpatient basis. For the patients who are booked for an outpatient procedure, the surgeon has to follow very strict selection criteria. Additionally, it is important for the surgeon as well as the patient to know which hospital is in the vicinity should any complications arise during and after the total knee replacement procedure. It is extremely important to be very selective in choosing which patient can undergo a total knee replacement procedure as an outpatient. Patients with significant medical issues are not candidates for outpatient total joint replacement surgery.

Is total knee replacement considered a disability?

Total knee replacement is an excellent option for end-stage arthritis so that the quality of life is improved. Total knee replacement is not necessarily considered a disability.

For the patients who undergo knee replacement surgery for workers’ compensation, I follow the New York City Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity and I award the disability based on the criteria described by the New York.

How long does it take to do a total knee replacement?

The total knee replacement surgery takes about one to one and a half hours depending upon the work that needs to be performed. For the patients who need more work like placement of a stem or correction of a deformity, additional time is needed. I always advise that by the time the patient is wheeling into the operating room to the time that the relatives are called in to see the patient, it may take several hours.

This is because time is utilized while the patient is prepped before the surgery, positioned before the surgery and draped before the surgery. I do not count this time as a surgical time. Additionally, after the patient is wheeled out of the operating room, nurses attend to the needs of the patient in the immediate postoperative period and relatives are called after the patient is settled in the postoperative care unit.

How much pain relief for increased mobility should I expect after total knee replacement?

The pain immediately after knee replacement surgery is different from the arthritic pain that the patient had before the surgery. The patients realize that the first time they step on the operated extremity, the pain from the arthritis is gone. What they have after surgery is surgical pain that gets better with time.

The patient should expect improved mobility after knee replacement surgery. The best predictor of range of motion after total knee replacement surgery is their range that was present before the surgery. This means that if the patient had significantly less range before surgery, the range after knee replacement surgery will be better. It is unreasonable to expect full range if the patient had a very stiff knee before undergoing the total knee replacement.

What exercises should I do after the surgery?

The patients should do the exercises as advised by their physical therapist and surgeon. It is extremely important to do range of motion exercises after total knee replacement. Physical therapists use numerous tricks to maximize the range of motion. Among the many exercises I advise is to keep the knee straight with a bump under the ankle and to push down on the distal part of the thigh and to gain as much extension as possible. The patients can use a bedsheet or a towel around their ankle and pull to bend their knee to maximize the flexion after knee replacement surgery.

They can squat with support to maximize the flexion. Additionally, if the patient comes in the office with their partner, I have the partner do some exercises with them in which the partner pushes down the ankle to maximize the knee flexion. The patients can do these exercises in their home apart from exercising with physical therapist. The physical therapist also gives them a “home exercise program”.

What kind of pain medications will I be able to take after the procedure?

Most patients are given a combination of medications to decrease their pain. The combination includes narcotic medication as well as anti-inflammatory medications. I start medication even before the procedure to help with postoperative pain relief. Injections are also given during the surgery to decrease the postoperative pain.

Will my postoperative pain be manageable after total knee replacement surgery?

We certainly try our best to keep the postoperative pain manageable. Out of a scale of 1 to 10, we want the pain to be less than 5. If the pain is not controlled with medication, IV narcotic medications are used as well as combination of medications are used to minimize the side effects of each one. Additionally, we use cold therapy packs or “cryocuffs” to alleviate the pain.

When will my first postoperative visit be after total knee replacement?

If the patient goes home and if the patient has staples or sutures, the patient visits the orthopedic surgeon in about two to three weeks to remove the staples/ stiches and for inspection of the postoperative wound. If the patient is in a rehab facility, then the rehab director removes the staples and the orthopedic surgeon usually sees the patient in about six weeks’ time.

At the postoperative visit, the surgeon mainly assesses two things – one is if the site of the incision is clean, dry and intact and secondly the range of motion. The patients at around six weeks should be able to bend the knee at least to 90 degrees. It is important to ensure that the expected range is achieved at six weeks because this is the time that the patient may need manipulation under anesthesia to improve the range of motion.

What is manipulation under anesthesia after knee replacement surgery?

If the patient does not have acceptable range of motion after knee replacement surgery, the patient is wheeled into the operating room, anesthetized and the surgeon manipulates the patient’s knee. The maneuver breaks scar tissue and helps with the range of motion. After the manipulation is performed, the patient does active physical therapy to ensure that the knee does not stiffen again.

How active should I be after total knee replacement surgery?

We want the patients to be active and pain-free. The only restriction that I have for the patients after knee replacement surgery is impact type of activities. I have many patients who ski, who do trekking, golfing etc. I also have patients who play doubles tennis. I advise against soccer and basketball after knee replacement surgery because these are considered impact activities.

How should I be feeling after surgery?

Immediately after the surgery, the knee is sore for several weeks. We use a combination of medications as well as cold therapy to help with the swelling and the soreness. It is important to work with physical therapy to ensure optimal results. The patients are encouraged to work with physical therapist, do a home exercise program and do active and passive exercises of the knee after knee replacement surgery.

When will my sutures or staples be removed after total knee replacement surgery?

Sutures and staples after total knee replacement surgery are removed around in about two to three weeks after the surgery if the wound has healed well. The visiting nurse can remove the sutures/staples if the patient is home. If the patient is in the rehab facility, the rehab physician can remove the staples. If the patient is home and if the visiting nurse is uncomfortable removing the staples, the patient should visit the orthopedic surgeon for removal of staples.

How long do I have to keep a bandage on my incision after total knee replacement?

I use a dressing over the knee after knee replacement surgery till the staples are removed. This dressing is typically changed by the hospitalist staff before the patient goes home. The patients are advised to keep this dressing until the sutures are removed. If the patient does not have sutures, I still keep the dressing on until the wound has completely healed (which takes about two to three weeks). If the dressing gets soaked or if the dressing peels off, we simply place a new dressing. I usually advise my patients to take some dressings home from the hospital or they can buy these dressings from a pharmacy after discharge.

When can I shower after total knee replacement surgery?

I encourage my patient to shower as soon as they feel comfortable. I feel showering improves their well-being after total knee replacement surgery. Most post-operative dressings do not allow water to permeate through them. If the dressing feels as if it’s soaked, the dressing is changed. If the incision gets wet with clean water, I do not see a big reason for concern. I request the patient to gently dab the incision with a clean towel and replace the dressing.

Occasionally the dressing may contain blood. If the drainage is significant, they should contact their provider. The patients can get into a bathtub after removal of the staples and sutures (when the skin is generally treated as being normal). The patients should be careful while getting in and out of the bathtub to ensure that it is safe and fall precautions are followed. Having a handrail by the bathtub is very useful. The patient should follow general common sense cleanliness precautions around their incision.

How long will I be on pain medication after total knee replacement surgery?

Most patients need pain medication after knee replacement surgery for up to six weeks. Very rarely do patients need pain medication after three months. With each passing day the patients should realize that the knee is getting better. They always have few better days than others but overall it should be a progressively better course. If the patient feels that there is deterioration in their condition for any reason, they should immediately seek help from their provider.

Will I go to a rehabilitation facility or home after total knee replacement?

Most patients go home after total knee replacement. If the patients are unable to go home, they go to a rehab facility of their choice. The patients are given a list of rehabilitation facilities with the case manager in the hospital.

My strong preference is for the patient to go home into a clean and familiar environment. We did send all patients to rehabilitation facilities several years ago but that trend has changed. I have found several problems with rehabilitation facilities including complaints by patients regarding their food, complaints regarding improper nursing care etc. Sometimes the orthopedic advice is not thoroughly followed by the rehab facility including use of blood thinners after the surgery. On occasion, I have also found that rehabilitation facilities do not give physical therapy as is advised by me.

Do I need a private physical therapist after knee replacement surgery?

Most patients do not need a private physical therapist. Physical therapy starts immediately in the hospital the day of surgery. My patients get therapy two times a day while they are in the hospital and at least two times a day when they are at a rehab facility. Occasionally if the surgery is done later during the day, they may not get therapy the same day of the surgery.

Do I need a knee immobilizer after knee replacement surgery?

The patients who have had a nerve block after knee replacement surgery do need knee immobilizer after the surgery. I advise this knee immobilizer so that the risk of falling is decreased. With a nerve block, the patient’s thigh muscles are weak but the pain is controlled. I have found that the patients feel that they can walk but because of the nerve block the muscles on the affected side are still weak. That knee can therefore buckle leading to a fall. For this reason, I advise using a knee immobilizer if the patient has had an anesthetic knee block after knee replacement surgery for ambulation.

Additionally I advise is that the patients should not be getting up by themselves the first few times after the surgery and attempting to walk. It is mandatory to have help the first time the patient walks after knee replacement surgery. Immediately after surgery, patients do not have good balance because of a variety of reasons including medications, weakness in the muscles, etc. and falls may lead to fractures around the knee or elsewhere.

How long will my new knee last?

I tell my patients that new knee replacement is like buying a brand new car. It depends on how patients treat it! The only activities we do not want patients to do is impact type of activities. There is excellent data at 20 and 30 years that has showed longevity of artificial knees.

Why do artificial total knees fail?

Artificial total knees may fail because of loosening that can happen over time because of fractures, because of infections, or because they become stiff amongst other reasons. The patient should be following fall precautions especially in the post-operative period to decrease a risk of fall and fractures around the knee joint. Physical therapists should be careful manipulating the knee in the postoperative rehabilitation to decrease the risk of fractures around the knee joint. They should use a short level arm to move the knee joint.

Infection in the knee joint can happen because of variety of reasons including the patient’s immunity being compromised, sterility not followed in the operating room and hospital not doing certain checks before the procedure (example; swabbing the nose to ensure the patient does not have MRSA, not giving antibiotics before the procedure, etc.).

How long will I be on a blood thinner after knee replacement surgery?

I use Aspirin after the knee replacement surgery in the majority of patients as a blood thinner. Very strong anticoagulants are used in patients who have a history of pulmonary embolism or who have certain diseases where the risk of blood clot is significantly more after joint replacement surgery. The patients use blood thinner for six to twelve weeks after the surgery. The patient’s risk of blood clots is especially present in the firsts few weeks after the surgery and the patients should most certainly use blood thinner within the first month of getting a knee replacement.

Is it normal for my total knee to make intermittent clicking noises?

Total knee replacements are more prone to make intermittent clicking noises than total hip replacements. The goal of total knee replacement surgery is to relieve the pain. The surgery is not as a “silencer”! Clicking noises are not uncommon after total knee replacements.

The reason for the clicking noises is maybe because the knee cap abuts against the metallic part below. The knee cap is made of plastic and the part that caps the shin bone is made of metal. When the plastic articulates against the metal, clicking noise may be elicited. Unless accompanied by pain, this noise is considered normal.

What should I be worried about immediately after total knee replacement surgery?

The risks of surgery are extensively discussed with the patient and the relatives prior to the procedure. After the patient is well taken care of in the hospital and is monitored round the clock in the hospital. The patient should be concerned of numerous symptoms arise after discharge from the hospital.

After discharge from the hospital, patients should immediately alert the provider if there is shortness of breath or if there is chest pain. Additionally if there is increased swelling in the extremity or if there is increased pain, if there is a fall and the patient is unable to walk, the patient should immediately call their surgeon. Use common sense! If anything does not feel right, call your provider!

When should I call my surgeon or primary care provider?

The patients are encouraged to call the surgeon if the patient has any concerns after getting the knee replaced. If there is increased swelling, increased pain, inability to walk after a fall, if there is spiking fever, if there is redness around incision, the patient should immediately contact their surgeon.

In the hospital, we usually have a medical doctor onboard for medical issues that may arise in the postoperative period including shortness of breath, chest pains, etc. Additionally, if there is weakness, drop in hemoglobin, changes in potassium or sodium, there is medical doctor onboard who addresses these issues.

What are the signs and symptoms of an infection after total knee replacement surgery?

Infection in the knee will present as redness, swelling and inability to bear weight on the joint. There will be accompanied high-grade fever. On examination, the joint will be red, hot, swollen and ranging the knee will cause extreme pain. There will also be accompanying fever. Blood draws may show increase in white cell count and inflammatory markers like CRP and ESR.

If an infection presents itself, it is treated in a variety of ways depending upon the time after the surgery, where the injection is in the knee joint; superficial or deep, etc. The treatment may vary from oral antibiotics to IV antibiotics to surgery that may need irrigation and debridement along with change of a plastic to its most severe form in which two-stage reconstruction is done in which the implant is removed. Antibiotic spacer is placed and IV antibiotics are given and final knee revision is done in about six weeks’ time.

What are the signs and symptoms of blood clot after total knee replacement?

Blood clot may present as swelling and pain in the calf muscles after knee replacement surgery. On examination, there will be significant tenderness in the calf muscle.

Swelling after knee replacement surgery is expected for several weeks after knee replacement surgery. The patients are advised to use sequential stockings until the swelling subsides. Compression stockings after a total knee replacement surgery are typically below knee stockings. If above knee stockings are used, it is important to ensure that the stockings do not roll and compress the behind of the knee that may actually increase the risk of blood clots because of kinking of vessels in the region.

If the patients are traveling, they are advised to drink plenty of water. If the patients are flying, they are advised to walk as much as possible in the airplane to decrease the risk of blood clots. Travel and flights significantly increase the risk of blood clots. The patients should also be very diligent in taking their blood thinners when they travel.

What are the signs and symptoms of pulmonary embolism after knee replacement surgery?

Pulmonary embolism is very rare after total knee replacement surgery. It is present as difficulty breathing and may be accompanied with palpitations (which means that the patient feels his or her heartbeats). On examination, there is decreased oxygenation to the lung and additional investigations like a VQ scan reveal the pulmonary embolus. Pulmonary embolus can be potentially fatal and the patient is immediately treated to decrease the potential issues that can be a sequalae of pulmonary embolism.

I still have swelling after total knee replacement. Should I be concerned about the swelling and what should I do about the swelling?

Swelling after total knee replacement stays for several weeks after the surgery. If the patient is concerned, they should seek an examination from the provider. If there is significant tenderness along the calf muscles and if the patient has a history of pulmonary embolism, it is important to do some diagnostic imaging that can include an ultrasound with doppler. Ultrasound with doppler is not typically recommended after total joint replacement surgery because there are small clots that are seen which are insignificant.

For the patients and providers who are not experienced in treatment of postoperative total joint replacement patients, these insignificant clots can cause significant concern. I have seen patients occasionally being rushed to the hospital and started on strong blood thinners after detection of these insignificant clots. Strong blood thinners have potential problems including increased bleeding in the joint, increased bleeding elsewhere in the brain as well as increased possibility of wound issues that can lead to long-term infections.

Is knee replacement right for you?

Are there non-surgical treatments I can try first, like medicines, injections, physical therapy, crutches, or assistive devises?
I always advise a non-surgical treatments, like physical therapy and injections before knee replacement surgery. There are two types of injections: cortisone injections and hyaluronic acid injections. As a rule of thumb, worse the arthritis, less time the injections last.
What’ll happen if I don’t have surgery?
In a well-indicated scenario, arthritis only gets worse with time. It does not get better.
Is a knee replacement a disability?
Knee replacement surgery is a surgery that is used to take away the knee arthritic pain. It should not lead to any disabilities. Patients should be pain-free and should be walking with full weight after knee replacement surgery. Unless there’s a complication, there is no disability after hip and knee replacement surgery.
Does knee replacement surgery work in all ages? Are there any ages that are excluded for knee replacement surgery?
Any patient who has pain and arthritis who has not benefited from non-operative treatments will benefit from knee replacement surgery. I follow the three-strike rule with pain interfering with activity of daily living, the x-ray showing arthritis, and on examination the pain coming from the joint as criteria for bringing up the conversation of joint replacement surgery. There is no patient who is too young. There is no patient who is too old for this procedure. There’s excellent literature to show that patients who are in their eighties and nineties have also done very well after joint replacement surgery. On the other end of the spectrum, it is not acceptable today to keep younger patients with arthritis is pain and to let them suffer until they become a certain age. With improved anesthesia and improved surgical materials we have been doing joint replacement surgery in very young patients.
What is a good question for the joint replacement surgeon that I am seeing?
You should ask how many surgeries the surgeon has done and how the outcomes have been. Which is the preferred hospital that the surgeons prefers to perform the surgeries? Also, it’s important to ask about the conflict of interest of the surgeon. You may ask if the surgeon is employed by the hospital and if the surgeon get any royalties from the implant companies. You should also know if your surgeon get any money from pharmaceutical companies. I am not employed by any hospital. I do not get money from any DME products or any pharmaceutical company and no implant company pays me. I work only for my patients.
How soon should I have surgery?
The knee replacement surgery is an elective surgery. There’s no rush in doing the surgery. I advise patients to get it done when everything around them is optimized. I tell my patients that the world should revolve around them when they should have surgery and they should get all the family support and all the support that they can during and after the surgery.

Before the Surgery

Is there anything that I can do before the surgery so it will be more successful for me?
There are numerous things that can be done before surgery to make the surgery more successful. One is during the preoperative stage it is particularly important to choose a hospital and a surgeon where a high volume of these surgeries are performed. The hospital will advise patients numerous things including swabbing the nose to look for MRSA that has to be diligently followed. Surprisingly, bacteria from the nose can travel to the joint and increase the risk of infection. Additionally, rehab can be done in which the muscles around the joint are strengthened, and that helps in post-operative rehabilitation.
Are there any exercises I can do to make my muscle stronger?
Depending upon the joint, whether the hip or the knee, there are numerous exercises that can be done to make the muscle stronger. I advise physical therapy and the physical therapist works with the patients to make necessary muscles stronger before and after the knee replacement surgery.
Can I learn to use crutches or a walker before I have the surgery?
That’s an excellent idea. The more you plan for the surgery the better and easier.
Do I need to lose weight before the surgery?
It is preferable to lose weight before the surgery; however, it’s understandable that it’s really difficult to do. Patients with knee and hip arthritis are unable to exercise, unable to run. They are unable to use a treadmill or an elliptical. They can do core exercises and upper extremity exercises to a decrease their weight. Additionally, patients may consult a weight loss surgery before the surgery. It’s important to take vitamin D after any weight loss surgical procedure to ensure that the vitamin D levels are adequate after weight loss surgery.
Where will I get help quitting cigarettes or not drinking alcohol if I need to?
The patients are strongly advised to contact their primary care providers who will support them in these endeavors.
How can I get home-ready even before I go to the hospital?
There are numerous things that can be done before you go to the hospital, making sure that everything is settled at home before the surgery. The hospital and the physical therapist at the hospital and you’ll have the social worker who can advise on what things should be done.
Do I need to stop taking medications before the surgery?
I strongly advise not to take any prescription pain medication before the surgery. Patients should not be taking aspirin, ibuprofen, Advil, motrin, or any other drugs at least two weeks before the surgery, because these increase the risk of bleeding during the surgery. I also advise patients not to take any herbal supplements, because they are shown to increase the risk of bleeding during the surgery.
What prescription drugs should I take before the surgery?
Patients who have medical issues should continue their medications prescribed by their primary care doctor or cardiologist or pulmonologist right up time of the surgery. Stopping these medications is not advised at all and I ask these patients to speak to their primary care provider about exactly what medications need to be continued and until what time.
What should I do the night before my surgery?
The night before the surgery, you can have dinner, have good sleep. The morning of surgery, I allow light drinks to be taken, like tea or coffee. If your surgery is the first thing in the morning, do not eat breakfast. If it is later in the day, a very light breakfast is allowed. And for patients who have surgery later in the day, I’d advise them to speak to the anesthesiologist preoperatively to decide when to eat or drink.
When do I need to be at the hospital?
I advise patients to arrive at least two hours before the surgical time. This allows them to get changed/dressed. And if the surgical time is moved up, they are there so that the surgery can be performed even earlier, depending upon availability of the operating room.
Do I need to shower with any particular soap?
For patients who have MRSA in the nose, the hospital prescribes mupirocin. We also give chlorhexidine swabs to clean the local area before the surgery.

Questions About the Surgery

Will I need blood transfusion during and after the surgery? Isn’t there a way of saving my own blood before the surgery so that it can be used during the surgery?
This is called auto-transfusion. The patient donates his or her own blood and that blood is transfused after the surgery. There are issues with that, including the fact that most insurances do not provide for that. And additionally, if you do not need that blood, that blood cannot be used for somebody else and it is thrown away. Additionally, now days, surgery is done in a very minimally invasive manner. We use a lot of techniques to decrease the blood loss, including use of tranexamic acid before and during the surgery.
How long will the surgery last?
Surgery typically is about an hour to one and a half hours. By the time the patient goes in and comes out it’s a lot longer than that. I advise relatives to be at least two to three hours by the time the patient goes in and I come out and speak with them.
What type of anesthesia will be used?
There’s regional anesthesia and general anesthesia. I prefer regional anesthesia because of the decreased risk of blood clots. Additionally, the pain control is better after regional anesthesia. Patients are able to get up and walk the same day of surgery with both kinds.
What approach would you recommend for the knee replacement?
There are two types of surgical approaches. Most surgeons follow the paramedian incision. There’s also muscle-sparing approach. However, the results of the muscle-sparing approach has not been very good for knee replacement surgery.
What are the options for prosthetic materials and how do they adhere to the bone?
There are two types of knee replacement surgeries for adhering to the bone. One is the cementation of the metal into the bone using polymethyl methacrylate. The other option is non-cemented arthroplasty, which means that the bone goes into the prosthetic surface. My clear preference is to use cemented arthroplasty because it is a time-tested technique. I’m aware of certain studies in which the trials for non-cemented knees were stopped because of early failures. I really prefer something which is time-tested. Therefore, all my knees are currently cemented. If I feel comfortable with the non-cemented option, in the future, I’ll definitely consider that.

After the Surgery

Will I be in a lot of pain after the surgery? What can be done to relieve the pain?
I start pain medication even before the patient is wheeled in to have surgery. We stay ahead of the pain. And we also give injection of numbing medication around the joint to decrease the pain after the surgery. We want the pain to be not more than two to three out of ten. We give pain medications and anti-inflammatory medications after the surgery to keep the pain down.
How soon will I be getting up and moving around?
I like my patients to stand up and walk the same day of surgery. Next day, they’re definitely walking with a walker, putting on as much weight as they want to on that extremity.
Will I have a catheter in my bladder?
Most patients do not need a urinary catheter. They are asked to go to the bathroom before the surgery. And after the surgery, they’re able to void their bladder. Most female patients do not need catheterization. Occasionally, I have found that male patients need a urinary catheter if they are not able to void their bladder.
How do I get into the bathroom after the surgery?
The physical therapist will help you to get in and out of bed, as well as in and out of the bathroom after the surgery. Patient are supposed to follow the same instructions after discharge from the hospital.
Will I have physical therapy in the hospital?
Physical therapy starts immediately after the surgery. I like it to be started in the post-operative recovery unit and then it continues throughout their hospital stay, and then later at home. I like therapy given to my patients at least two times a day.
How long do I need to be in the hospital?
Most patients after joint replacement surgery, go home the next day of surgery.
Where will I go if I need to recover more before going home?
Going home straight from the hospital is my preferred method. If you are not able to go home, they have facilities that are available and those are set up by the social worker before you go home from the hospital.
How much help will I need when I go home? Will I be able to get out of bed?
Before discharging from the hospital the physical therapist and the social worker make sure that it’s safe for the patient to go home after the procedure. They will be able to do activities of daily living. If they have stairs, they will be able to go up and down stairs. The day of surgery the patient is taught how to get out of bed and walk using a walker. There will be a nurse, as well as a physical therapist, assigned to go home with the patient and make sure that all the post-operative instructions are followed, make sure that pain medications that are prescribed are taken, and all the discharge instructions are followed.
Do I need a hospital bed?
Patients do not need a hospital bed when they go home. They’re able to get in and out of a regular bed.
Do I need to go to a rehab facility?
Most patients do not need to go to a rehab facility. I strongly prefer that the patients go home into a clean, known environment. Patients who have bilateral joint replacement surgery who live in a place where they cannot go up and down stairs and they are unable to do it after the surgery are the only patients who go to rehab facility.
What results should I expect after a knee replacement?
Knee replacement surgery is one of the most satisfying surgeries in orthopedics. However, it takes time for the patient to feel well. The pain that is there from the arthritis is gone after the surgery. It’s surgical pain that gets better with time. Occasionally, locking and clicking may be felt after knee replacement surgery. This locking and clicking is rare after hip replacement surgery. Even though patients have locking and clicking, the pain is significantly better after joint replacement surgery of the knee.
How much time am I likely to be bed-ridden?
The patients are not bed-ridden at any point in time. We want them to get up and move as soon as possible.
How long do I expect the recovery?
Recovery after knee replacement surgery takes three months. Most patients are significantly better within six weeks time.
How soon will I be able to walk after knee replacement surgery?
Patients after knee replacement surgery, stand up, take a few steps the same day of surgery. Next day, they walk with a walker, and I allow full weight bearing on the joint. They’re able to improve their walking and most of them are significantly better in three months’ time.
Will the patient be able to do activities like swimming, golfing, tennis and hiking? When can they do these activities?
I do not have any restrictions for my patients after joint replacement surgery. They’re able to do golfing, swimming, and hiking. For tennis, I advise them: doubles instead of singles. We don’t want impact type of activities, which will loosen up the joint. This is an artificial joint and has no ability to heal itself.
What kind of physical therapy will I have to do? Will this be at home or at a facility?
Most patients go home after knee replacement surgery. The physical therapist comes home and gives them therapy three times a week. There’s also a therapist in the hospital that helps them with physical therapy.
What follow-up treatment will I receive?
Most patients go home the day after the surgery. They see their surgeon in about two to three weeks’ time or the visiting nurse removes their staples in two to three weeks’ time. They follow up with their surgeon in six weeks and in three months. At six weeks, the range of motion should be ninety degrees or more. If not, patients may need something called manipulation under anesthesia to get improved range of motion. So the treatment follow-ups are typically at two to three weeks, at six weeks, then at three months.
Is there anything I won’t be able to do after the knee replacement surgery?
After rehabilitation is over, most patients are able to do everything they wanted to do. Some patients are unable to kneel in church after knee replacement surgery. I dissuade my patients against any impact-type of activity after total joint replacement surgery.
How long will I need physical therapy?
Most patients after knee replacement surgery need physical therapy for three months.
What kind of physical therapy will I need?
Most patients need strengthening and range of motion exercises after knee replacement surgery.
Do you use continuous passive motion after knee replacement surgery?
No, I do routinely not use CPM after the knee replacement surgery. Results have shown that there is no advantage of using CPM after routine knee replacement surgery.
How long should my new joint last?
I tell my patients getting a new joint is a lot like buying a brand new car. The better you treat it, the longer it’ll last. The worst results of joint replacement surgery is in patients who abuse their joints. The worst results are in young, active patients. If you treat the joint well, it should last a long time. Prior studies have shown that 95% of joints done twenty years ago are still in at twenty years. Today we are doing joints in younger and younger patients, and we hope, with newer materials, that they will last even longer.

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