Total Knee Replacement - Beacon Hospital

1Guidelines for Patients having aTotal Knee Replacement

Guidelines for Patients having a Total Knee ReplacementcontentsintroductionIntroduction 3What is a Total Knee Replacement? 4Preparing for Admission Checklist 5Pain Management 6Physiotherapy & Exercises 9Walking 14Stairs Technique 16Rehabilitation Goals 17General Recommendations (Sleeping, Driving etc.) 21Discharge Instructions 27Conclusion 31This information booklet has been written to giveyou and your family a basic understanding of what isinvolved when you require a total knee replacement.In this booklet we provide information, including thingsyou should know before and after your operation, aswell as information regarding your discharge fromthe hospital. It is important for you to understand thebenefits but also the possible problems that may occurafter this form of surgery.Throughout your stay in UPMC Beacon Hospital, you willreceive continuous advice and support from all membersof the orthopaedic team.2Exercise Diary 32Appendix: Potential Complications 34Individual Patient Notes 383

Guidelines for Patients having a Total Knee ReplacementWhat is a Total Knee Replacement?A total knee replacement is designed toreplace a knee joint that has been damagedby arthritis. Replacing the painful andarthritic joint with an artificial one gives thejoint a new surface that moves smoothlyand painlessly. This is a surgical procedurein which the injured or damaged parts arereplaced with artificial parts.will have better motion after a total knee replacement.Please refer to the Physiotherapy section for moreinformation on these activities.Preparing for Admission ChecklistSmoking: It is advisable to give up smoking, or at leastto reduce the number of cigarettes you smoke a day, assmoking interferes with wound healing. It also impairs bonegrowth and repair and will delay or even prevent healing ofthe joint after surgery.4The procedure is performed by separating the muscles andligaments around the knee to expose the knee capsule (thetough, gristle-like tissue surrounding the knee joint). Theends of the thigh bone (femur) and the shin bone (tibia)are removed and sometimes the underside of the kneecap(patella) is removed. The new knee consists of a metal shellon the end of the femur and a metal and plastic cover onthe tibia. The parts are sometimes held in place with specialcement. The operation normally lasts about 90 minutes.What can I expect from an artificial knee?An artificial knee is not a normal knee, nor is it as good asa normal knee. The operation will provide pain relief for tenyears or more.Activities that overload the artificial knee must be avoided.About 90 percent of patients with stiff knees before surgeryClothing: Loose comfortable clothing is advised e.g. longshorts, tracksuit bottoms or loose three-quarter lengthtrousers.Footwear: Comfortable lace up or slip on shoes with a lowheel are recommended. Please ensure there is a back tothese shoes.Valuables: Please leave all valuables and jewellery athome.Dentist: It is important that your teeth and gums arehealthy before your operation as bad teeth can be thesource of infection. Please make sure that you have had adental check up in the last six months.Skin preparation: Your skin around the area to be operated5

Guidelines for Patients having a Total Knee Replacementon will have to be prepared for surgery. This will involvewashing the area with a disinfectant agent the nightbefore and the morning of surgery as well as using specialanti-microbial wipes on the area. More information onthis is provided to you when you attend the pre-operativemeeting with the nurse. The pre-operative meeting is atime for you to speak with the orthopaedic nurses andphysiotherapists and ask any questions you may haveregarding your surgery and rehabilitation. Patients who arebeing admitted the day before their surgery will receiveinformation on skin preparation at this time.Planning your Discharge: If there is ANY possibility thatyou may require convalescence or additional help at home,now is the time to start planning and arranging it. It can beextremely difficult to get a bed in a convalescence centreat short notice. If you require further information regardingthis, we have an information pack to help you plan yourconvalescence. Convalescence is the term we use todescribe where you will go to recover after your surgery.This may be your home setting or you may require a shortstay in a nursing home.special pain management devices and ice. The pain willnaturally reduce as your wound heals and with regular useof analgesics (painkillers). It is imperative to keep your painwell controlled so you can mobilise comfortably, performyour physiotherapy exercises and resume normal activitiesafter your surgery.You will be required to rate or score your pain regularlyafter your surgery. You will be asked to give a numberbetween 0 and 10, where 0 represents no pain and 10represents the worst pain you can imagine. Your score willdepend on how intense your pain is.The nurses will administer appropriate treatments/medications depending on your pain score. The nurse willreassess your pain score after the treatment to make sure ithas worked to reduce your pain.0 = No pain, 10 = Worst pain imaginable0 1 2 3 4 5 6 7 8 9 10nopainmildpainmoderatepainseverepainvery severepainworst painimaginable6Pain ManagementPain is a common occurrence following any surgicalprocedure. It can be well managed with medications,7

Guidelines for Patients having a Total Knee Replacement8Analgesics are painkillers and can include tablets,suppositories and injections into your veins or skin. Youwill receive analgesics at regular intervals throughout yourrecovery to maintain pain control. You can ask your nursefor extra painkillers if you need them for soreness or beforeyour exercises. People using analgesia to manage pain areextremely unlikely to become addicted.If you have any medication allergies, please tell yournurse and doctor. If you have had unpleasant experiencestaking analgesia in the past or are concerned about takingpainkillers, please discuss this with your nurse or doctor.Side effects are very easily treated; they can includeconstipation, nausea, vomiting, itchiness, drowsiness andurinary retention.The special pain management devices can include a PatientControlled Analgesic (PCA) pump or an Epidural Infusion/Patient Controlled Epidural Analgesia (PCEA) pump.A PCA allows you to administer a small amount ofanalgesic into a tube (cannula) in your arm. You press aspecial button to activate the pump if you feel pain. Thispump can be used for 1-2 days after your surgery.The epidural infusion/PCEA involves inserting a tinyplastic tube into your back to administer analgesia andlocal anaesthetics to numb your joint area so you do notfeel pain. This pump can stay in place for up to 2 daysafter surgery. The medications infuse every hour and youmay have a special button (PCEA) to give yourself extraanalgesia if you feel pain.PhysiotherapyWhen muscles are not used, they become weak and do notperform well in supporting and moving the body. Your legmuscles are probably weak because you may not have usedthem very much due to your knee pain.The surgery can correct the knee problem, but the muscleswill remain weak and will only be strengthened throughregular exercise. You will be assisted and advised how todo this, but the responsibility for exercising is yours.Exercise ProgrammeExercise is very important following knee replacementsurgery.Frequency: You will need to exercise at least three times aday to ensure you reach your rehabilitation goals.Please be sure to read the exercises carefully and ask yourphysiotherapist any questions that you may have beforeyou leave the hospital.9

Guidelines for Patients having a Total Knee ReplacementThe following exercises start on day one. You may feeluncomfortable at first, but these exercises will speed up yourrecovery.1Ankle Pumps• With your legs straight, bend yourankles up and down, towards andaway from your face.• Repeat 15 times• Continue this exercise until you arefully recovered and all ankle andlower-leg swelling has subsided.3Quadriceps Contraction• With your leg straight out in front of you, tightenthe muscles at the front of your thigh, pushingthe back of your knee down into the bed.• The result should be straightening of the knee.• Hold the contraction for 5 seconds.• Repeat 15 times.2Knee Flexion• Lie on your back with your legs straight• Slowly bend your knee by sliding your foot uptowards your buttocks as far as you can.• Hold for the count of 5.• Relax and repeat 15 times.• Every day you should be able to bend it alittle further. Your therapist will measure theamount of bending.4 Inner Range Quadriceps• Place a towel in at the back of the knee of theoperated leg.• Push the back of the knee into the towel andlift the heel up off the bed.• Hold the contraction for 5 seconds.• Slowly return to your starting position.• Repeat 15 times.1011

Guidelines for Patients having a Total Knee Replacement5 Knee Extension Heel PropIt is critical that you are able to straightenyour knee fully, for normal knee function.• Place a small rolled towel under your heel.• Tighten your thigh muscles trying to pushyour knee downwards fully straighteningyour knee.• Hold for 5 seconds.• Repeat 15 times.You are also encouraged to put your foot ona foot stool when sitting out for long periodsboth to reduce swelling and to maintain kneeextension.67Straight Leg Raising• Start by tightening the muscles at the top ofyour leg.• Keeping your operated leg straight, raise theleg about 6 to 10 inches off the bed.• Hold for 5 seconds.• Lower the leg slowly to the bed.• Repeat 15 times.Sitting Knee Flexion• Practice knee bends sitting onthe bedside or in a chair.• Cross unoperated (good) leg overthe operated leg at the ankle.•Using your unoperated leg toassist, bend your operated kneeas far as possible.•Straighten and repeat. Repeat 15times.1213

Guidelines for Patients having a Total Knee Replacement8Standing Knee Extension• While holding on to asupportive surface, bend youroperated knee slightly.• Gently pull back your knee bytightening your thigh muscles,straightening your knee.• Hold for 5 seconds. Repeat 15times.on how to proceed.Walking pattern with crutches:1. Stand in the middle of your crutches.2. Place crutches in front of you. They should be acomfortable arm’s length away.3. Push down on the hand grips. Step forward to thecrutches with your operated (weaker) leg.4. Step past the crutches with your unoperated (good) leg.5. Repeat the same sequence.14WalkingIn most cases after an uncomplicated first kneereplacement (primary total knee replacement) you will beencouraged, when using crutches for support, to put yourfull weight through the operated leg.Your consultant will advise you when you can reduce yoursupport to one crutch or progress to a stick in the oppositehand.If you have a complicated primary total knee replacementor a revision total knee replacement, you will beinstructed to reduce the amount of weight bearing on yourleg. In such a case you will be given specific instructionsTips for walking with crutches:• Carry items in a backpack.• Maintain good posture when walking.• Wear shoes that fit well, support your feet, and arecomfortable.• Be careful when walking on uneven or wet surfaces.• Walk at a safe comfortable pace.15

Guidelines for Patients having a Total Knee ReplacementGoing upstairsGoing downstairsStairs Techniqueand banister for support.Going upstairs• Maintain crutches/walking stick on the step below.• Lead with the unoperated (good) leg up onto the stepabove.• Follow with the unoperated (good) leg onto the samestep.Hint: The good leg goes up the stairs first and the bad leggoes down the stairs first.16• Take your weight onto the unoperated leg by pushing oncrutches/walking stick and banister.• Follow with the crutch/walking stick onto the samestep.Going downstairs• Put crutch/walking stick down onto the step below.• Follow with the operated leg.• Take weight onto the operated leg using the crutchesRehabilitation GoalsKnee Replacement – Goals of CareThese goals have been developed to assist you inunderstanding your patient journey and also to outlineyour physiotherapy goals as a patient in UPMC BeaconHospital. Your goals are divided into two areas, Nursingand Physiotherapy, and these start right after your surgery.Therefore you have some goals that remain the same fromday one, with new goals added each day.17

Knee Replacement Goals of CareNursing GoalsYour Physiotherapy GoalsNursing GoalsYour Physiotherapy GoalsDay ofProcedureDay OneYou will:• receive adequate pain relief• be started on intravenous (IV)antibiotics• depending on the time of day youreturn from theatre, you will be givensomething light to eat and drink• commence use of your cryocuff (icetherapy)• may have an x-ray of your new jointcompleted on this day or on day one• anti-DVT medication will commencethis day or on day one.You will:• receive adequate pain relief• be started on medications to preventclots and be given IV antibiotics• have bloods taken to check your ironlevels after surgery• have a wash and get dressed withassistance• have cryotherapy applied to yourknee using the cryocuff, a minimumof three times per day• be encouraged to drink plenty offluids• A continuous passive motion (CPM)machine will be applied three timesdaily for one and a half hours eachday. The flexion (bending) range isincreased as high as is comfortable(aim for 85 degree bend by daythree).• If your consultant hasrequested a continuouspassive motion (CPM)machine, the nurse orphysiotherapist will applythis machine to your knee.• Complete knee exercisesunder the supervision of thephysiotherapist• Get out of bed with the helpof the physiotherapist• Mobilise a short distancewith a frame• Sit out for a short period oftime• Ensure CPM progression• Practise exercisesindependently• Participate in a secondphysiotherapy treatmentsession with exercises andwalking practice.Day TwoDay ThreeYou will:• receive adequate pain relief• be given medication to prevent clots• have the wound dressing checked toensure it is intact• have a wash and get dressed withassistance• have the cryocuff applied to yourknee at least three times per day• have the CPM machine applied• mobilise with the appropriate aid(Zimmer frame or crutches) underthe supervision of the nurse orhealthcare assistant.You will:• receive adequate pain relief• be given medications to preventclots• be checked by your nurse to ensureyour bowels have returned to normalfunction• have your wound checked to ensureit is clean and dressing intact• have resumed a normal diet• have your Discharge Plan reviewedby your nurse• have the CPM applied again, andrange is increased if required until 85degrees is reached.• be encouraged to mobilise withappropriate aid• Complete exercises with thephysiotherapist• Mobilise outside of yourroom with the frame• Be able to get in and out ofbed on your own• Progress to 2 elbowcrutches, if able• Complete exercisesindependently throughoutthe day• Have achieved a minimumof 75-80 degrees knee bendon the CPM• Sit out for a longer periodof time.• Mobilise for longerdistances outside ofyour patient room with aframe or crutches (yourphysiotherapist will adviseyou on how far to walk).• Learn how to climb stairswith the physiotherapist.• Complete exercisesindependently throughoutthe day• Have achieved a minimumof 80-85 degrees knee bendon the CPM• Sit out during the day.1819

Guidelines for Patients having a Total Knee Replacement20Day FourDay FiveNursing GoalsYou will:• receive adequate pain relief• be given medications to preventclots• be checked by your nurse to ensureyour bowels have returned to normalfunction• have your wound checked to ensureit is clean and dressing intact• have your Discharge Plan reviewedwith your nurse and implement anydischarge arrangements• continue with CPM and cryotherapy• be encouraged to mobilise.You will:• be given oral pain medication• be given medications to preventclots• have your wound checked to ensureit is clean and dressing intact• be checked by your nurse to ensureyour bowels have returned to normalfunction• implement discharge arrangements• be provided with written dischargeinstructions.Your Physiotherapy Goals• Mobilise with elbowcrutches at ward levelindependently• Climb a flight of stairs withthe physiotherapist• Have achieved 85-90 degreeknee bend on the CPM• Complete exerciseindependently throughoutthe day• Sit out during the day.• Mobilise safely andindependently• Independent in completionof your exercise programme• Have achieved a minimumof 90 degree knee bend• Understand the importanceof rehabilitation and followup outpatient physiotherapy• Ensure you have thenecessary equipment foryour rehabilitation.General RecommendationsSleepingWhile in hospital some patients find it harder to sleepfor various reasons, e.g. different bed and environment. Ifyou find that you are having this problem please let thenursing staff know as you may require something to helpyou sleep. After the day of the procedure you can sleepon your side or back unless otherwise indicated by theconsultant. If you decide to lie on your side then a pillowbetween the knees may provide additional comfort.NauseaSome of the medications you may be prescribed cancause nausea. Please inform the nursing staff if you feelsick or are getting sick. Your medications may need tobe changed/adjusted and the nursing staff can also getmedication prescribed to help relieve this nausea.Pain MedicationOn discharge from hospital you will be prescribed somemedications. At least one of the medications will be forpain. Plan to take your pain medication 30 minutes beforeyour exercises. Preventing pain is easier than chasing pain.If pain control continues to be a problem, contact yourgeneral practitioner.21

Guidelines for Patients Having a Total Knee ReplacementNutritionyour hospital stay.Aim to follow a well balanced diet which includesprotein, fats and carbohydrates. It is important to be wellnourished to promote wound healing, so eat well and donot attempt to lose weight at this time.The following nutrients are particularly important topromote wound healing:• Protein – found in meat, fish, eggs, milk, cheese,yoghurt, beans and pulses.• Vitamin A – found in liver, fortified milk, carrots,turnips, and leafy green vegetables.• Vitamin C – found in citrus fruits, potatoes and leafygreen vegetables.• Iron – found in liver, red meat and leafy greenvegetables.• Zinc – found in fortified breakfast cereals, red meat andleafy green vegetables.If you are on a special diet or have any queries, pleasediscuss with your doctor, nurse or dietician.Swelling and BruisingMost patients experience swelling and bruising in theknee after surgery. This is a normal part of the recoveryphase after a total knee replacement. The swelling cancause pain in your knee and may restrict the amount ofmovement you have in the joint. To reduce this, take themedications that are prescribed for you, and ice your knee.Use of IceYour knee may be hot, red and swollen after surgery. Icemay therefore be used during your hospital stay and athome, to help reduce the pain and swelling in your knee.A cryocuff may be placed on your knee for 15-20 minutes.Your sensation may be decreased after surgery, so useextra care.You shall continue to ice regularly during the day bothas an in-patient and on discharge home in order to helpcontrol swelling and any pain and also to encouragehealing. This should be done at least 3 times a day for thefirst 6 weeks after surgery and as required after that.Bowel CareDriving22A high fibre diet is recommended after surgery. You mayalso be prescribed laxatives (eg. Lactalose, Senokot) duringYour consultant will tell you when you are allowed todrive again after your operation. In order to be safe driving23

Guidelines for Patients having a Total Knee Replacementa motor vehicle, you must be in control of the pedalseffectively. It is recommended that you do not drive amotor vehicle until you have complete control over yourleg. This does not normally occur until at least 6 weeksafter your surgery. When you feel capable of driving, it isrecommended to complete a trial period in an empty carpark to accustom yourself to your new knee. Please checkwith your motor insurer prior to your return to driving.There may be additional requirements or restrictions tofollow after your surgery.Car TransfersWhen travelling in the car you should sit in the frontpassenger seat. It is important that you avoid longjourneys if possible.Before getting into the car, make sure you are standingon level ground and not on a kerb. Your driver shouldmove the seat back as far as it will go and recline the seatslightly.swing your legs into the footwell of the car.When getting out of the car, reverse the aboveprocedure and ensure the operated leg is out in front ofyou before standing up.TravelProlonged periods of sitting on airlines may predisposeyou to leg swelling and deep venous thrombosis, and it isrecommended that you avoid this until 6 weeks after yoursurgery. If you must travel, wear your elasticated stockingsand keep your leg elevated as much as possible. Pleasediscuss any imminent travel arrangements with yourconsultant.General Safety Advice for the Home:Please be aware of the hazards in your home as this willmake your recovery easier and safer.• Move electrical cords, phone lines and ensure clearpathways.24When getting into the car, stand with your back tothe car and lower yourself down slowly onto the seat,keeping your operated leg slightly out in front of you.Slide back into the centre of the passenger seat allowingyour operated leg to come onto the seat with slightlyknee bent. Keep leaning backwards, twist your bottom and• Store items within easy reach specifically in the kitchenand bathroom areas.• Remove rugs including bath mats and entrance mats.• Be careful with pets and young children.• Be aware of water spills, slipper floors and always think25

Guidelines for Patients having a Total Knee Replacement26before you move.• Pace yourself and take your time.Showering/BathingA shower usually has a small step in and care should betaken getting in and out. A shower chair, non-slip mat andgrab rail will maximise your safety if you choose to use theshower.If you only have a bath then transfers should only becompleted with assistance of family member/carersand with the use of assistive equipment eg. bath board.Sitting while washing at a sink or using a family member’sshower might be helpful alternatives. The websitewww.asssistireland.ie is a useful resource for informationand local suppliers of assistive equipment for showering/bathing. If you require more specific advice in relation tobathing the Occupational Therapist can assist you.Sexual ActivityResumption of sexual activity is possible on discharge.However, care should be taken to avoid excessive force onthe knee and the wound should be protected.StockingsYour consultant may wish for you to go home withelasticated stockings. These can be an important partof preventing the development of deep vein thrombosis(blood clots in the legs). It is recommended to wear thesefor 6 weeks after surgery.AntibioticsFollowing knee replacement surgery there can be agreater risk of developing an infection in the knee withsome procedures. Antibiotics to prevent the developmentof an infection in the knee should be taken whenhaving a bladder catheter inserted, urinary surgery (e.g.prostatectomy) or when having infected teeth removed.Always tell your dentist that you have had a total kneereplacement.Discharge InstructionsAssuming no complications arise after your operation, andonce your physiotherapist considers you independentlymobile, you will be discharged from hospital. This isusually about day four or day five of your stay. Somepeople go straight home, while others require some timein a convalescent home. When you leave the hospitalyou will be given an appointment to see your consultant,usually around 6 weeks after the operation. This is for aroutine check-up which will make sure you are progressingsatisfactorily and x-rays may be taken. It is important tostill bring your old x-rays with you at this time.27

Guidelines for Patients having a Total Knee ReplacementSubsequent appointments may be at 6 months, 1 year, or2 years after surgery.You will be advised to attend outpatient physiotherapywithin two weeks of discharge. You can either attenda physiotherapist in the hospital or one more local toyour home. If you would prefer to exercise in a groupsetting, UPMC Beacon Hospital provides weekly groupexercise classes for total knee replacement patients. Yourphysiotherapist will provide you with the details of theseclasses. You will need to continue your physiotherapyfor a minimum of three months after your surgery. Yourphysiotherapists will advise you after your surgeryregarding your requirements.Wound CareYou will leave the hospital with a simple surgical wound.Before leaving your dressing will be changed and thewound site checked. Keep the wound dressing clean anddry. The nurse looking after you will advise you on whenthe dressings need to be changed. You may then removethe dressing after showering and apply a fresh dressing.Please check with your nurse prior to discharge regardingyour consultant’s specific wound care instructions, andinstructions regarding removal of clips or stitches.the symptoms below occur then you will need to see yourGP or liaise with the centre for orthopaedics for advice andpossibly antibiotics.Signs of InfectionIf you develop any of the following signs of infection, itis important to report them to your doctor. The signs ofinfection include:• Redness around the wound site• Increased pain in the wound• Swelling around the wound• Heat at the wound site• Discharge of fluid – may be green or yellow• Odour or smell from the wound• Feeling of being generally unwell• Fever or temperatureMost people will have sutures (stitches) that will needto be removed approximately 10-14 days after surgery.This may be done by the GP, Centre for Orthopaedics,consultant or in the convalescence centre.Make sure you receive a copy of the Patient Wound CareDischarge Instructions prior to your discharge.28Infection may occur despite your very best efforts. If any of29

Guidelines for Patients having a Total Knee ReplacementActivities at HomeDuring the first 6 weeks after your surgery, we recommendlimiting your activities to walking with support, orwhen the dressing has been removed, to swimming inthe shallow end. We recommend that you refrain frommore strenuous activities such as golf and social tennisfor a period of 3 months. The following are some of ourrecommendations:Not Recommended after Surgery• Jogging or running• Contact sports and high impact aerobics• Vigorous walking or hiking• Skiing• Tennis• Repetitive lifting exceeding 50lbs• Ballroom dancing• Normal stair climbingConclusionWe hope that you have found this booklet useful andthat it has helped to relieve some of your fears andanxieties regarding your surgery.During your hospital stay, your medical team willbe available to discuss anything mentioned in thisbooklet or to answer any other queries you may have.We look forward to meeting you soon.Expected Activity after Surgery• Recreational walking• Golf• Driving• Light hiking• Recreational biking3031

Guidelines for Patients having a Total Knee ReplacementExercise Diary Following Total Knee Replacement SurgeryDay Post Operation: Day 1 Day 2 Day 3 Day 4 Day 5Time of Day: Morning Afternoon Evening Morning Afternoon Evening Morning Afternoon Evening Morning Afternoon Evening Morning Afternoon EveningTarget Volume(Repetitions x Sets)1. Ankle Pumps2. Knee Flexion3. Quads Contraction4. Inner Range Quads5. Knee ExtensionHeel Prop6. Straight Leg Raising7. Sitting KneeFlexion8. Standing KneeExtensionInstructions: The exercise programme will begin the first day afteryour surgery and the physiotherapist will teach you the exercisesthe first time you perform them. From then on you should recordthe number of repetitions of each exercise that you complete inthe boxes in the table above. The aim is to perform three exercisesets per day (morning, afternoon and evening).32 33

Guidelines for Patients having a Total Knee ReplacementAppendixPotential Complications of Knee Replacement SurgeryIncidence: THE MAJORITY OF PATIENTS WHO UNDERGO KNEE REPLACEMENTSURGERY HAVE A PLEASANT EXPERIENCE WITHOUT ANY COMPLICATIONS.OF ALL PATIENTS WHO UNDERGO TOTAL KNEE REPLACEMENTS, MORE THAN96% HAVE NO COMPLICATIONS. THE FOLLOWING IS A COMPREHENSIVELIST OF ALL PROBLEMS THAT COULD POTENTIALLY OCCUR. FOR INFORMEDCONSENT IT IS IMPORTANT THAT YOU KNOW OF THESE PROBLEMS BUTPLEASE BE REASSURED THAT THE VAST MAJORITY OF PATIENTS SUFFER NOCOMPLICATIONS.medication to try to limit the risk of a DVT forming. Starting to walk andmobilising is one of the best ways to prevent clots from forming. Howeverdespite all these precautions, some patients still develop clots and mayrequire treatment with further medication.Knee StiffnessKnee stiffness may occur after the operation, especially if the knee is stiffbefore the surgery. Manipulation of the joint (under general anaesthetic) maybe necessary.PainThe knee area will be sore after the operation. If I am in pain, I understandthat it is important to tell staff so that medications can be given. Pain willdecrease with time. Rarely, pain will be a chronic problem and may be due toany of the other complications listed below, or, for no obvious reason. Somereplaced knees can remain painful; however this is rare.Prosthesis Wear and LooseningWith modern techniques and new implants, knee replacements last manyyears. In some cases however, they fail sooner. The reason is often unknown.Wear may contribute to loosening. Loosening may cause pain and if looseningis significant, a second joint replacement may be required. This operation issignificantly more complicated than the original joint replacement.34BleedingThis is usually small, which is controlled during the operation. A bloodtransfusion or iron tablets may occasionally be required. Rarely, the bleedingmay form a blood clot or large bruise within the knee, which may becomepainful and require an operation to remove it.Blood Clot (DVT)/PhlebitisA DVT (deep venous thrombosis) is a blood clot in the vein. This may presentas red, painful and swollen legs (usually). The risk of a DVT is greater after anysurgery (and especially bone surgery). A DVT may pass in the blood streamand be deposited in the lungs (a pulmonary embolism/PE). This is a seriousand rare condition, which affects your breathing. The consultant will prescribeInfectionAntibiotics are given just before and after the operation, and the procedurewill be performed in an operating theatre with sterile equipment. Despitethis, postoperative infection may still occur. The wound site may becomered, hot and painful. There may also be a discharge of fluid or pus. This isusually treated with antibiotics, but an operation to wash out the joint maybe necessary. In rare cases, the implants may be removed and replaced ata later date. The infection can sometimes lead to sepsis (blood infection)and strong antibiotics may be required. Infection is now a rare complicationoccurring in less than 1% of patients. Strict protocols in the operating theatre,intra-operative antibiotics, special surgical gowns and meticulous attentionto surgical detail have helped achieve this low number, but for the unlucky1% it is a catastrophic outcome. Spread of infection from another part of the35

Guidelines for Patients having a Total Knee Replacementbody to a joint replacement can occur, sometimes years after the operation. Toprevent such infections, persons with a joint replacement are generally givenantibiotics with extensive dental procedures, urinary tract infections or surgeryas well as before other types of surgery. If an infection occurs anywhere in thebody it must be treated promptly with antibiotics.Blood/Fat Embolism (PE)A PE (pulmonary embolism) is a consequence of DVT (deep vein thrombosis).PE may occur if the clot detaches from the vein and travels to the lungand can make breathing difficult. A PE can be treated with blood thinningmedication, but can also be fatal.Joint DislocationIf this occurs, the joint can usually be put back into place without the need forsurgery. Sometimes this is not possible, and an operation is required followedby application of a knee brace.Nerve DamageRarely, nerves in the vicinity of the knee joint are stretched or damaged duringthe operation (a neuropraxia). This is often only noticed upon returning to theward where the patient may complain of altered sensation in the foot or, inmore severe cases, inability to move their foot outwards. Changes in sensationto the outer half of the knee may be normal. Every effort is made to preventthis; however damage to the small nerves of the knee is a risk. This maycause temporary or permanent altered sensation around the knee. Total kneereplacement surgery is done under tourniquet (where a blood pressure cuffis applied to your leg) and occasionally a nerve by the side of the knee canget damaged (the peroneal nerve), which may cause temporary or permanentweakness or altered sensation of the lower leg. Fortunately, the majority ofthese neuropraxias resolve over a period of time, sometimes months. In a verysmall minority the damage may be permanent.Bone DamageA bone may be broken when the prosthesis (replaced knee joint) is inserted.This may require fixation, either at the time or at a later operation.Periprosthetic FractureThis complication can occur after a knee replacement if the bone is weak,especially in the first two months after surgery. Sometimes it is caused by afall or stumble. Periprosthetic femoral fracture causes thigh pain with weightbearing and may cause shortening and rotation of the limb.Heterotropic OssificationThere is a small risk of developing ossification or calcification in the muscletissue around the knee after surgery. In the majority of cases, this involvessmall islands of bone that do not cause any functional restriction and areonly noticeable on x-rays. Rarely, in less than 1% of cases there may be moreextensive ossification that may cause stiffness and pain. This can be correctedby surgical removal but only after 12 months have passed since the surgery.Blood Vessel DamageThe vessels at the back of the knee may rarely be damaged and may requirefurther surgery.Stroke (CVA)/ Sudden DeathThis is a very rare complication that can occur after any major surgery andfrom any of the above.3637

UPMC Beacon Centre for OrthopaedicsUPMC Beacon HospitalSandyfordDublin 18Tel: 01 293 7575Email: orthoclinic@beaconhospital.iewww.orthopaedics.iewww.beaconhospital.ieUPMC Beacon Physiotherapy DepartmentTel: 01 293 6692Email: physiotherapy@beaconhospital.ieScan with your smartphoneto visitour websiteto downloadour free appVersion 2