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Knee Arthritis

Arthritis simply means an inflammation of a joint causing pain, swelling, stiffness, instability and often deformity. Severe arthritis interferes with a person’s activities and limits his or her lifestyle.

Man Suffering From Knee Pain Sitting Sofa

Causes

Osteoarthritis or Degenerative Joint Disease – the most common type of arthritis. Osteoarthritis is also known as “wear and tear arthritis” since the cartilage simply wears out. When cartilage wears away, bone rubs on bone causing severe pain and disability. The most frequent reason for osteoarthritis is genetic, since the durability of each individual’s cartilage is based on genetics. If your parents have arthritis, you may also get it.

Trauma – can also lead to osteoarthritis. A bad fall or blow to the knee can injure the joint. If the injury does not heal properly, extra force may be placed on the joint, which over time can cause the cartilage to wear away.

Inflammatory Arthritis – swelling and heat (inflammation) of the joint lining causes a release of enzymes which soften and eventually destroy the cartilage. Rheumatoid arthritis, Lupus and psoriatic arthritis are inflammatory in nature.

FAQ

How can a doctor diagnose arthritis?

Doctors diagnose arthritis with a medical history, physical exam and x-rays of the knee.

How painful is knee replacement surgery?

No surgery is painless, and knee replacement surgery is no exception. However, postoperative pain from knee replacement surgery is usually manageable and newer advanced methods of pain management have helped control surgical pain while reducing use of narcotic pain medicines. Despite the surgical pain, daily and weekly improvements are typically made.

How will my pain be managed?

Most patients getting knee replacement surgery undergo spinal anesthesia with sedation, so they are not awake during the surgery. This type of anesthesia has many benefits, not the least of which is the continuation of pain relief for several hours after surgery. Additionally, spinal anesthesia has been demonstrated in studies to have other benefits, such as decreased surgical blood loss and a decreased risk of developing lower extremity blood clots when compared with general anesthesia. The muscle relaxation provided by spinal anesthesia also makes performing the surgery easier and therefore less traumatic for the patient.

After surgery, patients are treated with other pain medicine, mostly taken by mouth. While it may seem surprising, often the postoperative pain from knee replacement can be managed simply with oral pain medicine. This spares patients from the side effects of stronger intravenous medicines. On occasion, injections of pain medicine may be needed, until the day after surgery. After this, most pain medicine is provided in pill form as needed. Patients are often discharged with a prescription of the pills that worked for them during their hospital stay.
Patients can also help relieve their pain with means other than pain medicine. For example, applying ice and elevating the knee after therapy can go a long way toward controlling the swelling that often causes discomfort after such activity. On the other hand, when patients have discomfort from stiffness, usually doing some exercises will help relieve this pain more than any medicine will.

How long will I have pain after surgery?

It is difficult to give a specific answer for this, but most patients notice good pain relief within the first 1-2 weeks after surgery, followed by continued recession of pain over the first 1-3 months. Surgical pain is usually at its worst for the first week after surgery. After this, patients are usually more comfortable. They may experience some increased pain when doing exercises or therapy, but this can be easily managed by taking pain medicine before therapy.

Is it OK to take pain medicine?

Many patients express concerns about taking pain medicine after surgery, particularly with respect to narcotic addiction. While it is possible to become addicted to narcotic pain medication, this is rare when the medicine is taken appropriately after surgery. Postoperatively, patients have a good reason to have pain and it is okay to take pain medicine at this time. It often takes less narcotic to control a person’s pain when the medicine is taken appropriately – that is, when the patient begins to experience real discomfort. In the early postoperative period, patients should not try to “hold off” on taking pain medicine because they think the pain will calm down in time. These patients who “hold off” until their pain becomes too severe often need more narcotic to control their pain than they otherwise would have needed if they had taken their pain medicine earlier.

What are the side effects of pain medicine?

Side effects of pain medicine and anesthesia include nausea, constipation, mood changes and sometimes a tired feeling. Having these side effects does not mean that a patient is allergic to the medication. If a patient has a problem with these side effects, often the medication can be adjusted or a different medication tried in order to minimize these effects.

When is my first post-operative office visit?

The 1st office visit after surgery is between 2 and 6 weeks from the date of surgery, depending on the surgeon’s discretion and protocol. If you have staples, the 1st office visit after surgery is often 2 weeks from date of surgery. Many patients have stitches under the skin and the incision is glued; these patients do not often have to be seen in 4-6 weeks.

When will my staples or sutures be removed?

Approximately 2 weeks after your surgical date, the staples or sutures will be removed. Some patients will have no visible staples or sutures and therefore will not need to have anything removed.

When will my dressing be removed?

If you have a specialized dressing that looks like a large band-aid, you may shower with the dressing in place. The dressing should be removed 5-7 days from the day of surgery. If you have a gauze dressing and tape on your knee, it will most likely be removed before you are discharged from the hospital. If not, it can be removed 2 days after surgery and the area should be kept clean and dry.

How long will I remain on anticoagulation (blood thinners that help avoid blood clots)?

Typically 2 to 6 weeks after surgery (the surgical team will specify the duration that they prefer for each individual patient). For most patients, who are at a standard risk for getting a blood clot, aspirin is prescribed. For other patients, especially those who are unable to take aspirin or who have a higher risk for getting a blood clot, low-molecular weight heparin (Lovenox) or warfarin (Coumadin) are used. If you are on warfarin, you will need bloodwork drawn 1 to 2 times a week and your medical consultant will adjust your medication dosage. If you are placed on aspirin or low-molecular weight heparin injections, you will not require blood testing.

Is swelling of my knee, leg, foot, and ankle normal?

Yes, swelling is normal for three to six months. To decrease swelling, elevate your leg and apply ice for 20 minutes at a time (3-4 times a day).

Is it normal to feel numbness around the knee?

Yes, it is normal to feel numbness around the incision and outer side of the knee, since the surgeon has to cut some microscopic nerves that provide sensation around the knee. This may persist forever, although the area of numbness may shrink over a few years.

Why is my leg bruised?

It is common to have bruising on the skin. It is from the normal accumulation of blood after your surgery. You can see bruising all the way down to your foot due to gravity.

What exercise should I perform at home?

Please do exercises as instructed by your surgeon. Remember, you are using your knee every time you stand up and walk around – this is actually doing physical therapy for your knee. Focus on walking as much as you can. It is also very important to stretch your knee after surgery even though it may be uncomfortable. Please do smooth straightening and bending stretches 5-10 times per day. This is often all that is necessary to appropriately heal from knee replacement. Additionally, you may have been given a link for FORCE Therapeutics that will help guide you on which exercises are safe after your total knee replacement.

May I go outdoors prior to my first postoperative visit?

Yes, we encourage you to do so.

May I drive or ride in a car before my first postoperative visit?

Yes, you may ride in a car. However, you must be off all narcotic pain medications and a walker prior to driving. It is a patient’s responsibility to determine his/her own safety. If your right knee is replaced, you may need to wait a month to six weeks before driving, depending on your ability to move your right foot from the gas pedal to the brake. If your left knee is replaced you can drive with your right foot once you are off pain medicines.

May I ride in an airplane before my first postoperative visit?

Yes, you may ride in an airplane. It is important to pump your feet and ankles frequently while sitting in the plane. Be sure to get up and move around at frequent intervals to prevent blood clot formation. You may find it more comfortable to sit in an aisle seat.

What is the maximum range of motion an artificial knee can achieve?

This depends on your preoperative range-of-motion. Your final range-of-motion will be close to the range-of-motion that you had before the surgery. Knees that were very stiff before surgery tend to end up a little stiffer than other patients who had more flexibility before surgery. It is important that you work on stretching exercises on your own. Physical therapy can help improve range of motion, but it is the daily stretching you do that can have the biggest benefit.

What is the short-term outlook?

The short-term outlook of total knee replacement is excellent. Most patients can stand the afternoon of surgery and begin exercise that day. With the support of walkers, crutches and canes, patients can walk with confidence, climb stairs and ride in a car by the time they leave the hospital. Physical therapy and motion exercises are the key to good results, and these should continue for months. Some swelling, aching and bruising are normal during this time. Most patients are up and about within six weeks after surgery.

When can I return to work?

Most patients will return to work within 1-3 months after surgery. This typically depends on the type of work you do and the speed of your recovery. A more sedentary job can be performed even sooner than a month (as soon as a week). A more physically demanding job may require as much as 3 months for you to properly recover before returning.

Can I return to my normal activities after a knee replacement?

Fortunately, knee replacement surgery not only restores our patients’ quality of life but, of equal importance, allows them to return to their activities of daily living. Please discuss specific activities with your surgeons, as some activities may need to be limited.

Definitions

Less invasive or minimally invasive surgery involves a smaller incision than the traditional techniques. However, there is a misconception that the length of the incision is the key determinant of the quality of the result and the speed of the postoperative recovery. In reality the speed of postoperative recovery depends very little upon the length of the incision, but rather is determined by multiple factors including the extent of the arthritis being treated, the quality of the surgical technique, and postoperative pain management and rehabilitation protocols. Perhaps one of the most important features of our knee replacement program involve optimized pain management protocols for rapid recovery, independent of the surgical approach used.
Techniques include “medial parapatellar,” “quad sparing,” “subvastus,” “mid-vastus” or “mini parapatellar” approaches. All of these approaches seek to minimize trauma to the extensor mechanism (quadriceps) and also all other anatomic structures around the knee. None of these approaches involve cutting across the quadriceps tendon. Clinical studies show that the outcomes of all of these techniques, when properly performed, are excellent with no significant differences in rates of recovery between any of these different approaches.
Less invasive surgery includes unique pre- and post-operative pathways for anesthesia, nursing care and rehabilitation. These have facilitated the early discharge protocols that get our patients home soon after surgery. While some patients are hospitalized for 3-4 days, many now are discharged one day after surgery, if desired

Orthopedic doctor‘s hand holding magnified lens and the reflex of lens show film X ray radiograph of osteoarthritis (OA knee disease) treated by total knee replacement surgery( TKR ). Medical concept

Total Knee Replacement

When the cartilage has worn away, an artificial knee (called a prosthesis) can take its place. The surgical options to implant the prosthesis are termed partial or total knee replacements. In this section, we discuss total knee replacement. The total knee replacement restores function of the knee by reducing pain and allowing patients to perform their activities of daily living. While the idea of getting an artificial knee joint may be frightening to some, it is one of the safest and most effective surgical procedures available.

Minimally Invasive Knee Surgery

Knee replacement is among one of the most common and successful orthopedic surgery. The indications for these surgeries are well established and their overall success documented by extensive research. Substantial pain relief and improvement in function is expected for most patients for 15 years or more after surgery.
Minimally invasive and small incision knee replacement surgery is merely a variation of traditional joint replacement surgery encompassing an array of modifications to the original technique.

What to discuss with your surgeon

You should have a clear understanding of the goals of your joint replacement surgery before you proceed. A discussion of joint replacement surgery should include a review of the technique that your surgeon suggests. If your surgeon offers minimally invasive or small incision surgery, ask about potential short-and long-term risks and benefits of this type of surgery. Review his or her specific results for contemporary and minimally invasive surgery in relation to fracture, infection, blood clot, nerve injury and dislocation rates. Complications appear to be more common when the surgeon has less experience with this type of surgery. Inquire about his or her qualifications, competence and proficiency with the technique. Understanding the usual post-operative course, including hospitalization, blood loss, rehabilitation and return to work is important.

Revision Knee Surgery

Repeat (also called “revision”) surgery is different than first time (also called “primary”) total knee replacement. The technical aspects of the surgery are more complex than the original total knee replacement, and recovery may be slower than the original surgery. However, the preparation for surgery and the hospital experience tend to be very similar to the primary knee replacement. There may be different weight bearing restrictions after surgery, as well as different rehabilitation protocols.

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Benefits

Revision total knee replacements are sometimes required if the original knee replacement has worn out or is causing pain or instability.

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Patients

Patients should undergo revision surgery if they have symptoms and/or imaging findings that warrant repeat surgery.

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Procedure

The technical aspects of the surgery are more complex than the original total knee replacement, however

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Recovery

What does my hospital stay look like?

You will arrive the morning of your surgery and get prepared for surgery. You will be taken to the preoperative holding area where your surgeon or member of the team will mark the correct operative location. You will meet the anesthesia team and nurses who will be involved in your operation.
After surgery, you will recover in the post-anesthesia care unit (PACU) as your anesthesia wears off. You will then be transferred to your room. Once your anesthesia wears off, physical therapy will assist in getting you out of bed and you will begin to walk. Once you can walk, eat normal food and have your pain controlled, you can leave the hospital.

How long will I be in the hospital?

On average, patients stay for 0-3 nights after total knee revision surgery. Your discharge may be as early as the day of surgery, or may be prolonged, depending on the complexity of your revision.

How painful is knee revision surgery?

No surgery is painless, and revision knee replacement surgery is no exception. However, pain after revision knee surgery should be manageable. Generally, the most difficult time is in the first 4 weeks after surgery.

How will my pain be managed?

Most patients getting knee replacement surgery undergo spinal anesthesia with sedation, so they are not awake during the surgery. This type of anesthesia has many benefits, not the least of which is the continuation of pain relief for several hours after surgery. Additionally, spinal anesthesia has been demonstrated in studies to have other benefits, such as decreased blood loss and a decreased risk of developing blood clots when compared with general anesthesia. The muscle relaxation provided by spinal anesthesia also makes performing the surgery easier and therefore may be less traumatic for the patient. Some patients may also receive a nerve block just after surgery to help control pain.
After surgery, patients are typically treated with oral pain medication. This spares the patient from the side effects of stronger IV medicine. If needed, IV medications may be used as well. Patients are often discharged with a prescription for the pain pills that worked for them during their hospital stay.
Patients can also help relieve their pain with means other than pain medicine. For example, applying ice and elevation to the operated leg after therapy can go a long way toward controlling the swelling that often causes discomfort after such activity. Maintaining activity can also help prevent stiffness and swelling, which can also lead to pain.

Is it OK to take pain medicine?

Many patients express concerns about taking pain medicine after surgery, particularly with respect to narcotic addiction. While it is possible to become addicted to narcotic pain medication, this is rare when the medicine is taken appropriately after surgery. Postoperatively, patients have a good reason to have pain and it is okay to take pain medicine as directed by your surgeon at this time. It often takes less narcotic medication to control a person’s pain when the medicine is taken appropriately – that is, when the patient begins to experience some discomfort. In the early postoperative period, patients should not try to “hold off” on taking pain medicine because they think the pain will calm down in time. These patients who “hold off” until their pain becomes too severe often need more narcotic medications to control their pain than they otherwise would have needed if they had taken their pain medicine earlier. This increases the chance that they may experience a side effect of the pain medications.

What are the side effects of pain medicine?

Side effects of pain medicine and anesthesia include nausea, constipation, and sometimes a tired feeling. Having these side effects does not mean that a patient is allergic to the medication. If a patient has a problem with these side effects, often the medication can be adjusted or a different medication tried in order to minimize these effects. Please call your surgeon’s office if you are having any issues with your medications.

When is my first post-operative office visit?

The 1st office visit after surgery is typically 2-6 weeks from the date of surgery. If you have staples or visible sutures, the 1st office visit after surgery is often 2 weeks from the date of surgery.

When will my staples or sutures be removed?

Approximately 2 weeks after your surgical date, the staples or sutures will be removed. Some patients will have no visible staples or sutures and therefore will not need to have anything removed.

When will my dressing be removed?

If you have a specialized dressing that looks like a large band-aid, you may shower with the dressing in place. The dressing should be removed 5-7 days from the day of surgery. If you have dressing that is wrapped around your leg, it will most likely be removed before you are discharged from the hospital. If not, it can be removed 2 days after surgery and the area should be kept clean and dry.

How long will I remain on anticoagulation (blood thinners that help avoid blood clots)?

These blood thinners are prescribed for up to 2-6 weeks post-operatively. If you are prescribed aspirin, you will take it twice a day for 4 weeks. If you are on warfarin (Coumadin), you will need your blood to be drawn twice a week to ensure that you are taking an adequate level of the medication. Your medical doctor who cleared you for surgery will arrange for monitoring your warfarin by blood labs and will communicate with you the dose you should take. Sometimes, other medications are used to reduce the risk of blood clots and you should follow your physician’s directions when taking these medications.

Is swelling of my knee, leg, foot, and ankle normal?

Yes, for three to six months. To decrease swelling, elevate your leg and apply ice for 20 minutes at a time (3-4 times a day).

Is it normal to feel numbness around the knee?

Yes, it is normal to feel numbness around the incision and/or on the outside part of your knee.

Why is my leg bruised?

It is common to have bruising on the skin. It is from the normal accumulation of blood after your surgery.

What exercise should I perform at home?

Please do exercises as instructed by your surgeon. Remember that if you are using your knee to do things (e.g. walking around), you are actually doing physical therapy for your knee. You may have been given a link for an on-line physical therapy program “Force Therapeutics” that will help guide you on which exercises are appropriate after your total knee replacement.

How long will I need to use a walker, cane, or crutches?

This varies with each patient. Patients often use a walker or crutches initially after surgery. Some patients may have restricted weight-bearing after revision surgery while others will not. Your surgeon will tell you about your weight-bearing status after your surgery.

May I go outdoors prior to my first postoperative visit?

Yes, we encourage you to do so.

May I drive or ride in a car before my first postoperative visit?

Yes, you may ride in a car, however, you must be off all pain medications prior to driving. It is a patient’s responsibility to determine their own safety. Patients must be able to operate their car safely.

May I ride in an airplane before my first postoperative visit?

Yes, you may ride in an airplane. Be sure to get up and move around at frequent intervals to prevent blood clot formation. You may find it more comfortable to sit in an aisle seat.

What is the maximum range of motion an artificial knee can achieve?

This depends on your preoperative range-of-motion. Your final range-of-motion will be close to the range-of-motion that you had before the surgery.

Potential Complications

Revision total knee replacements have higher risks compared to primary total knee replacements. There are higher risks of nerve and blood vessel injuries, increased risks of clots to the legs and lungs, and there is a higher risk of infection since another surgical procedure is being performed. Revision total knee replacement patients may undergo subsequent revision surgery. While inflammation of the leg veins (phlebitis) is not rare, the occurrence of symptomatic blood clots has been greatly reduced with the use of compression devices in the hospital and blood thinning medications such as aspirin. Early mobilization (walking and moving one’s foot up and down) are extremely important for helping to reduce the development of blood clots. Other complications include infection, wear, stiffness or loosening of the parts. In the instances where one of these complications occurs, they may need to be corrected with another revision surgery.