TOTAL KNEE REPLACEMENTA P A T I E N T ' S G U I D E T O

Normal knee joint(Side view)

Treatment by totalknee replacement

Knee joint destroyedby arthritis

STICKMENSTUDIO | 082 893 5612

Compiled by Dr Allan A van Zyl MBCHB (PRET), MMED (ORTHOP) (UOFS), F.C. ORTH (SA)

Private practice

3a Third Avenue

Westdene

Bloemfontein

Senior Specialist part time

Arthroplasty Unit

National Hospital and

University of the Free State, Bloemfontein

Mrs Dini Los BSC (PHYSIO)

Former head

Dept. of Physiotherapy

National Hospital

Mrs Ronette Hough B.ARB

Former head

Dept. of Occupational Therapy

National Hospital

The brochure is available from Dr Allan A van Zyl

PO Box 28772

Danhof

9310

Tel.: (051) 448-3051/2

E-mail: vanzyl@connix.co.za

Copyright reserved by Dr A A van Zyl

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· A patient's guide to total knee replacement ·

c/o Kellner Street & Parfitt Avenue BloemfonteinTel.: (051) 404 6666 Fax: (051) 444 1509

BLOEMFONTEINMEDI-CLINIC

We wish you all the best withyour knee replacement operation!

May you have a speedy recoveryand remember...

WE ARE COMMITTED TOQUALITY CARE!

This manual has been compiled to provide you and your family with a basic knowledge of total knee replacement surgery so that you may know what to expect from the operation.

It will also provide you with more insight into the procedures followed both before and after the operation.

A TOTAL JOINT REPLACEMENT (TOTAL HIP and KNEE REPLACEMENT) is the second most cost-effective treatment modality in the medical field, the most cost effective being the treatment of hypertension.

Keep in mind that you will come into contact not only with the surgical team but also with the physiotherapist and nursing staff, who will form an integral part of the team that will determine the success of your operation.

A total knee replacement is an operation that has been developed to replace damaged knee surfaces. Damage to the knee surface is caused mostly by arthritis. There is a common misconception that replacement of the entire knee is involved, when in actual fact the knee is merely fitted with a new surface during the procedure.

Side view of knee:

The knee has a hinge-type joint, which is replaced with an artificial joint of the same form during the operation. The artificial joint consists of a stainless steel component which fits over the end of the femur (thigh bone). This part then articulates with the plastic component that is placed in the upper end of the lower leg. The inside of the kneecap is also covered with a plastic “button”. These three components are attached to into the affected bones using a special type of cement (methyl methacrylate).

The purpose of this new knee joint is to reduce pain and stiffness and to increase mobility.

However, just like fillings in teeth, the artificial knee cannot last forever. If the artificial knee loosens from the bone, it will become necessary to replace it with a new component. There is a 5 - 10% chance that this might happen within the first 10 years after the operation, and a 10 - 20% chance that it might happen within 20 years after the operation. This means that there is a ± 80% chance that the knee prosthesis will remain in place for at least 20 years!

The life span of an artificial knee can be reduced by careless activities. Further information in this regard is given in this information brochure.

Pay attention to the following during this waiting period:

1. Try to lose weight (if necessary) for the following reasons:· It will relieve pain during the period you are waiting to have the operation done.· It will lower the risk of complications of the operation.· In the long run it should extend the life span of your artificial knee.

· Introduction ·

· What is a total knee replacement? ·

· What should you do while awaiting your operation? ·

Replace surfaces with artificialmaterial ('knee replacement')

Resection of worn surfacesNormal knee

2. Try to walk as much as possible using a walking stick or other aid, as this will reduce pain and the risk of any further knee damage.

3. Quadriceps exercises (in other words, exercises where the femoral muscles are contracted for 7 - 10 counts with a straight knee) are recommended to keep the muscles as strong as possible and to aid your recovery after the operation.

4. Visit your dentist if you have teeth that are troubling you.

5. Please inform your orthopaedic surgeon prior to admission if you have suffered any type of infection (especially colds and flu) in the four weeks preceding the operation.

6. Please inspect your whole body (ask a family member to assist you) for any sore, septic area or scabs. If any of the above is present in the week prior to your operation, you should inform your orthopaedic surgeon before being admitted to hospital.

7. If you are a smoker, please try and stop smoking, or cut down significantly, prior to your operation.

8. It is important not to shave the hair on your legs in the two weeks prior to your operation.

9. All routine medication should be brought with you to hospital.

10. Please leave all valuables at home.

11. Comfortable, baggy pyjamas with ample legroom is recommended.

12. If you are younger than 70 years, you may pre-donate blood for yourself prior to the operation (autologeous donation). Contact your surgeon should you wish to do so.

You will be admitted to the hospital at least one day prior to the operation. At this time you will receive a visit from the arthroplasty team.

The team consists of the following members:!orthopaedic surgeon;!anaesthetist;!physiotherapist; !specialist physician; and !sister in charge of the ward.

At this time the team will again perform a full physical examination. The necessary blood tests, X-rays and other special procedures will be performed.

The anaesthetist will advise you about taking routine medication on the day of surgery. The operation will once again be explained to you and the physiotherapist will demonstrates which exercises have to be done after the operation.

The evening before the operation you will have an antiseptic bath and an intravenous transfusion will be started.

The day of surgery you may brush your teeth and rinse your mouth without swallowing any water. You will be asked to change into a hospital gown and will be transported to the operating room on your bed. Your family may accompany you in the elevator.

The operation is performed in an ultra-clean air theatre. The duration of the operation itself is approximately 1½ hours, although the total time spent in the theatre complex is approximately 2½ hours.

· Procedures prior to the operation ·

· The day of the operation ·

Following the operation you will be returned to the ward. The affected leg will be covered with a bandage with drainage tubes visible beneath the bandage. It is very important that you start with deep breathing and calf-muscle exercises (by moving your feet up and down) as soon as the anaesthetic has worn off. You will be fitted with elastic support stockings that you must wear on both legs for a period of three weeks. These stockings will improve the circulation in your legs and reduce the risk of blood clots.

It is important that you lie with your knee as straight as possible during this time. No pillows may be placed beneath the affected leg. If swelling of the leg occurs the foot of the bed will be raised.

The day following surgery you may eat breakfast. The urinary catheter is removed and the first of several blood tests will be done. The first day after surgery you will be assisted to a reclining chair and physical therapy may begin under the care of a physiotherapist.

When starting to walk you may take full weight on the operated leg, unless ordered differently by your doctor.

With your first steps your rehabilitation programme begins in earnest.

The physiotherapist will explain the following to you:

1. How to get in and out of bed.2. How to walk using a walking aid.3. How to sit and get up from a chair.4. How to use the toilet.5. How to climb stairs.6. How to get in and out of a motorcar.

The drainage tubes are removed on the second day after the operation. On the third day after the operation the bandage is removed and the wound is inspected, cleaned and covered. On this day you will also be sent for X-rays to check your progress, and you will commence with bending exercises of the knee (see physiotherapist's programme).

Depending on your operation and rehabilitation, you will be discharged after approximately 7 days. Final wound inspection is done just before you are discharged, and your wound must then remain covered until the skin staples are removed 3 weeks after the operation.

IMPORTANT POINTS TO KEEP IN MIND UPON DISCHARGE FROM HOSPITAL:

1. Your white anti-thrombotic stockings or bandages must be worn for a period of three weeks after the operation.

2. Your skin staples are removed three weeks after the operation. If you stay near the hospital your staples will be removed at your surgeon's consulting rooms (please make your appointment well in advance), and if you stay far from the hospital your staples will be removed by your family doctor.

Six weeks after the operation, you must visit your orthopaedic surgeon once more for the first follow-up visit. During this visit new X-rays will be taken.

3. Once the skin staples have been removed, your wound will be covered for a period of two days. After these two days have passed, the wound must be left uncovered. You may then take showers, but remember to disinfect the wound daily with Dettol or Savlon after you have washed and dried the wound area thoroughly. Continue disinfecting the wound regularly for a period of approximately five days. Do not expose the affected leg to water for extended periods of time when bathing until the wound has completely healed.

4. It is important to take sufficient painkillers before doing any of the exercises, and you can push your knee until you experience discomfort, but not excessive pain.

· After the operation ·

5. A small percentage of people (±2%) will not have reached a 90°(right angle) limit of knee bending six weeks after the operation, and must then undergo a light manipulation under anaesthetic. If you experience difficulty bending your knee to an 80 - 90° angle four weeks after the operation, you must contact your physiotherapist for additional exercises.

6. Each day, for a period of at least three weeks, you must relax on your bed for ±30 - 60 minutes. You may prop your feet up to prevent swelling of the feet and ankles.

7. If you are experiencing any problems at home or if you are worried about your wound, please contact your attending orthopaedic surgeon immediately.

8. A patient who has recently undergone a total knee replacement will require moderate assistance for the first few weeks after his/her discharge. Assistance with dressing, preparing food, etc. is recommended.

Upon discharge you must make an appointment with your orthopaedic surgeon for 6 weeks after the operation so that he/she may evaluate your progress.

Slight swelling and/or redness of the wound are normal after a knee replacement operation. You will also notice that the knee feels warmer than the other unaffected knee for a period of three to six months after the operation. These symptoms will gradually disappear with time. Should these symptoms worsen, especially with accompanying progressive pain, you must contact your attending orthopaedic surgeon as soon as possible.

Due to the distribution of nerves near the skin surface, your may experience reduced sensation on the skin surrounding the scar. This is inevitable and will improve in time. You must be careful when placing a hot-water bottle or heater near the scar area, as it might cause a burn.

After this first appointment following your operation, you will again visit your orthopaedic surgeon 6 months later, and again 1 year later. Depending on your age, the type of knee replacement and other factors, you will visit the surgeon again 2, 3 and 5 years later for follow-up visits. (These examinations are very important for identifying problems at an early stage and preventing complications.)

·

1. INTRODUCTION

Before undergoing the operation it is important to understand that you will have to do exercises for a long time (±6 months) after the operation in order to ensure the best results from your operation. Walking or walking exercises are not sufficient. As a result of pain and disuse of muscles prior to the operation, the muscles surrounding the knee joint are often shortened and weak. It is thus important to give your full co-operation with respect to the exercise programme from the very first day following the operation.

2. IMMEDIATELY AFTER THE OPERATION

a. Chest physiotherapy: Regular sessions of deep breathing exercises and coughing is necessary to keep your lungs clear and to prevent problems.

b. Calf-muscle exercises: Regular calf-muscle exercises are necessary to reduce the risk of deep vein thrombosis (blood-clot formation).

c. Quadriceps exercises (in other words exercises where the thigh muscles are contracted with a straight knee) are also recommended to keep the muscles as strong as possible, as this will aid your recovery after the operation.

· Long-term follow-up ·

· Physiotherapy programme ·

The nursing staff will expect you to help in shifting yourself in bed. You can help by pulling yourself up by means of the overhead frame while supporting your body with your unaffected leg (see diagram below). It is very important to lift your buttocks regularly to prevent bedsores. The same procedure is followed when using a bedpan.

You will gradually be allowed to sit up in bed.

3. FIRST FEW DAYS AFTER THE OPERATION

a) On the day after the operation you may sit up in a chair and you may walk for the first time with the support of the physiotherapist.

b) For the first 3 days after the operation you may not bend your knee more than 40° when walking or sitting.

c) You may bear weight on the affected leg when you walk, unless your doctor recommends otherwise.

d) You may turn to any side, provided that you do not rotate on the operated knee.

e) It is important not to turn the operated leg too much to the inside or outside while walking. You must thus have your knee face forward then walking.

f) A walking aid (crutches or walking frame) will be recommended during your hospitalisation. You must use a walking aid for a period of up to six weeks after the operation. Thereafter you must only use the aid when walking long distances or over rough terrain.

g) If you were using a walking aid prior to your operation, you must please bring it along with you to hospital.

If the wound is healing satisfactorily and is not draining, you will be able to start bending your knee at approximately three days after the operation.

4. CLIMBING STAIRS

Up: First place the unaffected leg on the step, then the operated leg, followed by the crutches.

Down: First place the crutches on the step below you, followed by the operated leg and lastly the unaffected leg.

Always use the handrail when using stairs. It reduces pressure on your artificial joint and lengthens its life span.

5. DISCHARGE

If you are able to bend your knee at least 60 - 70° and can perform your exercise routine satisfactory, you may be discharged after approximately 6 - 7 days.

You will then be expected to follow a home exercise programme so that you will be able to bend your knee at least 90° at your six-week check-up.

You will have to continue with your muscle strengthening exercises for some time, because the stronger the muscles, the greater the support and protection provided for the artificial knee.

Swelling (oedema) normally occurs postoperatively, but will abate as soon as you start walking comfortably. Long periods spent seated can cause the leg to swell. We therefore recommend that you walk short distances regularly to improve the circulation in your leg. When sitting in a chair, try to take your knees and feet through the full range of movement. Move your knee regularly during the first three weeks even when lying in bed.

6. HOME PROGRAMME

Do not force your knee during the first six weeks; only exercise it by using your own muscle power and doing the exercises as shown to you by your physiotherapist.

· Exercises must be done on a firm surface.· Try to use your knee as much as possible during normal activities, in other words, do not always support

and favour your knee. Start using your knee normally from day 4, in other words bend the knee back as far as you are able and use it when standing up and sitting down.

· It is unnecessary to rest your leg on a stool when at home. If your leg is excessively swollen at night, raise the end of your bed slightly and sleep in this position. Remember that your knee joint requires a lot of movement.

· It is normal for the knee to feel somewhat stiff during the mornings, and also when you have been inactive for a long time. As healing takes place the stiffness will disappear if you exercise regularly.

7. EXERCISES

It is important to do your exercises regularly during the first six weeks after the operation. The success of the operation depends to a large extent on the exercises you do. Your knee will still be sensitive and you might still experience pain and swelling, but this discomfort will disappear when your knee joint is loose and fairly strong.

Walking alone is not sufficient exercise for a knee replacement!

The exercises as described below should preferably be done three times per day during the first three weeks, and you must move your knee as much as possible between exercises. If you sit still for too long, the knee may swell and feel stiff.

a) Sit up straight and keep your legs stretched out in front of you. Contract your thigh muscles, keeping your foot elevated. Hold for a count of 5 and relax (x10).

b) Lie on your back. Bend your unaffected leg while keeping your operated knee straight and locked. Slightly lift your leg and move sideways and back. Return to normal position (x10).

c) Straight-leg lifts. Keep the knee straight and lift your leg (x10).

d) Bollard exercises:Lie with a rolled-up towel under your heel. Straighten your knee using your muscles and hold for 7 seconds, then relax (x5).

Sit Roll the towel under your knee, lift your heel, straighten your leg, hold for 5 seconds (x10), compare with unaffected knee (see illustration on previous page).

e) Sit on a chair. Hold towel roll between the knees, squeeze the roll, lift the heel and lock the knee while squeezing. Hold for 5 seconds (x10).

f) Sit on a firm surface and swing leg to get a natural movement.

g) Sit on a table and dangle legs over the side. Straighten your knee and lower your leg while bending your knee as far as possible. (NB: Do no lift your buttocks.)

h) When bending the knee, bend it as far back as possible and hold this position by placing your foot on the ground. You may support yourself with your hands, but do not lift your buttocks while bending your knee.

i) Standing and sitting exercises (x5).

j) Sit, bend knee back as far as possible. Now shift buttocks forward slowly and bend within your pain limits. Hold for 7 - 15 seconds (x3).

k) "Masking tape" Measure yourself. This will be explained to you by your physiotherapist.

NB: Your physiotherapist may slightly adjust or vary your exercises and rehabilitation, depending on the condition of your muscles and knee.

General:

1) As soon as your knee is able to bend 90°, you may start to exercise on an exercise bicycle with slight resistance, or you may start being freely active in your exercises.

2) You may use a health walker, as this places almost no strain on your affected knee and promotes general health.

3) Swimming is very good exercise, and you may start with this as soon as your wound is completely healed and all the scabs have disappeared. However, never dive or jump into the swimming pool. Always climb into the pool slowly. The water resistance will help to strengthen and loosen your knee.

Six weeks after the operation

1. You may return to work provided that you follow a non-active working programme.

2. After six weeks you should be able to bend your knee 90° or more.

3. You can slowly start to walk without using a walking aid. However, it is recommended that you continue using a crutch or walking stick on the side of the affected knee when walking far distances or over rough terrain.

4. If your other knee or hip joint is also affected, however, you may continue to use a walking aid for an extended period of time in order to prevent strain on the other joints. This will not negatively affect your knee in any way.

5. If you can walk without crutches and your knee is strong enough you may drive a car again.

· Long-term programme ·

Three months after the operation

1. You can now return to a more active working programme, but never do work that requires more than slight bending or lifting. It is not advisable to return to heavy manual work.

1. If possible, prevent excessive strain on your artificial knee by not:

a) climbing a ladder;b) walking up very steep slopes;c) climbing stairs without using the handrail;d) jumping, running, jogging or pushing activities;e) picking up heavy objects; orf) walking long distances on loose ground or sand.

2. All kinds of sport places more strain on your artificial knee than normal daily activities, but golf and bowling are fairly safe.

3. If your are extremely overweight you are causing abnormal stress on your artificial joint. Guard against excessive weight gain, as it can shorten the life span of your artificial knee.

4. If you develop an infection in any part of your body, the germs may spread via your bloodstream and affect your artificial joint. Please contact your doctor immediately for antibiotic treatment should you develop any of the following:

a) severe flu;b) severe throat infection;c) tooth abscess, or in cases where a tooth is extracted;d) boils, infected cuts or sores;e) pneumonia; orf) bladder infection.

5. If you ever have to undergo any type of operation, inform your doctor of your artificial knee, that if necessary, suitable antibiotics can be prescribed.

•

REMEMBER THAT THIS IN ONLY A GUIDE TO YOUR REHABILITATION AND THAT YOUR PERSONAL PROGRAMME MY DIFFER, DEPENDING ON THE CONDITION OF YOUR KNEE

AND THE RECOMMENDATIONS OF YOUR DOCTOR.

· Precautions for the rest of your life ·