Total Knee Replacement Surgery

What is a Total Knee Replacement

A Total Knee Replacement also referred to as a Total Knee Arthroplasty is an operation to replace a knee joint that is affected by arthritis.


The procedure is a quality of life operation and is a highly successful operation.


Your new knee replacement can be expected to last for decades (90% are still functioning after 20 years).

Who are Candidates for Total Knee Replacement?

The procedure is usually recommended for older patients who suffer from pain and loss of function from arthritis or other knee degeneration and have failed to achieve satisfactory results from other conservative methods of therapy.


Each patient is assessed individually but Total Knee Replacement candidature is far greater than partial knee replacement and can include candidates who are:

  • Suffering Pain, or
  • Restricted Mobility that interferes with daily life
  • Stiffness, Deformity or Swelling


These symptoms would usually have been present for many months or even years, often getting worse over time and are more common with older patients or severely arthritic patients 


Benefits of Total Knee Replacement Surgery?

The decision to proceed with a Total Knee Replacement (TKR) is a cooperative one between you, your doctor, family and other medical professionals.


The benefits following surgery are the relief of symptoms of arthritis. These include

  • Severe pain that limits your everyday activities including walking, shopping, visiting friends, getting in and out of a chair, gardening, etc.
  • Pain waking you at night
  • Deformity- either bowleg or knock knees
  • Stiffness


Often TKR is a clear solution to help relieve symptoms and pain. Once the decision has been made to proceed with surgery, your doctor will explain the procedure and the risks (see below). A date for surgery is usually planned but can be deferred. 


What is Total Knee Replacement?

Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss, sometimes extra pieces of metal or bone are added. Custom implants are occasionally required.


Total Knee Replacement surgery involves resurfacing the worn parts of the knee and replacing the arthritic knee joint with artificial metal (cobalt chrome and titanium) and a plastic (highly cross-linked polyethylene) replacement parts called the 'prostheses'. 


The artificial knee joint is made from a surgical-grade metal alloy with a special wear resistant plastic insert.


About Total Knee Replacement Procedure


The procedure is designed to be performed with minimal local trauma 

  • The knee joint is exposed using a minimally invasive approach
  • the damaged portions of the femur and tibia are then cut at the appropriate angles using a high tech intra-operative computerised navigation system 
  • trial components are then inserted to check the accuracy of these cuts and determine the thickness of plastic required to place in between these two components. 
  • The patella (kneecap) will need to be resurfaced in most cases. 80% of the natural kneecap is retained
  • The real components are then inserted with or without cement and the knee is again checked for implant fit, alignment and stability
  • The knee is then carefully closed with dissolving sutures and skin glue. Sterile waterproof dressings and a compression bandage are applied.

Your Post-operative Steps

Pain Management

You will have pain medication by tablet or in a drip (intravenous). A splint is sometimes used for comfort.

Wound Care

Leave any waterproof dressings on your knee until your post-op review.

  • You can put all your weight on your leg.
  • Put ice on the knee for 20 minutes at a time, as frequently as possible.


Post-op review 

The first review will usually be after 10-14 days.


Physiotherapy 

You will be seen by a Physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.

Exercise and therapy can begin after a few days or can be arranged at your first post-op visit.


Complications

If you have any redness around the wound or increasing pain in the knee or you have a temperature or feel unwell, you should contact our office or your GP as soon as possible.


Why is Rehabilitation for TKR Essential?

Physiotherapy is an integral part of the treatment and is recommended to start as early as possible. Pre-operative physiotherapy is helpful to better prepare the knee for surgery. The early aim is to regain range of motion, reduce swelling and achieve full weight-bearing.


Sometimes, in-patient rehabilitation is required to regain mobility and independence.


Total Knee Reconstruction - Rehabilitation Program

  • Day 1-14

    Aims

    1. reduce post-operative pain, control effusion and minimise effects of surgery on soft tissue
    2. restore normal gait

    Goals

    1. reduce joint effusion
    2. prevent infection / facilitate wound healing
    3. re-establish muscle activation
    4. restore full extension
    5. manage donor site morbidity

    Treatment Strategies

    1. partial weight-bearing to full weight-bearing as tolerated
    2. use of ICE, co-contractions and external pressure support to control pain swelling
    3. static quads, co-contraction (progressing into weight-bearing positions) NB - quadriceps exercises are to be closed kinetic chain
    4. active range of motion aiming for a full extension by two weeks post-surgery
    5. prevent secondary patellofemoral joint problems (patellar mobilisation, myofascial releases ITB etc)
    6. retrain full extension at heel strike
    7. gentle hamstring stretches

  • 2-6 Weeks

    Aim

    Restore normal function.



    Goal

    1. full unrestricted ROM
    2. reduce persistent effusion
    3. early proprioceptive retraining
    4. develop muscle control and endurance

    Treatment Strategies

    1. 2-3 weeks - improve muscular control by progressing co-contractions eg; two leg quarter squats, step-ups and lunges
    2. introduce stationary bike, stepper and leg presses as tolerated (do not start these activities until any persistent effusion settles)
    3. Swimming once wound has healed
    4. 3-4 weeks - initially hamstring strengthening is achieved via co-contraction (closed kinetic chain). It is important to concentrate on hamstring stretches and increase resistance gradually to prevent recurrent injury. 4-6 weeks - open kinetic chain hamstring strengthening may begin but care must be taken to avoid strain injury as it impedes progress. Low resistance, high repetition weights to increase muscle endurance
    5. assessment and monitoring of gluteal control and length of hamstrings. ITB, gastrocs and soleus, etc will prevent secondary deficits from developing

  • 6-12 Weeks

    Aim

    Improve proprioception.


    Goals

    1. improve the endurance of leg musculature
    2. increase total leg strength

    Treatment Strategies

    1. progress general strength work
    2. slide board, lateral stepping
    3. riding a normal bike

  • 12 Weeks - 6 Months

    Aim

    Prepare to return to sport.



    Goals

    1. introduce more sport-specific activities
    2. develop  confidence
    3. introduce agility and reaction time into proprioception work
    4. Progress to open-chain excercises


    Treatment Strategies

    1. progress general strength work
    2. hopping and jumping introduced into proprioceptive retraining (focus on good landing technique)
    3. agility work (shuffle runs, ball skills, sideways running, skipping ropes etc)
    4. pool work may commence with flippers
    5. sports-specific activity (sport dependent)


  • 5 - 6 Months

    Goals

    Return to sport safely.


    Treatment Strategies

    1. open kinetic quadriceps exercises can be done safely
    2. introduce plyometrics and sport-specific drills
    3. return to training and participating in skill exercises
    4. improve power and endurance
    5. advice re: modification for a gradual return to sport

Treatment Process

After Your Replacement Surgery

After your operation, you will have a drip in your arm for pain medication and antibiotics. You may need between 3-5 nights in the hospital, followed by a stay in a rehabilitation facility. Crutches are required for 1 – 2 weeks following the replacement. 


Going Home After Replacement Surgery

Remember to arrange for someone to take you home, as driving is not recommended for several weeks following knee replacement.


Return to Work

You may return to light work duties after 3-4 weeks. You will not be fit to perform work duties that involve:

  • prolonged standing, 
  • heavy lifting,

  • Preparation for Surgery

    Pre-op

    • Quadriceps strengthening exercises using weights or resisted cycling
    • Intra-operative:
    • Minimally invasive tissue-sparing surgical technique
    • Computer-assisted surgical navigation to ensure optimal implant positioning and alignment
    • Limited tourniquet use to minimize tissue ischaemia
    • Carefully placed injections of long-acting local anaesthetic into the joint capsule for post-operative pain relief
    • Use of IV to locally minimise bleeding into the knee post-surgery

    Preparing mentally and physically for surgery is an important step toward a successful result. 

    • You may require a referral for a CT scan that is used for the Mako Robotic 3D planning. This scan should be done at least 2 weeks prior to surgery.
    • A treatment plan will be created specifically tailored for you 
    • I will need a complete list of your medications so that I can advise which ones should be stopped prior to surgery
    • The admitting hospital will advise you of the fasting time and your arrival time on the day before surgery
    • Do not eat or drink anything, including water, for 6 hours before surgery
    • Stop taking aspirin, or other anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery 
    • Stop or cut down on smoking to reduce your surgery risks and improve your recovery
    • Eat a well-balanced diet, supplemented by a daily multivitamin with iron.
    • Consider losing weight (if overweight) before surgery to help decrease the stress on the new joint. 
    • treat any tooth, gum, bladder or bowel problems before surgery to reduce the risk of infection

  • During Surgery

    Report any infections to me prior to surgery as the procedure cannot be performed until all infections have cleared up.


    When you leave the theatre, your leg will be wrapped in a bandage from foot to thigh (this is removed the next morning). After spending some time in recovery you will then be transferred back to your room on the ward. The physiotherapist will visit you later in the day to get you to stand and to take some steps.


    As the local anaesthetic wears off, the pain will increase. You will be prescribed both long-acting and short-acting narcotic pain killers to control this. On the day after surgery, you will have a routine blood test and an x-ray. Your doctor will show you the x-rays to help explain what he has done. 


    The physiotherapist will visit twice a day to show you exercises to get your knee bending and straightening, and help with your walking. Initially, you will be walking with a frame, but usually, progress to a single walking stick by discharge.

  • Day of Surgery


    • Report any infections to me prior to surgery as the procedure cannot be performed until all infections have cleared up
    • Do not consume alcohol - 24 hours prior to treatment
    • Do not eat anything  for 6 hours before surgery
    • Avoid vigorous physical activity or exercise 24 hours prior to surgery

  • Post Op Rapid Recovery Plan

    Your Total Knee Replacement Rapid Recovery Plan will assist you in recovering from surgery in the shortest time frame possible and should assist in the long term function of your new knee.


    Recovery from Knee Surgery will usually take about 3 months, and you can expect the knee to improve for 12 – 18 months.


    The physiotherapist will prepare an exercise programme. Much of the exercise programme can be done at home or at a gym, under your physiotherapist’s guidance.


    The Rapid Recovery Plan is a structured plan that will assist you in recovering from knee replacement surgery in the shortest time frame possible and should assist in the long term function of your new knee.


    The Rapid Recovery Plan is tailored specifically to you and will usually take about 3 months, and you can expect the knee to improve for 12 – 18 months. This is a scientifically based and proven medication regime for early post-operative comfort allowing early mobilization


    The physiotherapist will prepare an exercise programme. Much of the exercise programme can be done at home or at a gym, under your physiotherapist’s guidance.

    • Use of an IV anti-inflammatory medication and local corticosteroids as indicated to assist with pain relief and recovery
    • Early mobilization and full weight-bearing
    • Early transfer to a rehabilitation facility for more intensive physiotherapy 
    • Early hydrotherapy