Total Knee Replacement - OrthoInfo - AAOS (original) (raw)

If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.

If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.

Total knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacement is one of the most successful procedures in all of medicine. According to the American Academy of Orthopaedic Surgeons, more than 700,000 total knee replacements are performed annually in the U.S.

Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.

The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.

The knee is made up of:

• The lower end of the thighbone (femur)
• The upper end of the shinbone (tibia)
• The kneecap (patella)

The ends of these three bones are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily within the joint.

The menisci are located between the femur and tibia. These C-shaped wedges act as shock absorbers that cushion the joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.

All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.

The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.

• Osteoarthritis. This is an age-related wear-and-tear type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another, causing knee pain and stiffness.
• Rheumatoid arthritis. This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed "inflammatory arthritis."
• Posttraumatic arthritis. This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.

A total knee replacement (also called total knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surfaces of the bones are replaced.

There are four basic steps to a knee replacement procedure:

• Prepare the bone. The surgeon removes the damaged cartilage surfaces at the ends of the femur and tibia, along with a small amount of underlying bone.
• Position the metal implants. The surgeon replaces the removed cartilage and bone with metal components that re-create the surface of the joint. These metal parts may be cemented or "press-fit" into the bone.
• **Resurface the patella.**The surgeon cuts the undersurface of the patella (kneecap) and resurfaces it with a plastic button. Some surgeons do not resurface the patella, depending upon the case.
• Insert a spacer. The surgeon inserts a medical-grade plastic spacer between the metal components to create a smooth gliding surface.

Watch: Total Knee Replacement Animation

The decision to have total knee replacement surgery should be a cooperative one between you, your family, your primary care doctor, and your orthopaedic surgeon. Your primary care doctor may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.

When Surgery Is Recommended

There are several reasons why your orthopaedic surgeon may recommend total knee replacement surgery. People who benefit from total knee replacement often have:

• Severe knee pain or stiffness that limits everyday activities, including walking, climbing stairs, and getting in and out of chairs. It may be hard to walk more than a few blocks without significant pain, and it may be necessary to use a cane or walker.
• Moderate or severe knee pain while resting, either day or night.
• Chronic knee inflammation and swelling that does not improve with rest or medications.
• Knee deformity — bowing in or out of the knee.
• Failure to substantially improve with other treatments, such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries.

Candidates for Surgery

There are no absolute age or weight restrictions for total knee replacement surgery. Learn more: Obesity, Weight Loss, and Joint Replacement

Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total knee replacement are aged 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

An evaluation with an orthopaedic surgeon consists of several components:

• Medical history. Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.
• Physical examination. This will assess knee motion, stability, strength, and overall leg alignment.
• X-rays. These images help to determine the extent of damage and deformity in your knee.
• Other tests. Occasionally, blood tests or advanced imaging, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed.

In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.

Never hesitate to ask your doctor questions when you do not understand. Learn more: Total Joint Replacement: Questions Patients Should Ask Their Surgeons

Realistic Expectations

An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.

Most people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.

With normal use and activity, every total knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.

Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.

With appropriate activity modification, knee replacements can last for many years.

Possible Complications of Surgery

The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Infection. Infection may occur in the wound or deep around the prosthesis. It may happen within days or weeks of your surgery. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement. Learn more: Joint Replacement Infection

Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program to boost circulation and help keep blood clots from forming (see Blood Clot Prevention under Your Hospital Stay)

Learn more: Preventing Blood Clots After Orthopaedic Surgery

Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen.

Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery. This normally gets better with physical therapy and range-of-motion exercises, but if you are having difficulty improving your knee motion, your doctor may recommend a manipulation under anesthesia.

Manipulation under anesthesia is a non-invasive procedure that helps you regain motion if your total knee replacement becomes stiff. You are given general anesthesia to put you to sleep. Your surgeon then gently bends and straightens your knee joint, applying gentle force to break up any scar tissue or adhesions causing the tightness.

Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and most patients experience excellent pain relief following knee replacement.

Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Medical Evaluation

If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your primary care doctor several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process.

Patients with chronic medical conditions, like heart disease or kidney disease, may also be evaluated by a specialist, such as a cardiologist or nephrologist, before the surgery.

Tests

Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. They will tell you which medications you should stop taking and which you should continue to take before surgery.

Dental Evaluation

Although the incidence of infection after total knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.

Urinary Evaluations

People with a history of recent or frequent urinary infections should have a urological evaluation before surgery.

Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.

Social Planning

Although you will be able to walk with a cane, crutches, or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.

If you live alone, a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery if this option works best for you.

Learn more: Joint Replacement for Patients With Limited Social or Financial Resources

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

• Safety bars or a secure handrail in your shower or bath
• Secure handrails along your stairways
• A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
• A toilet seat riser with arms, if you have a low toilet
• A stable shower bench or chair for bathing
• Removing all loose carpets and cords
• A temporary living space on the same floor, if possible, because walking up or down stairs will be more difficult during your early recovery

Get more tips on preparing your home for your total knee replacement in this infographic (click on image for full infographic).

You will either be admitted to the hospital on the day of your surgery, or you will go home the same day. The plan to either be admitted or to go home should be discussed with your surgeon before the day of your operation.

Learn more about same-day surgery: Outpatient Total Joint Replacement

Anesthesia

Upon arrival at the hospital or surgery center, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are:

• General anesthesia (you are put to sleep)
• Spinal, epidural, or regional nerve block anesthesia (you are awake, but your body is numb from the waist down)

The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Procedure

The surgical procedure usually takes 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, then position the new metal and plastic implants to restore the alignment and function of your knee.

After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room or discharged to home.

If you are admitted to the hospital, you will most likely stay overnight and, in some cases, longer.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics.

Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids. A series of regional blocks may also be performed to help with post-operative pain — this should be discussed with your orthopaedic surgeon and your anesthesiologist.

Be aware that although opioids help relieve pain after surgery, they are narcotics and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Blood Clot Prevention

Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling:

• Periodic evaluation of your legs
• Support stockings
• Inflatable leg coverings (compression boots)
• Blood thinners (medications to thin your blood)

Foot and ankle movement is also encouraged immediately after surgery to increase blood flow in your leg muscles to help prevent leg swelling and keep blood clots from forming.

Physical Therapy

Most patients can begin exercising their knee hours after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

Preventing Pneumonia

It is common for patients to have shallow breathing in the early post-operative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed "atelectasis"), which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

The success of your surgery will depend largely on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery (if you are discharged home; if you are discharged to an acute rehabilitation unit or skilled nursing facility, staff there will oversee your post-surgery care).

Wound Care

You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.

Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength. Also, be sure to drink plenty of fluids.

Activity

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.

Your activity program should include:

• A graduated walking program — initially in your home and later outside — to slowly increase your mobility.
• Resuming other normal household activities, such as sitting, standing, and climbing stairs.
• Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.

You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.

Recognizing the Signs of a Blood Clot

Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. They may recommend that you continue taking the blood thinning medication you started in the hospital.

Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clots in your leg include:

• Increasing pain in your calf
• Tenderness or redness above or below your knee
• New or increasing swelling in your calf, ankle, and foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

• Sudden shortness of breath
• Sudden onset of chest pain
• Localized chest pain (pain that is felt in only one specific area) with coughing

Preventing Infection

A common cause of infection following total knee replacement surgery is bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.

After knee replacement, patients with certain risk factors may need to take antibiotics before having dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter the bloodstream. Your orthopaedic surgeon will discuss with you whether you need to take preventive antibiotics before dental procedures.

Warning signs of infection. Tell your doctor immediately if you develop any of the following signs of a possible knee replacement infection:

• Persistent fever (higher than 100°F orally)
• Chills
• Increasing redness, tenderness, or swelling of the knee wound
• Drainage from the knee wound
• Increasing knee pain with both activity and rest

Avoiding Falls

A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, or handrails, or have someone to help you until you have improved your balance, flexibility, and strength.

Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.

How Your New Knee Is Different

• Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car.
• Kneeling is sometimes uncomfortable, but it is not harmful.
• Most people feel some numbness in the skin around their incisions. You also may feel some stiffness, particularly with excessive bending activities.
• Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is normal. These differences often diminish with time and most patients find them to be tolerable. Learn more: Why Do Knees Make Noise?
• Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.

Protecting Your Total Knee Replacement

After surgery, make sure you do the following to protect your knee replacement:

• Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
• Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
• Let your dentist know that you have a total knee replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics before having dental procedures.
• See your orthopaedic surgeon periodically for routine follow-up examinations and X-rays. Your surgeon will talk with you about the frequency and timing of these visits.

Extending the Life of Your Knee Implant

Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery.

Following your orthopaedic surgeon's instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.

To assist doctors in the surgical management of osteoarthritis of the knee, the American Academy of Orthopaedic Surgeons has conducted research to provide some useful guidelines. These are recommendations only and may not apply to every case: Surgical Management of Osteoarthritis of the Knee - Clinical Practice Guideline (CPG) | American Academy of Orthopaedic Surgeons (aaos.org)