Timeline of Knee Replacement - Dr Nilen Shah | Joint Replacement Surgeon, Mumbai

The nurses and the junior doctors will make a final check that all your reports are in order and that you have taken the right medicines, stopped the blood thinners as you were advised, and you have all the required X-rays etc . and that you are starving for at least 6 hours. The vital signs that is your pulse, blood pressure, respiration rate will also be recorded to confirm that there are no last-minute surprises. The junior doctor will report everything to the anaesthesia team as well as the medical team if required. The knee to be operated would be marked by an arrow to confirm that it is indeed the knee to be operated. This mark is very important. The knee will be washed again with the antiseptic solution ( 4 % CHG ) and wrapped in a towel. You are advised to pass urine and empty the bladder before surgery. Now you are ready to be taken to the operation theatre.

In the operation theatre reception

The theatre nurse will receive you with all the papers and the X-rays ; reconfirming that everything is in order. You will also meet the anaesthetist who will explain what is to be done to keep you comfortable during the operation. After this, you will be taken to the operation room.

In the Operating Room

The anaesthetist will choose (with your consent ) either an injection in the back ( called spinal or regional anaesthesia ) or a full ( called General Anesthesia ) for the operation. Monitoring equipment which will measure your vital signs ( pulse rate, Blood pressure and respiration ) will be attached so that a continuous check of these parameters can be kept during the operation. You may choose to be awake during the operation if a spinal anaesthesia is administered or prefer to take a sleeping injection.

After anaesthesia, the leg will again will be thoroughly washed with an anti-septic solution and suitably prepared so that the operation can be performed. You will not get any pain and most people remark that they did not realise when the operation started or when it ended. Generally, the operation takes 1 hour to be completed although the time spent in the operating room is approximately 2 hours.

After the operation, there will be a bandage on the leg and the legs may feel numb for a few hours. You may have a tube inserted for drainage of urine and another tube in the thigh as an adductor catheter ( for pain relief )

After this , you will be shifted back to the ward. In the ward, of the first 4 hours, you will have supplemental oxygen and the knee will be kept in a bent position as shown. Because of the way the surgery is done and the medicines that we use , there will be minimal to no pain. We will ask for special anti-embolism stockings to be applied to the legs.

Once the numbness of the legs is reduced and you would be able t0 move the leg relatively comfortably. You should start the following exercises as soon as possible :

Toe stretch and Ankle pumps

In the lying down position, you should try to move your toes and ankle towards and away from you as shown. This helps in the circulation and reduces the likelihood of a clot formation.

Quadriceps sets

Put a pillow underneath the heel as shown and practise tightening the thigh muscles. After tightening the thigh muscles, hold form a count of 1 to 10 and then relax. This should also be done at least 10 times every hour .

SLR – Straight Leg Raise – You should practice lifting the leg in the air after tightening the thigh muscles and pulling of the ankle and the toes towards you ( as shown ) at least 5 times every hour.

Sitting by edge of the bed and dynamic knee extension

Once you are able to lift the leg in the air comfortably and your vital signs ( pulse, BP ) is ok, you will be asked to sit by the edge of the bed with both your knees dangling. Do not keep the leg tight at this juncture and the knee will be bent to around 90 degrees by its own weight.

Dynamic quadriceps exercise ( Active Knee Extension )

Try to straighten the knee from the bent position by the edge of the bed as shown. ( If you pull the toes up, this becomes easier ) You should try to straighten the knee fully and hold to a count of 1 to 10 .

Do active knee extensions, 5 times every hour

These five exercises, ankle pumps, Quadriceps sets, SLR, sitting by the edge of the bed and Knee Extensions – form the major chunk of the exercises required after the surgery.

If these are properly done by 4 to 6 hours after the operation, you are ready to stand up and walk.. Some people may feel giddy or weak, and may not be able to walk properly. But most people are able to walk with support and help from the physiotherapist relatively comfortably after the operation within a matter of a few hours -( 6 to 8 hours )

Discharge readiness

The number of days people stay in the Hospital following a Knee Replacement has been steadily reducing. Currently, most people are able to go home the day after the operation whereas some patients ( typically operated early morning ) are able to go home the same day of the operation.
We can discharge the patient once we are sure that the patient will be able to manage at home. For this to occur, the patient should be able to sit up from a lying down position in bed, sit by the legs dangling by the side of the bed, get up form the bed, walk a bit and to be able to sit on a chair and to get up with support ( walker ). The pain should be under control and the dressing over the knee should be nice and dry. ( A few blood spots on the dressing are common ) Additionally, the patient should have used the washroom, should have passed urine comfortably, should have eaten and if there are other diseases such as diabetes, blood pressure etc . they should be under reasonable control. There should be enough home help and the patient and the relatives should also be willing to take the patient home.
Stair climbing is optional and my advice is that only if stair climbing is needed at home, it should be practised. Otherwise, it can be done later. It is not necessary to wait for a bowel motion before going home.

At home – day 1

You would have been sent home with stockings on the legs . These are special stockings to prevent blood clotting in the legs. You have to wear them more or less the whole day but may take them off at night.
The aim in the first few days ( 1 to 3 ) is to make sure that the pain is well controlled , the knee keeps moving and to avoid swelling . The operation also is a form of injury to the knee and our body needs rest to recover.
We need only simple exercise with or without a physiotherapist. Exercise needs to be done for 5 to 10 minutes every waking hour with 2 hours of rest in the afternoon. The exercises in the first few days are the same that you have done in the Hospital.
Ankle pumps , Quads sets , SLR , sitting by edge of bed and dynamic quads ( Active Knee extension )

Resting in bed

Keep a pillow under the heels of the legs. DO NOT KEEP A PILLOW UNDER THE KNEE. ( Elevation of the legs reduces swelling – Try to keep toes above the nose during the elevation of the leg )
Every hour – do 10 quadriceps sets – i.e. pushing the knee down on the bed with your own muscle. ( quadriceps ) In other words, you have to tighten the thigh muscles – and hold the thigh muscles tight for a count of 1 to 10. This is the basic exercise of the knee and you would have been shown this exercise before surgery and also in the Hospital before discharge.

SLR ( straight Leg Raise )

Every hour, 5 times, you need to raise the operated and the unoperated leg, alternately, in the air keeping the knee as straight as possible. (And count from 1 to 5 )
How high to raise the leg? – You may raise the leg as high as comfortable.
Keeping the knee as straight as possible is extremely important and you should avoid bending the knee while lifting it. Do not raise both the legs together as this may strain your back unnecessarily.

Knee bends

You also need to bend the knee by the edge of the bed or whilst sitting on a chair, as much as the knee would bend comfortably and then make the knee straight again. It will help to pull the toes up whilst straightening the knee. You need to hold the knee for a count of 1 to 5. Avoid sitting on a low sofa or a stool. ( Preferably sit on a chair with handles so that you can take the support of your hands to get up .)

Walk

You need to walk for just a few minutes every hour. You may walk with support as comfortable and may move from one room to the other, walk in the corridor etc. Again, the stairs are optional.
The way the surgery is performed – You do not necessarily need a dedicated physiotherapist at home. (Interestingly, all the patients who were operated just before the lockdown due to Coronavirus – have also done equally well after the operation – despite no physiotherapist at home.)

Follow the rule of thirds

I.e. 20 min every hour spend in exercise. (The other 40 min – rest )
Spend 1/3 of these 20 mins – in walking
1/3 – in knee bending and straightening exercises
1/3 in static knee exercise and ankle pumps.

Sleep and Diet

You need to take normal diet ( not too oily or spicy ) preferably home-cooked food. It is normal to have a little loss of appetite after surgery. Most people find that falling asleep is difficult after surgery. This is why we always prescribe a sleeping tablet. You can take it if required.

Pain

The amount of pain is a little variable but is not as much as once thought. We would have prescribed pain killers to be taken by all and then extra pain killers which may be taken if the knee is extra painful. If you need to take extra pain killers, that does not mean that there is anything wrong. Pain is subjective and different people get different amounts of pain. Applying ice packs, elevating leg and not to overdo exercises help in relieving pain.

Care of the wound

We would have applied a water proof dressing on the wound. It is all right to bathe, but one should avoid getting the dressing excessively wet. It is normal to see some skin discolouration and ecchymoses around the knee especially on the inner side. ( these would all settle over 4 to 6 weeks )

Care at Home from 3 to 15 days

Essentially you would be doing the same things as in the first three days but more easily and with greater vigour and for greater time as tolerated . You may also add some hip exercises to your routine . The basic hip exercise is sideways leg raise.

Sideways leg raise

You should lie on your side with the operated keg underneath and bent at 30 degrees. The other leg is kept straight. Now the unoperated leg is to be raised in the air by 30 degrees from the hip. Hold for a count of 1 to 5 and do 10 repetitions.
Now you lie down with the unoperated leg below and keep the operated leg straight. Now you can do 10 sideways leg raise of the operated leg.

Can I go out of the House ?

You may start going outside your home , in the compound etc. You may still avoid stairs unless necessary and avoid low seating . Sitting on the commode is generally OK.

Do I need a physiotherapist at Home ?

The need for a dedicated physiotherapist is not necessary. If you follow the exercises that we have outlined and do them well, you will not need a physiotherapist at home. Remember that a knee operation is also a form of injury to the knee and you primarily require rest. It is normal to have more pain on some days than others. You may take the extra painkillers as required. It is also normal to have some lack of sleep and some loss of appetite. Interestingly , all patients who had been operated before lockdown have done equally well without dedicated home physiotherapists

Do I need to change the dressing ?

The dressing does not require changing until you are seen again at around 2 weeks form surgery.

WARNING SIGNS

General
If one feels out of breath, has pain in the chest area or feels excessive uneasiness, or the level of consciousness drops or feels paralysed or any other major problem – one needs to contact the hospital urgently and may need to be readmitted.
Knee related
If there is excessive bleeding or oozing from the wound or the leg appears misshapen, or you are not able to walk the way you had started walking after the operation, then also one may need to seek medical help.
Kindly note the numbers for urgent medical attention-
Recovery from 2 weeks to 3 months
You would have had a visit at around 2 weeks time from the operation to see us. Hence, any further questions and doubts could be tackled at that time also.
In general , the level of exercises can increase as tolerated , one may start going out of the house for small errands or for work. One should also start ones’ routine now and not wait for “ full recovery “ and postponing things. Here , the underlying principle is to try normal activities gently , slowly , repeatedly as tolerated until happy.Obviously , if there is undue discomfort or pain , you need to stop.
Most people by this time would be at 60 to 80 % of their recovery.
There will be occasional episodes of pain and swelling but they would reduce. If there were ecchymoses around the knee , they would be settling . You may still wear stockings for excessive swelling . You will also feel some areas of numbness around the knee and burning etc from the knee . This is normal and would reduce over 6 to 12 months . If burning is very intense , we can prescribe medicines for it.
Please be very sure that the knee is fully straightening and do not keep a pillow underneath the knee . If it is not happening , you may need special exercises to achieve that.
Most people would also be back at work by this time . Some discomfort around the knee , heaviness , a feeling of something artificial is very common and most patients would be complaining of this . Some patients also find that their appetite and sleep are still disturbed but is getting better. Almost all patients would be walking for 20 to 30 minutes by this time relatively easily. ( subject to physical ability and the state of the other joints ) Stair climbing, if not done earlier, is also started and practised.

Recovery from 2 weeks to 3 months

You would have had a visit at around 2 weeks time from the operation to see us. Hence, any further questions and doubts could be tackled at that time also.
In general, the level of exercises can increase as tolerated, one may start going out of the house for small errands or for work. One should also start ones’ routine now and not wait for “ full recovery “ and postponing things. Here, the underlying principle is to try normal activities gently, slowly, repeatedly as tolerated until happy. Obviously, if there is undue discomfort or pain, you need to stop.
Most people by this time would be at 60 to 80 % of their recovery.
There will be occasional episodes of pain and swelling but they would reduce. If there were ecchymoses around the knee, they would be settling. You may still wear stockings for excessive swelling. You will also feel some areas of numbness around the knee and burning etc from the knee. This is normal and would reduce over 6 to 12 months. If burning is very intense, we can prescribe medicines for it.
Please be very sure that the knee is fully straightening and do not keep a pillow underneath the knee . If it is not happening, you may need special exercises to achieve that.
Most people would also be back at work by this time . Some discomfort around the knee , heaviness , a feeling of something artificial is very common and most patients would be complaining of this. Some patients also find that their appetite and sleep are still disturbed but is getting better. Almost all patients would be walking for 20 to 30 minutes by this time relatively easily. ( subject to physical ability and the state of the other joints ) Stair climbing, if not done earlier, is also started and practised.

Recovery from 3 months to 1 year

This is the time to gradually get back to “ normal “. This is not normal before the operation but “ normal “ before arthritis. the patients may exercise their knees, hips, walk and diet to become healthier. They may go out for walks, enjoy nature, see movies, dramas, visit religious places, shrines or whatever they fancy. They may go out of the city as well.
They can continue the gentle exercises for the knees and the hips for better toning of the muscles and better gait.
Obviously, each patient is different and each patient’s requirements are also different. The aim here is for the patient to get back to their desired quality of life. However, it is still not uncommon for patients to complain of pain, especially at night. If the patient is able to walk properly and bend the knee well then probably there is nothing wrong. However, if there is the consistent complaint of pain, investigations including aspiration of the knee ( inserting a needle in the knee to withdraw some fluid ) may be required to rule out infection.

Long term care of the Operated knee

The modern knee Replacements are designed for long term function from 10 to 20 years or even more. However, as in all things mechanical some maintenance is required. At least once in 3 years, the operated Knee should be X-rayed to ensure that the replaced joint is looking OK on the x-rays. As it is a replaced knee, any problem with the knee will initially manifest with X-rays, even before any symptoms develop. Apart from this, the knee is to be used but not to be abused. By that is meant, that the knee is to be used judiciously.

What are the complications associated with a Knee Replacement ?

The complications can be General ( affecting the whole body ) or local ( related to the Knee )
The General complications can be a heart attack, embolism, stroke etc. Depending upon the severity, even deaths have been reported after a Knee Replacement. Obviously, as we screen the patients well the likelihood of this kind of a complication is very low.
The local complications can be infection, instability, loosening, fracture, dislocation, complications related to the knee cap, muscle-tendon rupture etc. Again the likelihood of these complications is very low in experienced hands. When a partial Knee Replacement is carried out, there are added risks of the progression of arthritis in the other urn-replaced compartments or of dislocation of the mobile bearing. ( in Oxford replacements ) Again, even this risk is small.

Follow Up

You would be advised to follow up at 2 weeks, 6 weeks, 3 months, at a year and then every 3 years from the operation. Obviously, if there is need you can follow up at any time. It is important to maintain optimum weight and to have a healthy lifestyle. Also, it is advised to have the knee Xrayed once in 3 years. If an actual physical follow up is not possible, a virtual follow up can also be done.
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