Orthopaedic Surgery - Total Knee Replacement Surgery: What is Involved and What to Expect

Dear ....................................................................................................

You have been listed for a total knee replacement (TKR). You will be given an appointment to attend a rehabilitation clinic.

This is a mandatory requirement for all patients undergoing a TKR. Failure to attend this group may have implications for your surgery.

You may be given a walking aid for you to take home and practice with. We realise that in some cases this may not be practical for you, so alternative arrangements can be made.

In the leaflet you will find a measurement sheet, which we would like you to complete prior to the pre-habilitation clinic. If you are not able to do this we can do this at a later date. The measurements are important as it gives us information on any equipment that you may require to use within your home following your operation. This is not necessary for all TKR patients. Any equipment you may need is supplied and may be fitted prior to your admission to hospital; this will be discussed with you during your clinic visit. All equipment will be removed once you no longer require it.

Many thanks.
 

Measurement sheet

It would assist the Occupational Therapy Department if you could please measure the following (in inches or centimetres).

Any problems please phone the Occupational Therapy Department on 0161 206 4557

PLEASE ONLY COMPLETE THE INFORMATION IN THE BOXES

OFFICE USE ONLY
Patient Name:……………………………………………………………….......
Leg Length:…………………….
Hospital Number:…………………………………………………………........
Ward:……………………………..
Date Form Issued : ....... /....... /.    Date Form Collected : ....... /....... /.......
Date Equipment Ordered : ....... /....... /.......
Equipment Received on Discharge:...........................................................

Having a total knee replacement

What a Total Knee replacement involves:

The knee comprises of the lower end of the femur (Thigh bone) and the upper end of the tibia (shin bone). There is also a joint between the patella (kneecap) and the femur.

When you have a total knee replacement the surgery involves:

• The bottom end of the thigh bone (femur) is replaced with a single curved piece of metal
• The top end of the shin bone is replaced by a flat plate of metal with a plastic covering which acts as cartilage
• Components are sometimes cemented in place or cementless versions are used

General information

You are about to have a knee replacement. The advice and exercises that are shown in this leaflet will help you to recover from your operation and get the most out of your new knee. We are here to help you, but the responsibility for the optimal outcome is yours, by doing your rehabilitation exercises regularly.

Whilst you are in hospital, your physiotherapist will help you to regain your mobility by teaching you how to walk effectively with crutches. They will also teach you exercises to regain the movement and strength in your knee.

All the exercises you are expected to perform are written in this leaflet. It is essential that you practice these before you have your operation as this will help to strengthen your knee muscles and enable you to become familiar with the exercises.

During your hospital stay you will also be seen by an Occupational Therapist (O.T). They will assess your ability to manage activities of daily living and help you regain your independence. The O.T will be wearing a white tunic, and green trousers.

What to bring to hospital

As you will be expected to exercise after your operation you will need to bring appropriate footwear and clothing with you i.e. flat comfortable shoes and loose day clothes. Please ensure the clothing you bring with you is appropriate for you to exercise in.

If you live alone, please bring contact details into hospital of someone who has access to your house so that we can arrange to deliver any equipment you may need at home, before you are discharged.

Day of admission

You may be admitted either on the day of, or on the day before your operation. Where possible, the therapy team will assess you on admission, to establish your potential requirements for discharge i.e. equipment that will maximize your independence post-operatively. If this is not possible you will be seen after you have had your surgery.

You will be given a gown to change into before you are taken to theatre. A Theatre Nurse will accompany you from the ward to the operating theatre where they will make sure you are comfortable and ready for your operation.

After the operation you will go to the recovery room. From there you will be taken back to the ward.

After your operation, there will be a large bandage on your knee and your wound will be closed with a row of staples. You may also have an ice pack over your knee. You will be wearing a pair of elastic full length stockings (TEDs), which will come up over your knee to your thigh. You will need to wear these for 6 weeks following your operation as they reduce the risk of you developing a blood clot and help control the swelling in your knee.

You will be given pain relief either orally or via a PCA (Patient Controlled Analgesia).

It is essential that you receive adequate pain relief following your surgery to ensure you can comply with your rehabilitation.

Following your operation

On the day of your operation you may be seen by a physiotherapist on the ward who will assist you to:

• Get out of bed and practice walking with crutches or another walking aid that is suitable for you
• Start your knee strengthening exercises (see page 13). Your physiotherapist will help you with these initially but you will be expected to perform all your exercises by yourself every 2 hours whilst in hospital and at home
• You will also start to bend the knee

You are encouraged to elevate the leg when you are resting and ice should be used regularly to help with swelling control.

On the following day, you will continue your exercise. After your physiotherapist has shown you what to do, it is your responsibility to continue working on your exercises or you will develop a stiff knee. Your physiotherapist may put you on a CPM (continuous passive movement) machine to bend your knee. The CPM machine may be used on your knee from the outset for the first 1-2 days.

You will also progress your walking so that you are happy to walk independently with crutches.

If you have stairs at home your physiotherapist will make sure you can safely negotiate the stairs before discharge. If necessary it can be arranged for you to have grab rails or an additional banister rail fitted.

If the team who are looking after you feel that you may need some extra help at home whilst you are recovering from your knee operation this will be discussed with you and you will have the opportunity to speak to a social worker on the ward.

Your O.T. will assess your ability to manage activities of daily living such as:

• Getting in/out of the chair and bed
• Getting on/off the toilet
• Bathing/showering
• Getting washed and dressed
• Preparing/transporting food and drinks

This will help the occupational therapist to see whether you will require any equipment. Where possible you are encouraged to be independent without the use of equipment to ensure that you are bending your knee as much as possible. The O.T will also encourage you to be independent on the ward.

How to use elbow crutches

Sitting

Place the crutches into the “H” position. Then place one hand onto both handles and stand up. Once you are balanced in standing, place each hand through the arms of the crutches and hold the handles (the handles should be facing forwards).

• Take each handout of the crutches and place them into a “H” position. Once you feel balanced reach back with your free hand for the arm of the chair. In a slow and controlled manner lower yourself into a sitting position.

Standing

The safest standing position can be seen in the photograph. Each crutch should be slightly in front and out to the side of your feet, this increases stability when standing.

Stairs

• If using a banister/stair rail take your hand out of the crutch and pass it over to the other side gripping it (as in the photograph) with your other hand

Going up

1. Non-operated leg
2. Operated leg
3. Crutch

Coming down

1. Crutch
2. Operated leg
3. Non-operated leg

Discharge

You will discharged between days 1 and 4 after your operation providing:

• You are safe and independent with elbow crutches and activities of daily living
• You are safe and independent on the stairs (if applicable)
• You can bend your knee sufficiently
• Your thigh muscles are strong enough to lift your leg straight off the bed.
• The hospital staff are happy with your progress
• Any equipment or services you may need have been arranged

Following discharge

• At home, you will need to continue with all your exercises every 2 hours until your first outpatient physiotherapy appointment
• You should continue to put ice on your knee to reduce swelling
• You will attend out-patient physiotherapy after discharge, either the Total Knee Replacement Group at Salford Royal or as an out-patient at your local hospital
• You may have been referred to a community therapy team who will see you at home to review your exercise programme and ensure that you are able to manage activities of daily living
• Your stitches/clips will be removed approximately 7 to 10 days following your operation. This will be arranged by the nursing staff on the ward

It is essential that you continue to wear your TED stockings for 6 weeks, as they will help to prevent a blood clot.

• You will continue to use your elbow crutches/walking aid until you are safe to mobilise without an aid
• You will be sent a follow up appointment to attend clinic. This appointment will be approximately 6-12 weeks following surgery.

At post-op clinic visits, an appropriate member of your consultant’s team will see you; this may include extended-scope physiotherapists. An x-ray of your knee may be taken on arrival at this clinic.

Exercises

Strengthening exercises (from the day of operation)

Your physiotherapist will direct you on when to progress your exercises.

• Pull your toes up, tighten the muscle on the front of your thigh by pushing your knee down into the bed.
  Hold for 10 seconds, repeat this 10 times.

• With a towel rolled up under your knee, straighten your knee by tightening the muscle on top of the thigh. Be sure to keep the back of your knee on the towel.
  Hold for 10 seconds, repeat this 10 times.

• Tighten the muscle on the front of your thigh and lift your leg 20cm from the bed keeping the knee straight.
  Hold for 10 seconds, repeat this 10 times.

• Sit on a chair, pull your toes up, tighten your thigh muscle and straighten your knee.
  Hold for 10 seconds, repeat this 10 times.

Knee bending exercise

• Lie or sit up on your bed. Slide your heel towards your bottom, use a towel or your hands to assist the knee bend as far as possible.Hold for 5 minutes before you release.

• Sit in a chair. Bend your knee back underneath you as far as you can then use the weight of your other leg over your operated leg to increase the stretch.
  Hold for 10 seconds, repeat this 10 times.

Knee bending exercise

• Place a towel under your heel so that your knee is not touching the bed. Tighten the muscle on the front of your thigh by pushing your knee down towards the bed.​​​​​​​
  Hold for 10 seconds, repeat this 10 times. Your physiotherapist may ask you to place a weight over your knee to increase the stretch.

• Keeping your thigh flat on the bed, use a towel around your foot to pull and lift the heel off the bed. Use one hand to hold the towel and one hand to push down on your thigh and stop it coming off the bed. Then try and tighten your thigh muscle to hold this position when you release the towel.​​​​​​​
  Hold for 10 seconds, repeat this 10 times.

Advanced exercises (as an outpatient)

• Stand leaning with your back against a wall and your feet about 50cm from the wall. Slowly slide down the wall a few inches.​​​​​​​​​​​​​​
  Hold for 10 seconds and slowly return to the starting position. Repeat this 10 times.

• Place your operated leg on a step, slowly step up and down keeping the movement controlled.​​​​​​​
  Repeat 10 times.

• Sit on a chair, put equal weight through both legs and stand up. Slowly with/without hands lower yourself back into the chair.​​​​​​​Repeat this 10 times.

• Cycle on the static bike for 5 minutes with the seat in the lowest position you can tolerate.

• Stand facing the wall bars, your operated leg lifted up onto a high step or wall bars. Slowly bend forward so that you feel a stretch on the front of your knee.​​​​​​​
  Repeat 10 times.

As well as doing exercises to strengthen your new knee, your physiotherapist will assist you in returning to normal walking with or without a walking aid.

Application of ice

The application of ice is often very effective on hot, swollen and painful joints so it is important to use ice after your operation.

Ice should be applied to your knee for 15-20 minutes. A longer application time may result in an ice burn.

Method

A bag of frozen peas, crushed ice cubes in a bag or cold pack may be used.

• Place a damp tea towel over the front of your knee and place cold pack on top
• After five minutes check the area for an ice burn (excessive redness)

Precautions

• NEVER apply ice straight onto the skin
• NEVER apply ice to an area where you cannot differentiate between hot and cold
• If you suffer from bad circulation, NEVER apply an ice pack to your knee until you have consulted your physiotherapist

Problems to watch out for

You may notice some numbness around your incision. This is normal. The numb area will shrink in size but you may experience a small area of numbness permanently.

Signs of possible problems include:

• Increased temperature. It is normal to have a slight fever following surgery but anything more or that lasts may indicate a problem
• Increased knee soreness not reduced with medication
• Dramatic increase in knee swelling
• Stomach upset after taking medication
• Increase drainage or dressing problems
• Sustained loss of knee movement
• Marked calf pain or swelling

If you experience any of these problems, please contact your GP or the Orthopaedic Ward.

Contact details

Physiotherapy department, Salford Royal
0161 206 5328

Occupational therapy department, Salford Royal
0161 206 4557

For more information go to www.thekneedoc.co.uk