Partial and Total Knee ReplacementMobile, AL
People who experience knee pain on a regular basis may try to treat it with over-the-counter pain medication and rest, only to find that the relief is temporary and fleeting. The pain continues to worsen until even walking up a few steps is almost impossible without feeling pain. The person needs to seek professional treatment in a medical practice and not a store.
When it comes to a patient struggling with pain in his or her knee, each patient can be different. In some cases, a patient may need to replace the entire knee or only the damaged portion. With this in mind, we offer partial and total knee replacement.
Partial Knee Replacement
After we take X-rays, we will be able to accurately determine which areas of the knee have damage. With partial damage, the main goal will be to remove and replace the damaged areas. Damaged tissue between the bones within the knee joint can cause the patient pain that requires professional treatment. People may not realize that arthritis is not always apparent in the entire knee, but only part of the knee.
Thus, a partial knee replacement is the necessary surgery. With this surgery, we can help to replace the damaged part of the knee or kneecap in order to promote relief and functionality. Since the incision for a partial knee replacement is smaller than a full knee replacement, the recovery can be a bit faster. With partial knee replacement, we can help preserve all healthy parts of the knee.
Total Knee Replacement
Total knee replacement involves replacing the entire knee joint. When a person has arthritis in the knee or other areas of the body, the joint can sustain enough damage that it is beyond saving. With partial knee replacement, there is enough of the knee that is still able to function properly. When there is not enough left, total knee replacement is the most effective option.
A total knee replacement will replace the joint where the femur and tibia, thigh bone and shin bone, meet. With 3D printing technology, we are able to create a sturdy and exact fit replacement for the kneecap. The exact fit will allow for precision and long-term recovery.
Since each patient is unique, it is important to customize the procedure for each patient. There is no one-size-fits-all size for partial or total knee replacement surgery. With multiple types of replacement options and designs, we will find the specific treatment that works for the individual patient. Since there are multiple options, we understand that people will have questions about the process.
How long does the surgery take?
While the length of time can vary for each patient, the average time is about 2 hours. Before the surgery, we will review the amount of time for the surgery with the patient. In many cases, the patient will need to spend some time under medical supervision in the days following the procedure.
What is the recovery process like?
Following surgery, the patient may need to spend a few days in a hospital to ensure there is no sign of infection or other issues. After we determine there are no issues, the patient will be able to return home. This process can change per patient. Following the first few days after the surgery, the patient will spend the next 4 to 6 weeks recovering. Recovery will include stretches and exercises that help the body adjust to the new joint and promote full functionality.
What happens during the surgery?
During the surgery, our team of professionals will remove either part of the knee or the entire knee in order to replace it with an implant that is an exact fit. We can remove the damaged portion in order to promote pain relief and use without pain.
Is arthritis the only cause for needing knee replacement surgery?
No. While the most common cause is osteoarthritis, other causes can include trauma and some degenerative diseases.
What are signs that I need this type of surgery?
If the pain continues to get worse and limits movement, then it is time to consider professional treatment. Far too often, people will assume just waiting it out is the best way to treat knee pain. In reality, the pain will only get worse and surgery may be the most efficient solution.
Will I feel different with the implant in my knee?
Yes and no. While you will feel a bit of difference when adjusting to the implant, the implant will match the shape of your knee perfectly. This way, you will be able to adjust with less difficulty than other methods. You will feel relief from the pain the knee caused before the procedure.
This guide is intended as a primer on the basics of knee replacement for patients. It is by no means comprehensive, but my intent is to explain the risks and benefits of this surgery and to outline the process surrounding the procedure and recovery. As always, knowledge is power. The more you know, the more you are able to be an active participant in your recovery and the less anxiety you will experience during your surgery and rehabilitation. This information is not intended to frighten, but to educate about risks associated with knee replacement surgery. This information ensures that you are able to assist your care team in watching for potential issues and that your consent for the procedure is truly an INFORMED consent. Determining when/if surgery is appropriate involves SHARED DECISION MAKING between patient and surgeon.
My philosophy of practice is a focus on specialization, attention to detail, and appropriate use of the latest technologies and protocols to obtain the best possible results.
I am committed to providing good information to patients so that they can make the best decisions about their care.
Infection: Infection is one of the most dreaded complications of knee replacement surgery. In most large studies, the rate of infection after knee replacement is noted to be approximately 1%. Infection of a prosthetic knee may require multiple additional surgeries to treat (including removal of the prosthesis) and in extreme cases can even lead to amputation (less than 0.2% of knee replacement cases). Infection risk can be increased by multiple factors such as: obesity, smoking, diabetes and other immune suppressing conditions. Each patient’s risk factors will be evaluated and managed in conjunction with their primary care physician and in some instances surgery may be deferred if risks are felt to be excessive. Multiple steps are taken to prevent infection including pre-surgical skin cleansing, meticulous sterile technique in the OR, appropriate use of intravenous antibiotics before and after surgery, multiple antiseptic washes during surgery and use of watertight antimicrobial dressings. We are constantly updating our process of infection-prevention and seeking ways to minimize these unfortunate occurrences.
Stiffness: The primary determinant of range-of-motion after knee replacement surgery is range-of-motion before knee replacement surgery. In other words, a knee which has become very contracted prior to surgery is more likely to have motion difficulties after surgery. Additionally, major surgeries of the knee require careful attention to post-operative therapy/rehabilitation. This requires diligence and very active participation by the patient in order to achieve a good result. Depending on a physical therapist alone is not sufficient. However, there are some instances where the surgeon, patient and therapist do everything correctly and the knee still becomes stiff. The human body heals by means of scar tissue, and this scar tissue sometimes results in stiffness of the knee. Approximately 3-4% of patients may experience stiffness which requires a manipulation under anesthesia. This is a procedure which typically takes place 1 or more months after surgery in which the knee is manually bent while the patient is asleep under anesthesia. This is sufficient to produce better motion for most patients. A very small percentage of patients may have residual stiffness which becomes permanent or necessitates additional surgeries.
“Mechanical” complications: Orthopaedic procedures are by their nature different from other surgeries. These surgeries involve more than the removal of diseased organs or tissues and typically include an attempt to reconstruct normal anatomic structures. Patients live with the effect of our reconstructive efforts with every step they take after surgery. Even surgeries performed with the best intentions, the best hands and the best technologies sometimes have an imperfect outcome. It is always possible for an extremity to become incorrectly aligned or improperly rotated or for a joint to become unstable or for an implant to fail prematurely. Fractures around the knee during surgery may occasionally occur during knee replacement (the largest published series of these indicated a prevalence of less than half of 1%). Similarly, ligaments or tendons may be torn or cut. Putting an exact percentage on these types of issues is a bit difficult due to their wide range and to the variance of what is considered acceptable by the patient and their surgeon. Major issues of this type are relatively uncommon and usually fixable. However, correcting these problems may require additional surgeries and rehabilitation time.
Blood Clot: Deep vein thrombosis, or DVT, occurs when a blood clot forms in one of the deep veins of the body. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. While there are a number of risk factors for developing a DVT, two of the most common are experiencing an injury to your lower body and having surgery that involves your hips or legs. A DVT can have serious consequences. If a blood clot breaks free, it may travel through the bloodstream and block blood flow to the lungs. Although rare, this complication - called a pulmonary embolism - can be fatal. Even if a blood clot does not break free, it may cause permanent damage to the valves in the vein. This damage can lead to long-term problems in the leg such as pain, swelling, and leg sores. Symptoms of DVT occur in the leg affected by the blood clot and include:
- Swelling (also normal after knee replacement)
- Pain or tenderness (also normal)
- Distended veins
- Red or discolored skin
- A firmness or thickening of the vein called a “cord”
Many patients, however, experience no symptoms at all. In some cases, a pulmonary embolism may be the first sign of DVT. Symptoms of pulmonary embolism include:
- Shortness of breath
- Sudden onset of chest pain
- Spitting up or vomiting blood
The incidence of DVTs which produce symptoms is felt to be less than 1%. Our emphasis is always on PREVENTION of clots and the terrible complications which they can cause. Strategies to prevent complications include “mechanical” prevention with compression stockings or devices, “pharmacologic” prevention with aspirin or other blood thinners and most importantly EARLY MOBILIZATION after surgery.
Medical complications: Medical events such as heart attacks, strokes, allergic reactions, seizures or complications of anesthesia are quite rare, but can potentially occur with any operation. Most of these are related to underlying health problems and this is one of the main reasons for preoperative medical evaluation and optimization. These types of complications are possible with any surgery and are not specific to orthopedic procedures.
Nerve damage: Nerve damage after knee replacement can occur but is uncommon. Published studies indicate that the rate of occurrence is significantly less than 1%. When this does occur it is typically a palsy of the common peroneal nerve. Damage to this nerve may result in a “drop foot” which may or may not resolve as the patient recovers from surgery. Most commonly this is associated with correction of large valgus (knock-knee) deformities. Numbness adjacent to the incision is normal and occurs in virtually 100% of cases.
Bleeding/Blood vessel damage: All knee surgeries by necessity result in bleeding. Improved surgical techniques and new medications have significantly reduced blood loss from knee replacement surgery. Blood transfusions are increasingly rare and most surgeries do not require use of a wound drain. Bruising and swelling due to post-surgical bleeding vary. Increased risk of bleeding is associated with the use of certain blood thinners. Return to the OR for evacuation of a hematoma occurs in less than 1% of cases. Laceration or blockage of a major artery in knee replacement is potentially devastating , but is rare and occurs in less than 1 in 1000 cases.
Pain: Pain is certainly expected to accompany surgery. Managing this pain is a top priority in order to facilitate early mobilization and rehabilitation. In some rare cases pain may persist after surgery or pain may not be diminished to the degree that the patient hoped or expected.
Metal Hypersensitivity/Allergy: Orthopaedic implants are made of metals which are typically non-reactive in the body. A small number of patients (very difficult to determine an accurate percentage) may develop a hypersensitivity to metals contained in the implants such as nickel, cobalt or chromium. While rare, this situation may require revision surgery. Please notify your Surgeon if you are allergic to any metals or have a history of skin sensitivity to jewelry.
Medication: Recovery from knee replacement surgery typically requires some use of narcotic pain medication. These medications may cause significant constipation. It is important to be aware of this and use whatever dietary adjustments or medications are needed to avoid severe problems. Additionally, these medications are HIGHLY addictive. Please plan to reduce and eliminate these medications as soon after surgery as possible.
Unforeseen Events: Despite our efforts to control every event associated with surgery, some things are simply beyond our control. Complications may occur which are so rare that they could not reasonably be predicted. (A good friend of mine finished a procedure with illumination from a flashlight after the hospital in which he was operating collapsed during a tornado!) Most common complications are described previously in this manual, but others may occur as well.
Overlapping Surgery: Overlapping surgery is not actually a risk of surgery, but is a situation of which patients should be aware. “Overlapping” refers to a scenario in which your surgeon performs all essential portions of the procedure but may be performing another operation in a separate room at times while you are still “in the operating room”. In my practice, this means that you may be transferred to and from the OR without me being present and that the closure of your incision will be performed by a trusted Physician Assistant (P.A.). My own knee incision was closed by a P.A. from our practice, so I am 100% confident in this process. Students, resident physicians or visiting surgeons may occasionally be present in the operating room as observers but are not participants. All critical portions of the procedure are performed by me alone! A study on this method was presented at the American Association of Hip & Knee Surgeons 2017 annual meeting and it was found to be equivalent to consecutive(non-overlapping surgeries) with NO increased risk of complications.
Other Indicated Procedures: Surgical consent forms frequently include the phrase “other indicated procedures”. This means that during the course of a surgical procedure, circumstances may dictate that the best course of action is to deviate from the original plan. In such a situation, the surgeon uses his/her best judgment to determine a “plan B” that is best for the patient. When this happens more or less may be done than was originally planned or implants may be used that are different from what was originally discussed with the patient.
It is important to have reasonable expectations of knee replacement. Knee replacement is a great investment in improved mobility and quality of life, but reconstructed joints are rarely as good as a natural human knee. While recovery varies substantially, most patients can expect their knee to heal and improve for 12-18 months after surgery. Recovery requires a commitment to active participation in therapy/rehabilitation and often requires a good deal of patience as well. Only a very small minority of patients will experience a true “complication” with their surgery, but a modest percentage (10-15%) may be dissatisfied with their replacement despite having normal clinical findings and normal x-rays. Much research and effort is currently directed at improving overall satisfaction and achieving feel and function closer to that of a normal knee.The overwhelming majority of patients can expect to have a good or excellent result from this procedure and it is very successful at relieving pain from damaged or arthritic knees. For most patients knee replacement is an incredibly positive experience which substantially increases their quality of life. It is important to note that all patients and all knees are different. Everyone recovers differently depending on their general health and the state of their knee prior to surgery. Some patients even experience different rates of recovery between surgery on their 2 different knees. Some general guidelines can be provided, but each patient’s experience will be different.
Surgery Day: The initial surgery will take place in a hospital or surgery center. Improvements in anesthesia and pain control allow many of these procedures to be accomplished as an outpatient or with extremely short hospital stays. There is certainly pain/soreness in the first hours and days, but with modern techniques this is typically well managed. Some patients find that the knee becomes most sore on the 2nd or 3rd day after surgery- this is not cause for alarm, it is very normal and usually begins to gradually improve day by day. It is important during these early days to use compression stockings, cold therapy (or ice),elevation and prescribed medications to control swelling and pain.
Early Post-op Days: Physical Therapy is initiated in the hospital or surgery center. This is then continued at home with a home therapist. In the first few days after surgery a walker is used. This if employed for safety reasons. After surgery there is expected weakness of the leg due to the operation and the associated nerve block and use of a walker can aid in fall prevention. Once the patient and physical therapist determine that the patient is safe and stable without a walker, it can be discontinued and a cane is used until normal walking resumes.
Early Post-op Weeks: By 2 weeks after surgery most patients will be off of their walker. Many patients begin outpatient therapy soon after surgery, and by 2 weeks most patients have progressed from home therapy to therapy in an outpatient office setting. Patients become progressively more mobile during the first several weeks following surgery.
Early Post-op Months: During the first few months after surgery, mobility continues to improve as well as range-of-motion and strength. While patients often note that they no longer have “bone on bone” pain there can still be substantial soreness of the soft tissues around the knee particularly during the first 3 months after surgery. Patients often note difficulty with getting a really good nights sleep and stiffness after prolonged sitting or immobility during this stage of recovery. Warmth around the knee and numbness at the outside part of the incision are also very normal at this time.
First Post-Op Year: After the first few months of recovery, most patients have returned to work and nearly all of their desired activities. However, many patients will still experience some mild degree of stiffness, activity-associated swelling, and soreness. These symptoms tend to become less noticeable over time. As scar tissue matures the knee improves gradually for approximately a year to 18 months.
First Post-Op Year Specific Activities:
- Showering- Typically, a watertight dressing is placed after wound closure while the patient is still in the operating room. This allows the patient to begin taking showers immediately after surgery. Once this dressing is removed it is OK to shower the incisional area and use soap. The surgical site can be patted dry with a towel after the shower. Soaking the wound in a pool or tub is only permitted after the incision is fully healed- typically about 3-4 weeks after surgery.
- Work- Return to work depends on the individual patient’s job requirements and how they are progressing after surgery. Those with jobs that primarily involve sitting often may return to work in 2-3 weeks (sometimes part-time work is helpful initially). The more standing, walking, carrying and stair climbing a patient is required to perform at work; the longer it will take to return to full duty. Almost all patients can be back to work by 3 months after surgery.
First Post-Op Year General Activities:
Patients can basically resume normal activities as they feel comfortable doing so. Return to each desired activity should be cautious and gradual. The only activity which I routinely advise against is running or jumping for exercise. In other words, activities such as jogging which repetitively produce impact loading of the joint. There is little or no published evidence to “prove” that running or jogging will damage or loosen knee implants, but I (like most joint replacement specialists) discourage patients from doing it. Walking, swimming, golf, lifting weights, tennis, cycling and most other sports and exercises are fine and help to preserve fitness and mobility. Kneeling is not prohibited, but is difficult for some patients due to pressure on the knee. Those who kneel routinely for work or leisure activities typically use some type of knee pad after replacement procedures.
Frequently Asked Questions
The most common questions asked have to do with the surgery and expected return to work or other activities - hopefully many of these questions are answered in the preceding sections. Here are some others.
Q- When should I consider knee replacement surgery?
A- Knee Replacement should be considered when you have knee pain which limits your activities and does not respond to conservative treatments such as ice, physical therapy, injections or over-the-counter pain medicines.
Q- What materials are the replacement parts made of?
A- The implants are made of metal (typically Cobalt Chromium or Titanium alloys) and plastic (polyethylene).
Q- Can you be too old for knee replacement?
A- Not really. If you are otherwise in good health, surgery can be feasible at most ages. I have performed replacements on several patients in their early 90s with great success. If knee pain limits mobility or health, it may be wise to address it BEFORE other factors keep you from being a surgical candidate.
Q- Can you be too young for knee replacement?
A- Knee Replacement surgery should be very carefully considered in young patient. Conservative treatments should be attempted first with surgery discussed only if these are unsuccessful.
Q- My knee replacement makes noise. Is something wrong?
A- This is very normal. The surfaces of a knee joint separate during normal motion. In a normal healthy joint which is covered by cartilage, this does not produce a sound but when the metal and plastic surfaces of an artificial joint come together they may click or make other sounds. It is usually not indicative of a problem, but should be evaluated by your surgeon if it is painful.
Q – Should my knee be warm after surgery?
A- It is entirely normal for a knee which has undergone replacement surgery to feel warm to the touch (vs. the opposite knee) for several months after surgery.
Q- How long do knee replacements last?
A- Patients have often heard myths about knee replacement and are concerned that they will have to “have it redone in 10 years”. The fact is that in most large studies 80-90 % of replacements are still in place and functioning well at 15 and even 20 years. Our hope is that modern implant designs and materials will produce even more durable results than what we currently see.
Q- What should I bring for surgery?
A- Please bring a valid photo ID, insurance card and a list of your medications. You will want comfortable shoes and clothes that are easy to get on and off as well as any toiletries that you would want or need for a brief stay. If you have sleep apnea, please bring your CPAP machine. If you have a cold therapy machine or sleeve please bring it with you.
Q- What medicines should I take or not take before surgery?
A- You will need to discontinue supplements and any blood thinning medication (aspirin, Coumadin,Plavix,vitamin E,fish oil,etc) 1 week prior to surgery unless instructed otherwise by your doctor. Other specific medications should be taken or not taken as instructed by your doctor.
Q- What can I eat or drink before surgery?
A- You should have nothing to eat for 8 hours prior to your arrival time for surgery. You may consume clear liquids up until 2 hours prior to your arrival time at the hospital. Clear liquids include water, black coffee, and sports drinks. Please do NOT consume: alcohol, juices which may contain pulp, or coffee with cream or milk - this will result in your surgery being cancelled.
Q- What time will my surgery be?
A- Other than the first case of the day, we are not able to predict exactly what time your surgery will take place. We will always attempt to be respectful of your time, but please be patient with both us and the hospital/surgery-center staff as there may be some waiting involved. Please refer to your arrival time.
Q- How long does knee replacement surgery take?
A- This can vary a lot depending on the patient, the surgeon, the techniques being used and what is actually included in the “surgery time”. I routinely tell patients that surgery takes approximately 1 & 1/2 hours. In an uncomplicated procedure, implants are placed in about 1 hour with additional time allotted for closure.
Q- What can I do to prepare for surgery?
A- I recommend pre-operative physical therapy to prime the joint for surgery and to prepare you for what you will need to do afterwards. To prepare your home, you will want to remove loose rugs or other tripping hazards. It is often helpful to prepare and freeze some meals so that they will be readily available. You may wish to consider a pedicure prior to surgery as toenail care can be difficult in the weeks immediately following surgery. If you live alone you will want to arrange for someone to stay with you to assist in your care for the first several days after surgery.
Q- Will I need any equipment after surgery?
A- A case manager at the hospital will assist you in obtaining a walker, shower chair or other needed equipment. In some situations this may be arranged beforehand.
Q- Will my knee replacement set off metal detectors?
Q- I have numbness around my incision. Is this OK?
A- This is normal and happens in virtually every case. You will recover some sensation near the incision over time, but a small area at the lateral aspect of the incision will remain numb or have diminished sensation.
Q- Will I need antibiotics prior to dental cleanings or procedures?
A- This is somewhat controversial. There are very reasonable dentists and surgeons who do not do this routinely. At the time of this writing, I still recommend it and happily provide a prescription when needed.
Q- Will I be sent home with pain medicine?
A- Yes. Patients are typically prescribed 1 or 2 pain medications as well as an appropriate medication to prevent blood clots and a muscle relaxer. These can be adjusted as needed to find something that works well for your pain. It is recommended that you obtain these through the hospital pharmacy to make it easier on you during the immediate post-op days.
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