This booklet aims to improve your understanding of your personalised totalkneereplacementandtherehabilitationprocess.

Osteoarthritiscanaffectanyjointinthebodybutismorecommoninjointsinthelowerlimbweight-bearingjoints,eghipandknee.

Ajointisformedwheretwobonesmeet.Theendsofthebones,whichformthejoint,arecoveredinarticularcartilage.Thisprovidesasmooth,slipperyandlowfrictionsurfacethatalsocushionsthejoint.Healthycartilageabsorbsstressandallowsthebonestoglideacrosseachothersmoothly.

Theword arthritismeans joint inflammation. Also known as ‘degeneration’ or‘wearandtear’arthritis,osteoarthritisisthemostcommontypeofarthritisanddevelopsoveralongperiodoftime.It affects the articular cartilage,which can start towear away. Sometimes thisaffectsonesideofthekneejointmorethantheother.

PatientInformationAndRehabilitationGuidelinesFollowingPersonalisedTotalKneeReplacementSurgery

Anatomy

Osteoarthritis

Thisisanoperationthatreplacesyourkneejointwithanartificialprosthesis.Eachprosthesisismadeupofthreemainparts:

1. The tibial component (bottom portion) replaces the top surface of thelowerbonethetibia,andismadeoftitanium.

2. Thefemoralcomponent(topportion)replacesthebottomsurfaceoftheupperbone(thefemur)andthegroovewherethepatellafits,andismadeofcobaltchrome.Ahigh-densitypolyethylenespacersitsbetweenthem.

3. Aplasticpatellarcomponent(kneecapportion) israrelyusedtoreplacethesurfaceofthepatellawhereitglidesinthegrooveonthefemur.

ProfessorMcNicholasusestheZimmerPSIkneereplacement.Thisimplantusescomputertechnologytoperfectlyalignthekneereplacement,providingamorecustom fit for the long triedand testedprosthesis foryourknee. Thismethodcantake4-6weeksforyourpersonalisedjigtobeready.Ifyoucannotwaitthatlong,theconventionalmethodofreplacingakneejointcanbeused.Unlike hip replacement surgery, knee replacement requires a lot morephysiotherapy treatment after the operation and a lotmore effort by you, thepatient,toregainbending,straighteningandstrengthofyourknee.

Whatisatotalkneereplacement?

Onceyournewjointhashealedproperly,youshouldlookforwardtosomeorallofthefollowingbenefits:

§ Greatlyreducedjointpain.§ Increasedlegstrength.Withoutkneepainyouwillbeabletoexercise

moreandthiswillhelptobuildupthemusclesaroundtheknee.§ Improvedqualityoflifebyallowingyoutododailytasksandlow-impact

activitiesingreatercomfort.§ Correctionofangularlegdeformityi.e.knock-kneeorbow-legs.

Noteveryonewishestohave,orrequires,kneejointreplacementwhentheyhavedamagetotheirarticularcartilage.Somepeoplewillhavedifferentpaintolerances,andothersmaynotwishtoundertaketherisksthissurgerycarries.Alternativestosurgeryinclude:

§ Regularpainmedication§ Usingwalkingaidstoreducestressonthejoint§ Weightlosstoreducestressonthejoint§ Specialshoeinsertsthathelptocushionthejoint§ Exercisestomaintainjointmovement,musclestrengthandhelpwithpain

relief§ Activitymodification

Otheralternativesforsomepatientsifarthritisislimitedtoonepartoftheknee:

§ Hightibialosteotomy:shinbonecanbecutandbenttochangetheweightbearingforces.

§ Atlassurgery:Offloadingweightthroughtheaffectedpartoftheknee§ Unicompartmentalkneesurgery:replacinghalfthekneejoint

Onlywhenthesemeasuresfailtogiveacceptablepainrelief,isatotalkneereplacementoffered.

Benefitsofsurgery

Alternativestokneereplacementsurgery

It is important that you should be satisfied with the result of your kneereplacement.Itissaidthatakneereplacementthatworkswellcangiveyouthekneeofasixtyyearold.Satisfiedpatientswithrealisticexpectations:

§ Followinstructionsbetter§ Recoverquicker§ Theirreplacementlastslonger

Satisfactionhasbeenshowntodependonthesethreefactors:

1. Severity of preoperative pain and stiffness. The more pain you havebeforetheoperation,thegreaterthereliefthesurgerymaygive.

2. Outcome of the operation. The less the operation relieves the pain thelesserthesatisfactionwillbe.

3. Expectationsbeforetheoperation.Very high expectations usually are not satisfied by knee replacement. It isimportant to realise that not all your knee pain may be abolished after yoursurgery.Immediatelyaftersurgery,thegnawingseverepainwillhavegoneandbereplacedbysurgicalpain.Thismaylastupto6-18monthsbutshouldlessenovertime.Painmedicationmaystillbeneededbecauseofthis.Youmayexperienceoccasionalpain inyournewkneeafterwalkingandotheractivities.Thereliefofthistypeofpainisindividual,dependingontheseverityofpreoperativedeformityinyourknee,onthestateofyourmuscles,andsoon.Rememberyoursurgeonreplacedonlythedamagedjointsurfacesbutcoulddonothingtothemuscles,ligamentsandothersofttissuesequallydamagedbythe“joint”disease.

Tobegintheprocedure,yoursurgeonmakesanincisiononthefrontofthekneetoallowaccesstothejoint.Oncethekneejoint isopened,aspecialpositioningdevice (cutting guide) is placed on the end of the femur. This cutting guide isusedtoensurethattheboneiscutintheproperalignmenttotheleg’soriginalangles(evenifthearthritishasmadeyoubow-leggedorknock-kneed).Withthehelpofthecuttingguide,yoursurgeoncutsseveralpiecesofbonefromtheendofthefemur.

Satisfactionaftersurgery

Theprocedure

Theartificial kneewill replace theseworn surfaceswithametal surface.Next,thesurfaceofthetibiaisprepared.Anothertypeofcuttingguideisusedtocutthetibiainthecorrectalignment.Thepatellawouldrarelybereplaced.PMMA cement is used to sit between the bone and your implant, acting like agrout,tofillinthesmallspacesbetweentheboneandmetalbacksurfaceofthenewkneereplacementratherthanaglue.Themetalfemoralcomponentisthenplacedonthefemurandsecured.Themetaltraythatholdstheplasticspaceristhenattached to the topof the tibia.Theplastic spacer is thenattached to themetal tray of the tibial component. Finally the soft tissues are sewn backtogetherandstaplesorsuturesareusedtoholdtheskinincisiontogether.

Complicationsdooccur.Someareminorandsomerequirefurthersurgery.Itisimportantyouunderstandthisbeforeproceedingwithsurgery,theyinclude:.Complication RecordedinliteratureAnaestheticrisksNumbnessontheoutersideofthescar

Anaesthetistwilldiscuss100%

Infection 1%

Deepveinthrombosis(clotinthecalf)Proximaldeepveinthrombosis

50-70%0.1-4%

Pulmonaryembolism(clottothelung) 0.1-3%

Damagetoartery 0.02–2%

Nerveinjury 0.3-2%

Stiffnessrequiringamanipulationoroperation 1.3–12%

Painfulknee 1%

Fracturesligamentdamagecausinginstability

0.05–2.5%0.02%

Looseningrequiringremovaloftheimplant

2%by10years

WoundandskinproblemsKneearthrodesis(permanentstiffening)Abovekneeamputation

1-5%0.001%0.003%

Death

0.4to1%

Complications

Anassessmentof your fitness toundergo surgery includingadetailedmedicalhistory, height, weight, blood pressure and pulse will be performed beforesurgery.Bloodtestsandahearttrace(ECG)mayalsobeneeded.If you have any tooth or gum problems before surgery ensure you get thistreatedas youdonotwant germsentering theblood streamand infecting thejointreplacement.For72hourspriortoyouradmission,avoidalcoholicdrinksanddrink3-4litresoffluide.g.tea,watereveryday.Ifyousmoke,trytostoppriortoyouradmissiontohospital.Follow the advice given by the pre-operative assessment nurse about yourmedicines,includingherbalremedies.Ifyoulivealone,itisadvisabletostockupyourfreezerwitheasytocookmealsforwhen you returnhome. See if you canmake arrangements for someone tohelpwithbuyingfreshfoodandhelpwithcleaningandlaundry.Get a neighbour, friend or relative to look after your house. If you develop acough,cold,chestorskininfection,orainfectedin-growingtoenail,pleaseletusknow,asitmaybenecessarytopostponesurgeryuntilyouhaverecovered.Youcanalwayschangeyourmindregardingsurgery,itisnotaproblem.Allweask is that you inform Professor McNicholas so that the slot can be given tosomeoneelse.

You are asked not to drink or eat anything for at least 6 hours before youroperation.You will be seen by Professor McNicholas and your Anaesthetist before youroperation.In the anaesthetic room, youwill have aneedleput into your armandwill beplacedonananaestheticmachine.Surgeryusuallytakesaround1hour.

Beforesurgery

Thedayoftheoperation

Youwillwake-upinthetheatrerecoveryroom.Onreturntothewardyouwillhavethefollowing:

§ Dressings–woolandcrepebandageontheknee.§ Dripsanddrains–theremaybesmalltubesinthebackofyourhand.You

mightalsohaveatubeintoyourbladder(catheter).§ Analgesia– thismaybeoralmedicationorpatient controlled analgesia

(PCA),whichlookssimilartoadrip.

DayoneYouwillbeassistedwithafullbedbath.Youwillhaveabloodtest.Thedripwillbetakendownifyouaredrinkingwell,notfeelingsickanddonotneedabloodtransfusion.Thedrainsanddressingswillberemoved.You will be able to start some exercise, under the supervision of thephysiotherapist.Theexercisesareshownlaterinthebooklet.Youwillbegivenbreathingexercises tohelpyourchestafter theanaesthetic,and theyalsohelpcirculation.Movingbothyour feet andanklesupanddownand in circlesquitevigorouslyalsohelpscirculation.If you feelwell enough, youwill beable to sit outofbed,withassistance.Youmayfeeltiredsotakeitslowly.Whenlyinginbed,orsatinthechair,keepmovingfeetandanklesupanddowntohelpwithyourcirculation.Thephysiotherapistorassistantwillseeyou1or2timesaday.Weaimtohaveyouupandwalkingthedayoftheoperation.Usetheadviceandexercisesinthisbooklettohelpyoutreatyourselfregularly.DaytwoThebandageswillbe removed.Asplintmayrarelybeusedwhenwalking,butwillberemovedforexercise.You will start to walk, usually with a Zimmer frame at first, and graduallyprogresstocrutches.The physiotherapist will instruct you on exercises to get your knee bending.Should this prove difficult, then a continuous passive motion (CPM) machinemaybeused.Thisbendsthekneeforyouandcanbeleftonforlongperiods.The

Aftersurgery

aimistogetthekneetobendtoatleast90degrees.ItdoesnotreplacetheneedforyoutocontinuewithyourownexercisesThekneewillfeeltightandsoretobendbutwillgeteasierwithtime.Thekneewillstillbesore,sokeeptakingpainreliefmedicationasneeded.Ifthekneeisswollen,icewillbeoffered,donotkeepthisonformorethan15-20minutes.Youmayaskforiceatanytime.Elevatingthelegonastoolorbedwillalsohelpreduceswelling.Many patients are now well enough to go home the day after their kneereplacement,oncetheyaresafelymobileandcomfortablewithpainkillerstheycantakeathome.DaythreeandonwardsYouwillhaveacheckx-raytaken,whenitiscomfortabletodoso.Yourwalkingwill continue to improve as you becomemore confident. The catheter in yourbladder, ifyouhaveneededone,willberemovedwhenyouareabletowalktothetoilet,andyouwillbegivenanintramuscularinjectionofantibiotics.Kneeexerciseswillcontinueand,whenyouareabletoliftyourlegwithouthelp,thekneesplintwillbediscarded.Anoccupationaltherapistmayseeyoutogiveadviceonwashinganddressing.Ifyou live alone, theymay check that you canmanage to get yourmeals safely.They can also advise you if you need help with shopping or cleaning. Somepeople can have problems sitting, if chairs and toilets are too low. Theoccupationaltherapistcanarrangeanynecessaryequipmenttoaltertheheightofthesethings.When you are safe on your crutches, the physiotherapists will show you thecorrectwaytonegotiatestairs(ifappropriate).WhencanIgohome?Youwillbeallowedtogohomewhenyourkneeisbendingwell,andProfessorMcNicholas ishappywithyourprogress.Youwillalsoneed tobesafeonyourcrutches,beabletonegotiatestairs,managetogetoffachair,toiletandbed,andgenerallybeabletolookafteryourselfathomeifnecessary.Most people leave hospital 3-5 days following their surgery. If there are anypostoperative complications, thenyoumayneed to stay longer.You can travelhomeinacar.Anambulanceisonlyarrangedinspecialcircumstances.

Youwillbeseeninclinic2weeksafteryouroperationtoremoveyourclips.Afterthatyouwillbeseen,3,6,12weeksand3,6,9,12months,2,5,10yearsannuallyafterthat.

Returntoworkwilldependgreatlyonthejobthatyoudo(desk-basedjobs2-4weeks;manualjobs6-12weeks;jobsrequiringladdersetc.3-4months).Returntodrivingat6weeksformanualgearedcarsandautomaticcarsifitistherightlegthathasbeenoperatedon.Ifitistheleftlegthathasbeenoperatedon,youmaydriveanautomaticcaroncethewoundsarehealedat2weeks.You should notify your insurance company of the procedure that has beenundertakentoensurethatyourcoverisvalid.Forfurtherinformationfollowthisweblink:https://www.gov.uk/driving-medical-conditionsFlying is not permitted for 8weeks following surgery due to a higher risk ofdevelopingabloodclot.Forfurtherinformationfollowtheweblinkbelow:http://www.nhs.uk/chq/Pages/2615.aspx?C%20ategoryID=69

The success of this operation depends on the surgery, and also yourrehabilitationafterwards.Itisimportantyouareawareofthisandwillingtoputlots of effort in yourself. You may need to exercise your knee for 6 monthsfollowingyoursurgery,orlongerifnecessary.The followingexerciseswill be taught toyouduring the first fewdaysof yourhospitalstay.Theyshouldbeperformed3-4timesdaily,with5-10repetitionsofeach.1.Bendandstraightenyouranklesbriskly.

2.Lyingonyourbackorsittingrotateyourankles.Changedirections.

GeneralAdvice

Rehabilitation(Physiotherapy)Programme

Follow-up

3. Lying on your back or sitting with legsstraight. Pull your toes up towards you andpush your knee down firmly against the bed.Hold5seconds.

4. In lying/sitting with leg straight. Lift your leg 2-3inchesonlykeepingkneestraight.Hold5seconds.

5. Lying on your back. Squeeze buttocks firmlytogether.Hold5seconds.

6.Sittingwithbacksupported.Placearolledtowelunder your knee. Pull your toes up towards you,straightenyourkneeandpush itdownagainst thetowel.Youcanaddasmallweightovertheankletomakethemusclestronger.Hold5seconds.

7. Sitting on a chair or bed with the leg to be exercisedsupportedasshown.Usearolledtowelundertheheelifsittingonabed.Letyourkneestraighteninthisposition.

8. Sit on a chair. Pull your toes towards you, tighten yourthighmuscleandstraightenyourknee.Hold5seconds.

9. Sit with leg straight. Push your kneecap outwards. Hold 5seconds.

10.Sitwithlegstraight.Pushyourkneecaptowardsyouroppositeleg.Hold5seconds.

11. Sitting on the bed place a sock on your foot. Place aslippery board/tray under your foot and a band around it.Bend your knee as far as possible. Gently pull the band tobendalittlemore.Hold5seconds.

12.Sitonachairwithyourfeetonthefloor.Bendyourkneeasmuchaspossible.Youcancrossanklesanduseoppositefoottopulltheoperatedlegfurtherunder.

13.First takeastepupwithyourhealthy leg.Thentakeastepwithyouraffectedleg.Thenbringyourcrutchupontothestep.Alwaysgoonestepatatime.

14.Firstputyourcrutchonestepdown.Thentakeastepwith your affected leg. Then take a stepdownwith yourhealthy leg, onto the same step as your affected leg.Alwaysgoonestepatatime.

Exercisesyoumaydoinhospital,orwhenyouareathome.15.Standwithsupport.Pushuponyourtoes.

16.Standwithsupport.Bendyouroperatedkneebehindyouandliftyourfootoffthefloor.

Exercisesyouwilldointhephysiotherapyoutpatientdepartment.17.Sitonachair,withacushionunderyourkneeandaweightaroundyourankle.Pullyourtoesuptowardsyou, tightenyourthighmuscleandstraightenyourknee.Hold5seconds.

18. Lying on your backwith knees bent. Squeeze yourbuttocks together and lift your bottom off the floor.Returntostartingposition.

19.Standinfrontofa20-40cmstep.Stepupwithonelegleadingandthenrepeatwiththeotherlegleading.

20. Sittingwithyourarmscrossed. Standupand then sitdownslowlyonachair. (Thiscanbemadeeasierormoredifficultbychangingtheheightofthechair).

21.Standwith/withoutsupport.Liftonelegandbalance.

Whenyoureturnhome,keepyourlegelevatedforthemajorityofthetimewhenyouareresting,tohelpwiththereductionofswelling.Itisverynormalforyourlegtoswellandthiscantakemanyweekstogetbetter.If your knee becomes more swollen and warm it may be worth using ice toreduceyoursymptoms.Todothis,makesuretheiceisinasealedbag,andthenwrappedinadamptowel.Alternativelyabagoffrozenpeaswrappedinadamptowelmaybeused.Applytheicefornolongerthan10minutesatanyonetime.Youcanuseiceeveryhourifnecessary.

GeneralInformation

Makesureyoucontinuetodoyourexercisesatleast2-3timesaday.Graduallyincreasethedistanceyouwalkoverthecomingdaysandweeks.Avoidstandingforlongperiods,asthiswillbeuncomfortableandleadtomoreswellinginthekneejoint.Donottwistyourknee,ascanhappenwhenyouturnyourbodywithoutmovingyourfeetSkincareOncethewoundhashealed,youcanmassagethescarandsurroundingareawithanon-perfumedmoisturisingcreamoroil.Thishelpstokeeptheskinsuppleandmobile,whichcanmakethekneeeasiertobend.Pleaseaskyourtherapistifyouareunsurewhenorhowtodothis.Ifyouexposeyourkneetothesun,makesureyouapplyasunblockorhighfactorsuncreamtothescar,asinitiallyitisverysensitiveandcanburneasily.Remembertoletyourdentistknowthatyouhavehadajointreplacement.Thedentistmayneedtogiveyouantibiotics followingcertaindentalprocedurestopreventinfection.Pleaseseekadviceifyouexperienceanyofthefollowing:

§ Thewoundbleedsordischargescontinuously.§ Youfeelfeverish,shivery,haveatemperatureorfeelsick.§ Yourkneebecomesveryhotandred(Itisnormalforthe§ woundtofeelwarmtotouch).§ Increasedpainnothelpedbymedicationorrest.§ Increasedpainfulswellingnothelpedbyiceandelevation.§ Increasedpaininthecalfmuscle.§ Suddenonsetofshortnessofbreathandpainwhenyoutakeabreathin.

Goalstoaimfor:Thefollowingaregeneralgoals.Youmayfindyouachievemostornoneofthese,but it is important to remember every person is an individual and you willprogress at your own rate. Everyone’s joint and surrounding tissues are alsodifferentatthetimeofsurgerysotryandavoidcomparingyourprogresstothatofothersyouseeduringyourrehabilitation.

§ Toregain90degreesofkneebendby1weekpostoperatively– ideallypriortodischargefromhospital.

§ Tobeabletogetthekneefullystraightwithin2weeks.§ Beabletowalkwithoutwalkingaidsbetween6-12weeks§ Backtodrivingattheearliest6weeks.§ Beabletoclimbstairsnormally3-4months.

§ If your knee is your only painful joint, you should be able to stop yourpainreliefby6-12weeks.

VTEisacollectivetermfortwoconditions:

§ DVT (deepveinthrombosis)–thisisabloodclotmostcommonlyfoundinadeepveinthatblockstheflowofblood.

§ PE(pulmonaryembolism)–apotentialfatalcomplicationwhereabloodclotbreaksfreeandtravelstothelungs.

Whilstyouarelessmobile,especiallyduringthefirstfewweeksfollowingyourprocedure,theriskofVTEishigherbecauseofyourimmobility.ProfessorMcNicholaswillprescribeyouadailyinjectionofheparintohelpthinyourbloodandtheseshouldlastapproximately14days.Youwillbeshownhowtoinjectthisdrugyourself.Symptoms:

§ Swelling – youwill have some swelling due to your surgery but if youhaveanyconcernspleasecallforadvice

§ Pain–anynewpainwewanttoknowabout§ Calftenderness§ Heatandrednesscomparedwiththeotherleg§ Shortnessofbreath§ Chestpainwhenbreathingin

ThingsyoucandotopreventVTE

§ Movearoundasmuchaspossible.Besensiblethough,shortandregularmovementisbest

§ Drinkplentyofwatertokeepyourselfhydrated§ Westronglyadviseyounot to smoke– thiswillhavebeendiscussed in

preopbutwecanalsoreferyoutooursmokingcessationteamwithintheHospital.

§ Move your ankle around asmuch as possible to keep your calfmusclepumping

Smallpreventativemeasurescanhaveahugeimpactonyourrecovery.

VTE(bloodclots)

Writtenby: MsAHatcher,OrthopaedicPhysiotherapistSpecialistMrRichardNorris,OrthopaedicPhysiotherapistSpecialistProfessorMJMcNicholas,ConsultantOrthopaedicSurgeon

MissFRashid,OrthopaedicRegistrarDatelastreviewed: April2016